Podcasts about renato lopes

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Play Episode Listen Later Oct 19, 2022 7:37

C. Michael Gibson and Renato Lopes discuss extended DOAC prophylaxis in medically ill, hospitalized patients with COVID-19.

Episode 152: PRONOUNCE: Prostate Cancer Drugs and CVD

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Play Episode Listen Later Jul 20, 2022 10:24

Renato Lopes and C. Michael Gibson discuss PRONOUNCE comparing the cardiovascular safety of degarelix vs. leuprolide in patients with advanced prostate cancer and CVD.

#54 Drops - Renato Lopes Moreira revela temas do livro "Futebóis"

Café com o Editor

Play Episode Listen Later Jan 26, 2022 2:21

Nesse episódio, Renato Lopes Moreira, coautor de "Futebóis: reflexões no campo, na quadra e na escola", revela os temas que serão abordados pelo livro. --------- Reserve seu livro: www.mywhats.net/reservalivro.

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Voz Batista 02-11-21 #terça

Convenção Batista de Pernambuco - CBPE

Play Episode Listen Later Nov 2, 2021 30:53

No programa de hoje você ouve o Voz Batista para Crianças, com a tia Raiza Rafaely e também ouve um testemunho do Pr. Renato Lopes, da PIB em jardim Maranguape falando sobre o projeto social desenvolvido pela igreja. Ouça e compartilhe! Deseja ouvir o programa VOZ BATISTA na Rádio Evangélica FM 100,7 MHz? Acompanhe aqui no Podcast da Convenção Batista de Pernambuco - CBPE. E não deixe de compartilhar suas redes sociais.

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Circulation October 19, 2021 Issue

Convenção Batista de Pernambuco - CBPE

Play Episode Listen Later Oct 18, 2021 27:21

Please join author Khurram Nasir and Associate Editor Sandeep Das as they discuss the article "Social Vulnerability and Premature Cardiovascular Mortality Among US Counties, 2014-2018." Dr. Carolyn Lam: Welcome to Circulation on the Run your weekly podcast, summary, and backstage pass to the journal and its editors. We're your co-hosts, I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center in Duke-National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Poly Heart Center, VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, I'm really excited about today's feature discussion. It's really meaningful on so many levels. It discusses social vulnerability. In other words, social determinants of health and its association with premature cardiovascular mortality among US counties. Now, even as an ex-US person I learned a lot, so everyone is going to want to listen in. But now let's start with going through some exciting papers in today's issue, shall we? Dr. Greg Hundley: You bet Carolyn. So, I'm going to grab a cup of coffee and we'll get started with the first article. And really gets into the world of cardiovascular risk and prostate cancer management. Dr. Greg Hundley: So, Carolyn in the light of improved prostate cancer survivorship, and the competing risk of cardiovascular disease, there's an ongoing need for rigorous cardio oncology clinical trials. As you probably know, androgen deprivation therapy is a cornerstone of prostate cancer therapy. Through different pituitary gonadotropin releasing hormone receptor mediated mechanisms both GnRH agonists, as well as antagonists, either indirectly or directly inhibit luteinizing hormone secretion, consequently inhibiting testosterone production. These GnRH agonists are the most commonly prescribed form of androgen deprivation therapy with only 3 to 4% of patients receiving a GnRH antagonist. Dr. Greg Hundley: So, Carolyn the relative cardiovascular safety of gonadotropin releasing hormone antagonists compared with gonadotropin releasing hormone agonists in men with prostate cancer and known atherosclerotic cardiovascular disease remains somewhat controversial. And therefore these authors led by Dr. Renato Lopes from both Brazil, as well as the Duke University Medical Center in Durham, conducted an international multicenter, prospective randomized open label trial, and men with prostate cancer and concomitant atherosclerotic cardiovascular disease were randomized one to receive gonadotropin releasing hormone, antagonist degarelix or the gonadotropin releasing hormone, agonist leuprolide for 12 months and the primary outcome was time to first educate major adverse cardiovascular event that combined the endpoints of composite death MI and stroke over these 12 months. Dr. Carolyn Lam: Nice Greg, and what did they find? Dr. Greg Hundley: Right Carolyn, due to slower than projected enrollment and fewer than projected primary outcome events enrollment was stopped before the 900 plan participants were accrued from May 3rd, 2016 to April 2020, a total of 545 patients from 113 sites across 12 countries were randomized. Baseline characteristics were really balanced between the two study groups. Now Mace occurred in 5.5% of the patients assigned to degarelix and 4.1% assigned to leuprolide and so in summary, Carolyn, this pronounced study is the first international randomized clinical trial to prospectively compare the cardiovascular safety of a gonadotropin releasing hormone antagonist as well as agonist in patients with prostate cancer. And the study was terminated prematurely due to smaller than planned number of participants and events. And so no difference in mace at one year was noted between the two groups and this pronounced study really provides a model for interdisciplinary collaboration between urologists, oncologists and cardiologist with a sheer goal of evaluating the impact of cancer therapies on cardiovascular outcomes. Dr. Carolyn Lam: That's so cool, Greg. I heard the presentation of these results at the ESC by Dr. Renato Lopes and it's a really cool and important study, but a paper I want to present is an analysis from Emperor preserved on inpatient and outpatient heart failure events. Dr. Greg Hundley: Great. Carolyn, so remind us, what did the Emperor preserved trial show? Dr. Carolyn Lam: Emperor preserved showed that in patients with heart failure and preserved ejection fraction empagliflozin reduce the primary endpoint of cardiovascular death or hospitalization for heart failure, primarily related to a lower risk of hospitalizations for heart failure. Greg you're smiling, because you can see me beaming because we finally have a robustly positive outcomes trial in have pep in this trial. Nonetheless in the current analysis, Dr. Milton Packer from Baylor Heart and Vascular Institute and others used prospectively collected information on inpatient and outpatient events, reflecting worsening heart failure, and pre specified their analysis in individual and composite end points. Dr. Greg Hundley: I've been in suspense here. What did they find? Dr. Carolyn Lam: Empagliflozin reduced the risk of severe hospitalizations as reflected by admissions requiring the use of ionotropic or vasopressor drugs and the need for intensive care. Empagliflozin also reduce the risk of outpatient worsening heart failure events, including the need for urgent care visits, diuretic, intensification, and unfavorable changes in functional class. So, basically benefit across the spectrum. Furthermore, because there's controversy about the effect across the spectrum of ejection fraction. The benefit on total heart failure hospitalizations was found to be similar in patients with an ejection fraction of above 40, but less than 50% and between 50 to 60%, although it was attenuated at the higher ejection fractions and we'll hear a lot of discussions about this. Dr. Greg Hundley: Wow, Carolyn. Just more information that keeps coming out about SGLT-2 inhibition. My next paper comes from the world of preclinical science and angiogenesis is a dynamic process, involves expansion of a preexisting vascular network that can incur in a number of physiologic and pathologic settings. But despite its importance, the origin of the new angiogenesis vasculature is really poorly defined in particular, the primary subtype of endothelial cells, whether they be capillary, Venus or arterial that might be driving, this process really remains undefined. These authors led by Dr. Michael Simmons at Yale University school of medicine, fate mapped endothelial cells using genetic markers specific to arterial, Venus and capillary cells. Dr. Carolyn Lam: What did they find Greg? Dr. Greg Hundley: This team study results found that Venus endothelial cells were the primary endothelial subtype responsible for the normal expansion of vascular networks, formation of arterial, venous malformation, and pathologic angiogenesis. And these observations highlight the central role of the Venus endothelium in normal development and disease pathogenesis. Dr. Carolyn Lam: Wow. That's really interesting. I don't think I've ever really paid attention to that bit. Venus endothelium. Thank you for that. Now what else is in today's issue? Well, there's an exchange of letters between Doctors Zhang and Liao regarding the article anti hypertrophic memory after regression of exercise induced physiologic, myocardial hypertrophy is mediated by the long noncoding RNA M heart 779, then ECG Challenge by Dr. Ahmed on challenges of interpreting smart watch and implantable loop recorder, tracings. There's cardiology news by Tracy Hampton and Highlights from the Circulation Family of journals by Sara O'Brien. These regular articles are just really worth a read. You learn so much from just these short lovely summaries. There's On My Mind paper by Dr. Meyer on a targeted treatment opportunity for taking advantage of diastolic tone. And there's also a Research Letter by Dr. Brozovich on a rat model of heart failure with preserved ejection fraction changes in contractile proteins, regulating calcium cycling and vascular reactivity. Dr. Greg Hundley: These journal issues, there's so much information. I'm in a close out with an in depth piece from professor entitled antithrombotic therapy in patients undergoing transcatheter interventions for structural heart disease. I really look forward to your feature discussion on the social vulnerability and premature cardiovascular mortality in US countries. Dr. Carolyn Lam: Thanks Greg. It's good. Dr. Carolyn Lam: Today's feature discussion focuses on an extremely important topic of social vulnerability and premature cardiovascular mortality. So pleased to have the corresponding author of the feature paper, Dr. Khurram Nasir from Houston Methodist and Dr. Alana Morris, who is the editorialist for this paper. And she's joining us from Emory University in Atlanta, Georgia. So thank you both of you for joining and Alana if you don't mind, I'm going to borrow some of the words from your really-excellent editorial to bring us into the discussion. You very nicely brought up that early race and ethnic disparities and a death toll from COVID 19 really, laid the foundation for us having Frank conversations about vulnerable populations and has really brought to light social determinant of health and social economic inequality as risk factors. Now that's, COVID 19. And frankly, if we put everything in a global view of what kills most of us, it's still cardiovascular disease, which is why this paper is just so important, but current recognizing I'm not from the US, lots of our audience are not from the US. Could you please walk us through what your paper looked at and what it means? Dr. Khurram Nasir: Sure. Klan, thank you so much for having us today and what a wonderful editorial by Dr. Morris on this. As you pointed out about the COVID challenges, we were all touched by the significant disparities, really in a one of the lifetime crisis, such as COVID. But the reality is that even in times of calm the benefits, for example, cardiovascular disease prevention access have not been shared equally among vulnerable groups. So I'm a preventive cardiologist, and it gives me immense pride that despite being the number one cause of morbidity mortality for so long as a cardiology community, we have made significant strides over the last three decades, cutting into our losses. And if you look at the trends it's appeared and I'm very hopeful that we'll soon be losing the number one killer tag in US. At the same time we are seeing that those cuts are being lost, especially in the young individuals. Dr. Khurram Nasir: And at one point while we celebrate these decline. But the thing that bothers many of us that unfortunately these gains have not been equal, especially for our more vulnerable patients. And apart from the well documented, I think racial disparities that we all know and are becoming more aware. I think health disparities also form across various fourth lines and I believe the deepest and more persistent divides is around income. And you can even go a step further in US, unfortunately for our international group is unfortunate fact that in US, your zip code may hold more sway than your genetic code. And an example was made famous in St. Louis, Missouri Del marble award, which is known as the Delmer divide, a title that was made famous by a four minute BBC documentary that showed, that a sharp dividing line between the poor predominantly African American neighborhoods in the north and more affluent, largely white neighborhood in the south with health falling across this divide. Dr. Khurram Nasir: And in our practice, we see this phenomenon clearly in our own backyard. So, inspired by this sterling. We wanted to determine that a mirror geographical measure, where we can get insights of conditions where people live, learn, work, play, grow, and age, and commonly now known as the social determinants of health. Can that explain some of these rising risks, especially in the premature cardiovascular disease. So to design this study, we reached out to the CDC social vulnerable, the index that has been created that ranks communities and zip codes based on 15 factors across food domains, socioeconomic status, household composition of disability, that in includes single parents, elderly or children, minority status and language and housing type and transportation, all of them are put together and for each census. And then eventually at the county level, you can classify what their social vulnerability is. And as you know, this was really developed in to identify places where in times of disaster and emergencies, you can focus a little bit more, but we thought about how do we connect this to, for example, our data on mortality from CDC wonder. Dr. Khurram Nasir: And once we did that, we found very interesting patterns that across the scale social vulnerability, there is a risk dose dependent fashion and the age adjusted mortality rates for premature cardiovascular disease, which we define as less than 65, went from the least vulnerable and became the worst across the most vulnerable. At the same time, we also found this double jeopardy issues where this association was varied by race, gender, and ruler. And what we found that specifically Non-Hispanic lack individuals were more likely for certain types of cardiovascular, premature, such as stroke and heart failure, mortality, as compared to the rest, even if you were from the least vulnerable to the most women also unfortunately had a twofold higher risk of CBD mortality. And what is becoming clearly this whole ruler urban that a two to five fold risk of CBD mortality was seen among the least vulnerable. So this is in just the motive of our study, what we did and what we found. Dr. Carolyn Lam: That is so wonderful. Thank you for setting the context and then just to reiterate, so this was all within the US. Alana, could you maybe help frame how important these findings are for us? Dr. Alana Morris: Yes. I think that this analysis is so important, particularly within the context of some of the things that we see happening politically in our country and our landscape right now. And I think we tried to touch on some of those issues in the editorial. Again, I think that the COVID 19 pandemic, if you want to put that against this landscape has really brought into the forefront of our minds, this issue of disparities. Of course, there are many of us who have been thinking about researching and writing about disparities for a long time, but the issue of disparities really, came into the public mindset with the COVID 19 pandemic. The question now is how do we address these as we go forward? And what we're seeing politically is this question of how do we address inequalities that have been present for really since the beginning of time and maybe are widening and perhaps threaten many of the advances that we've made in terms of cardiovascular disease, morbidity, and mortality. Dr. Alana Morris: I think we have to think about in the US, universal healthcare coverage, because we have to be able to prevent disease and treat disease. And as current addressed, there are neighborhood zip codes where people not only don't have access to healthcare, but they don't even have access to the ability to promote health. They don't have access to things like parks, where they can exercise. They don't have access to healthy foods or grocery stores and in a country like the United States where there's so much wealth, you need to think about the fact that certain individuals, don't have the ability to access a grocery store, to access healthy food. It's just really striking and mind boggling that we have this, the difference in rural versus urban locations where some of our US residents, unfortunately don't have access to primary care clinicians, certainly not specialty clinicians is really very mind boggling. And we've seen this play out with the pandemic, but hopefully once we get past the COVID 19 pandemic, we still have to come back to a place where again, we're taking care of not only preventives or services to prevent the onset of cardiovascular disease, but certainly once people are diagnosed with cardiovascular disease, we want to get them access to specialty care. So we have to think as a community, how do we prevent disease, but also treat disease once disease is diagnosed within our country. Dr. Carolyn Lam: What you just said about the zip code being more powerful about, than the genetic code, that's like a quotable code. It's incredible. And for those of us coming outside of the US, we don't even realize how much that plays a role, even just within the US. But now let's get to exact point that Alana pointed out, which is what are the next steps. And could you maybe suggest Khurram, and Alana maybe come first, but what's the one thing you want to get out or the one next thing that should happen after this Dr. Alanna Morris: We put a figure in to the editorial that I think really gets to the heart of the matter, I think that those of us who are in healthcare or those of us who think about public health really would ask the question of, why in a country that has as much wealth as the United States, do we not have universal healthcare, most countries across the world that are in an economic position similar to the United States do have universal healthcare coverage for their residents. And you see much better statistics in terms of longevity for their residents as compared to what we have in the United States. And what you see when you look at the United States is that where there is the most vulnerable residents as per analysis identifies those states are the ones that actually don't have, Medicaid expansion. Dr. Alanna Morris: They don't have a safety net for their residents. And so there's really contrast and this disparity that just does not make sense. It does not make sense where there are residents in the United States, which need the most help and they just don't have it. They just are not able to get access to preventive services as well as diagnostic services. And it really just doesn't make sense what we're doing in the United States, in my humble opinion. And I think in the humble opinion of many of us who want to take care of patients, but just cannot, Kern and I both practice in states where this is an issue. And I think that's one big driver. But again, I think when we also think about the built environment in the US and how we think about promoting health and how we talk to patients, when we talk about individuals in the US, we try to give them advice about therapeutic lifestyle changes, how to exercise, how to eat healthy, to prevent disease. That's easier for certain individuals as compared to others, depending upon where you live, depending upon those five digits that make up your zip code. So if we really want our residents to be healthy, we have to create an environment that enables them to do that. Dr. Carolyn Lam: Wow, thank you very much. And as I let Khurram have the final words even about where you think mixed research should be. I just want to highlight that incredible figure from your editorial Alana. I mean, it is really started, there are three panels to it, everyone. The first one chose the social vulnerability index, the second, the premature cardiovascular disease mortality, and then the third, the status of Medicaid expansion. And you can see the colors are just vivid in, how it all makes sense and goes together. So pick up our journal and have a look, but then finally Khurram? Dr. Khurram Nasir: So, Alana, your figure was fantastic and so much add perspective to our findings. As you were saying, it took me back to 35 years back when, where we are before Medicare disparities, even in access to hospitals were dramatic. So where we practice in the south one third of the hospitals would not admit African Americans even for emergency. Now, this is where the policy comes in and suddenly in 1965 using the carrot of Medicare dollars, the federal government virtually ended the practice of racially segregating patients, doctors, and medical staffs, blood supplies so that is the direction that we need to go from the policy perspective and trying to affect the upstream determinants. Now moving forward, as I think more, and especially as a physician, I think while the census level measures are extremely useful to help refine these policy and focus programs in vulnerable areas. Dr. Khurram Nasir: I also think that there is a parallel need to start focusing on similar efforts at the individual level. The first thing is how do we even identify social determinants at this patient level? Are there three main categories, income, education, possibly healthcare, but I think that we need to broaden this. And in the past we have been challenged because we didn't have a set of consensus of the defined SDUH framework. But thankfully now in 2021, we have the healthy people, 2020. Actually for international community, the WHO there is a WHO framework of identifying SDOH at an individual level and in US a more comprehensive Kaiser family foundation. And not only that, we looked at superficially broadly, but we have to go deeper beyond these components of economic instability, education, housing, social context on healthcare beyond insurance, and even food. Dr. Khurram Nasir: For example, income and employment are predominant pillars of income stability, but it may not capture the full picture. For example, difficulty paying bills out of pocket cost and death related to medical care, same in education, where we captured the highest degree, but issues around health and digital literacy and language proficiency may be even more important. So not only we have to broaden the scope, but we have to go in depth. And thirdly, what I've realized from these kind of studies that we have to go a step further, that social disparities don't occur in silos. And we have to look at the aggregated information. And maybe it's time to potentially learn from advances in genetics, in what we have learned that manifestation of disease, especially cardio metabolic rather than being influenced by few major genes is manifested secondary to multiple interacting genes. So can we create similar to a poly genetic risk score, which is an aggregation of genetic smaller risk to a relevant something similar called poly social risk score. Dr. Khurram Nasir: Now, this is an area that our group has been extensively working. And over the last 12 months, we have tried to construct a comprehensive poly social risk score at an individual level based on almost about 50 sub components of the social determinants. And we have suddenly finding very interesting associations with premature CAD stroke. Almost one in two young individuals with stroke, have the worst poly social risk code at the individual level. I think so the next steps will be definitely validation of this tool, incorporation in practice, whether it's adoption and effective interventions can be tied. But the final thing, what I truly want to say is that I'm hopeful that these efforts, the census level at an individual level, at a societal level and the health system are waking up to the importance of social determinants that we can think outside the box and have strong community partnerships. Multi Pro strategies driven largely by social economic environmental factors. So we can all make a lead towards the mission of achieving social justice and equity that eventually cascades through the health system and beyond. So we had enough time to illuminate the issues and challenges. Now it's the time to act. Dr. Carolyn Lam: Thank you so much Kern for a beautiful paper. We are so proud to be publishing it in circulation. And thank you, Alana lovely, editor that we've said so many times. Thank you audience for joining us today. You've been listening to Circulation on the Run from Greg and I please tune in again. Next week, Dr. Greg Hundley: This program is copyright of the American heart association, 2021. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American heart association for more visit ahajournals.org.

Voz Batista 18-10-21 #segunda

Play Episode Listen Later Oct 18, 2021 30:59

No programa de hoje você ouve Voz Batista para Crianças, com a tia Raiza Rafaely e uma palavra do Pr. Renato Lopes, pastor da Primeira Igreja Batista em jardim Maranguape. Ouça e compartilhe! Deseja ouvir o programa VOZ BATISTA na Rádio Evangélica FM 100,7 MHz? Acompanhe aqui no Podcast da Convenção Batista de Pernambuco - CBPE. E não deixe de compartilhar suas redes sociais.

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EP35 - Fazendo o bem na pandemia - com Renato Lopes

Filhos de Francisco Podcast

Play Episode Listen Later Sep 30, 2021 63:45

Estima-se que, em 2021, 1 em cada 8 latino-americanos (12,5%) vivem em situação de extrema pobreza, a forma mais intensa de escassez, na qual nem as necessidades básicas são cobertas. Segundo a Comissão Econômica para a América Latina e o Caribe, esse é o nível mais alto em 20 anos; no Brasil, esse número triplicou com a pandemia, atingindo 27 milhões de pessoas - e, na nossa vizinha Venezuela, chegou a 21 milhões, que representam estarrecedores 77% da população do país. O que cada um de nós, com nossas limitações, podemos fazer diante disso? Para abordar o assunto, convidamos Renato Lopes, que há décadas dedica sua vida a ações de enfrentamento da pobreza, abordando também questões ambientais e espirituais. Ele é diretor de uma ONG com mais de 30 projetos, membro do comitê eclesial para a Amazônia e coordenador de um instituto dedicado à formação de voluntários em todo o Brasil. Para conhecer e ajudar: ABAN - https://www.aban.org.br/ Instituto Humana - http://www.institutohumana.org.br/ REPAM - https://repam.org.br/ Nossas redes: Instagram.com/filhosdefranc Facebook.com/filhosdefranc Twitter.com/fidefrancisco Youtube.com/FilhosdeFranciscoPodcast Podcastfilhosdefrancisco@gmail.com

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Papo de Jogatina - Desafio de Criar Conteúdo para o Hobby - Feat. Renato Lopes e Torugo

BGG II - Podcast

Play Episode Listen Later Sep 13, 2021 107:08

Fala Meus Queridos Sejam bem vindos ao Juntanto as Peças o podcast oficial do canal Alcatéia Lúdica. Esse episódio é uma conversão da live quinzenal Papo de Jogantina para a mídia podcast. Nessa live, tivemos a presença do Renato Lopes do canal Tábula Quadrada e do Torugo do canal Mesa Secreta para bater um papo bem bacana sobre os desafios de criar conteúdo para jogos de tabuleiro. Observação: Por ser uma conversão, as partes que não fazem sentido sem assistir o vídeo foram retiradas, por isso, o podcast tem uma duração menor que a live. Ouça Também no Spotify:https://open.spotify.com/episode/0LNz6ewZUsWWFMjchkqahL Assine nosso feed e ouça no seu agregados favorito: https://anchor.fm/s/68e14228/podcast/rss

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Prosa com Renato Lopes - Episódio 24 (PODCAST)

Nordicast

Play Episode Listen Later Jul 1, 2021 149:31

Fala Povo! Neste novo quadro, Paulo e Renato Simões recebem convidados para ter dois dedinhos de prosa. Sem pauta, sem ser entrevista, somente um bate papo. Neste episódio o convidado é Renato Lopes do Tábula Quadrada! Agradeço ao covileiro Marco Ferreira pela edição! Aos poucos vamos colocando os Prosas em dia! Link para Campanha o Padrim: https://www.padrim.com.br/CovildosJogos Apoie também pelo PicPay: https://picpay.me/coviljogos Jogos de tabuleiro é na Playeasy: https://playeasy.com.br/ Acessórios Realísticos é na Gorilla 3D: https://www.gorilla3d.com.br/ Para mais vídeos, resenhas em texto e para ouvir nosso podcast, acesse: https://covildosjogos.com.br

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Prosa com Renato Lopes - Episódio 24 (PODCAST)

Nordicast

Play Episode Listen Later Jul 1, 2021 149:31

Fala Povo! Neste novo quadro, Paulo e Renato Simões recebem convidados para ter dois dedinhos de prosa. Sem pauta, sem ser entrevista, somente um bate papo. Neste episódio o convidado é Renato Lopes do Tábula Quadrada! Agradeço ao covileiro Marco Ferreira pela edição! Aos poucos vamos colocando os Prosas em dia! Link para Campanha o Padrim: https://www.padrim.com.br/CovildosJogos Apoie também pelo PicPay: https://picpay.me/coviljogos Jogos de tabuleiro é na Playeasy: https://playeasy.com.br/ Acessórios Realísticos é na Gorilla 3D: https://www.gorilla3d.com.br/ Para mais vídeos, resenhas em texto e para ouvir nosso podcast, acesse: https://covildosjogos.com.br

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Handstandtalk #145 - Renato Lopes

Handstandtalk

Play Episode Listen Later Mar 2, 2021 55:14

Renato Lopes - Licenciado em Ed. fisica, personal trainner, formador de PT's, coach de Crossfit ...fica a conhecer a sua historia, percurso e imensa energia!!!

crossfit renato lopes

Semana Imobi Especial - Retrospectiva do Mercado Imobiliário 2020

Semana Imobi

Play Episode Listen Later Dec 18, 2020 39:19

Nesta edição do Semana Imobi, a equipe do Imobi Report conta mais sobre o processo de produção da newsletter e do portal, além de debater os destaques de 2020. Com participação de Denis Levati, Michel Prado, Ana Carolina Bendlin e Ana Clara Tonocchi, e edição de Renato Lopes. Acesse, se inscreva e acompanhe mais conteúdos aqui: https://imobireport.com.br.

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S2E1 - Blockchain in Brazil: A Hidden Blockchain Powerhouse

Blockchain Won't Save the World

Play Episode Listen Later Nov 28, 2020 52:43

Welcome to Season 2! New theme music, more guests, and a different way of looking at Blockchain technology, culture and community through the eyes of Blockchain experts in the less-publicised nations around the world - and we're starting with Brazil. There is more Blockchain activity happening in Brazil than almost anywhere in the world, and Brazil has produced some of the most talented minds in Blockchain. Adoption of the technology is tightly linked to the strengths and deficiencies of Brazil as a nation, and it's fascinating to observe. In this episode we cover: - Brazil's relationship with technology, and how Brazil is a Blockchain leader despite lagging behind tech adoption in other areas - Examples of national Blockchain use cases in Public and Private sector - from National Identity to Agri Business to Finance and Crypto Assets - How Blockchain is spoken about in society and the press - The make-up of Brazil's Blockchain community: Fintechs, Cypherpunks, Gov-techs and Enterprise Adopters - The main personalities in Brazilian Blockchain, and who you should be following - Case studies on start-ups in Agri-business and Renewable Energy, and Henkel's 'Reci-Chain' for Recycling - What more is needed to bring Blockchain initiatives to scale in Brazil, and key learnings for other countries Shout to my guests: Mauricio Magaldi, Rosine Kadamani, Gladstone Arantes, Tatiana Revoredo, Renato Lopes, Deborah Aguirre, Kiko Duarte, Isaque Eberhardt and Igor Ferreira

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Circulation November 03, 2020 Issue

Podcast Academia de Medicina

Play Episode Listen Later Nov 2, 2020 22:21

This week’s episode features author Karolina Szummer and Associate Editor Emmanouil Brilakis as they discuss the article "Comparison Between Ticagrelor and Clopidogrel in Elderly Patients with an Acute Coronary Syndrome: Insights from the SWEDEHEART Registry." TRANSCRIPT BELOW Dr Carolyn Lam: Welcome to Circulation on the Run. Your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Dr Greg Hundley, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Carolyn, this week's feature article, we're going to investigate antiplatelet therapy use, but in older patients, as opposed to those that are middle-aged, and have sustained a prior acute myocardial infarction. But, before we get to that, how about we grab a cup of coffee and jump into the other papers in the issue? Dr Carolyn Lam: Absolutely, Greg. I've got my coffee right here, and I really want to start with a paper that adds to our understanding of, guess what, the sodium=glucose cotransporter 2 inhibitors, SGLT2 inhibitors, and their diuretic and natriuretic effects in combination with loop diuretics. Of course, a clinically really important question since now we know that SGLT2 inhibitors improve outcomes in patients with heart failure in whom they are likely to be co-prescribed with a loop diuretic. So, Professor Chim Lang from University of Dundee and his colleagues performed the RECEDE-CHF trial, which was a randomized double-blind placebo-controlled crossover trial of 23 patients with type 2 diabetes and HF REF taking regular loop diuretics who were randomized to the SGLT2 inhibitor empagliflozin 25 milligrams once daily or placebo for 6 weeks with a 2-week washout period. The primary outcome was change in 24-hour urine volume from baseline at week 6. Dr Greg Hundley: So, empa versus placebo. What did they find? Dr Carolyn Lam: In patients with heart failure and type 2 diabetes taking a regular loop diuretic, empagliflozin caused a significant increase in urine volume at both day 3 and week 6, compared to placebo, as well as empa also caused a significant increase in electrolyte-free water clearance. Though there was a small non-significant increase in natural uresis with empagliflozin at day 3, this was absent by week 6. These results suggest that empagliflozin may have an advantageous diabetic profile in patients with type 2 diabetes and heart failure in addition to loop diuretics, with only a short transient natriuresis. Dr Greg Hundley: Very nice, Carolyn. Great information. Diuretics, heart failure reduced ejection fraction, and empagliflozin. Well, my clinical paper comes from Dr Renato Lopes from Duke University Medical Center, and this is a sub study from the ISCHEMIA trial that evaluates whether an initial invasive strategy in patients with stable ischemic heart disease and at least moderate ischemia improves outcomes in patients with a history of heart failure or left ventricular dysfunction when the EF is greater than 35%, but less than 45%. Dr Carolyn Lam: Aw, that mid-range ejection fraction. Favorite topic. So, Greg, what did they find? Dr Greg Hundley: Those with heart failure and left ventricular dysfunction randomized to the invasive versus the conservative strategy had a lower rate of the primary outcome, 17% versus 29%. Whereas those without heart failure and left ventricular dysfunction did not, 13% versus 14%. A similar differential effect was seen for the primary outcome, all-cause mortality and cardiovascular mortality, when invasive versus conservative strategy associated outcomes were analyzed with LVF as a continuous variable for those with and without prior heart failure. Dr Carolyn Lam: Wow, that is clinically important, Greg. So, can you summarize our take home message? Dr Greg Hundley: Well, Carolyn, ischemia trial participants with stable ischemic heart disease and at least moderate ischemia with a history of heart failure or LV dysfunction, were at increased risk for the primary outcome. And in this small high-risk subgroup with heart failure and an ETF between 35% and 45%, an initial invasive approach was associated with a better event free survival. This result should really be considered for hypothesis generation and future studies. Dr Carolyn Lam: Greg, for the next paper, do you remember hydrogen sulfide? The stuff we learned about in school. It's the gas with that characteristic foul odor of rotten eggs. Well, guess what? This whole paper is about hydrogen sulfide, and in the body, it actually has antihypertensive and anti-inflammatory effects, and its endogenous generation key enzyme is cystathionine gamma lyase, or CSE, and that's expressed in CD4+ T cells. So today's paper provides insights into how all of these players work together in the development of hypertension. To investigate the pathophysiological relevance of this CSE hydrogen sulfide system, co-corresponding authors, Doctors Geng and Cai from Fuwai hospital and Chinese Academy of Medical Sciences, Peking University Medical College, as well as Dr Xu from Peking University Health Science Center in Beijing. Well, they and their coauthors performed elegant experiments involving peripheral blood lymphocytes, isolated from hypertensive patients or spontaneously hypertensive rats. They also looked at mice with CSE-specific knockout in T cells, and CD4 null mice. Dr Greg Hundley: Well, Carolyn, what did they find? Dr Carolyn Lam: Well, they found that endogenous cystathionine gamma lyase, or CSE, and hydrogen sulfide, but not cystathionine beta-synthase, in lymphocytes, responded to blood pressure changes. Deleting CSE in CD4+ T cells exacerbated angiotensin II-induced hypertension by reducing circulatory and renal T regulatory numbers. Hydrogen sulfide from CSE self-hydrates, liver kinase 1, thereby activating the AMP kinase energy pathway to promote TReg differentiation and proliferation, which then attenuates the vascular and renal immune inflammation, and thus, prevents hypertension. Dr Greg Hundley: Carolyn, this sounds like a very thorough study. What are the clinical implications? Dr Carolyn Lam: Endogenous CSE hydrogen sulfide in lymphocytes may be both a potential biomarker of hypertension, or its complications, or hydrogen sulfide donor may be a therapeutic approach to lower hypertension. Dr Greg Hundley: Great, Carolyn. Well, my next paper comes from Professor Goo Taeg Oh from Ewha Women's University, and it really involves the world of inflammation. So Carolyn, as you know, macrophages produce many inflammation-associated molecules released by matrix metalloproteinases, such as adhesion molecules, as well as cytokines, which play a crucial role in atherosclerosis. In this paper, the authors investigated the relationship between Ninjurin-1, or nerve injury-induced protein 1, a novel MMP9 substrate expression, and atherosclerosis progression. Dr Carolyn Lam: Ninjurin-1? Interesting. So, what were the results? Dr Greg Hundley: Well, Carolyn, Ninj1 expression and atherosclerosis progression were assessed in atherosclerotic aortic tissue and serum samples from coronary artery disease patients and healthy controls, as well as athero-prone, apolipoprotein E-deficient, or APOE -/- wild type mice. Two important findings, Carolyn. First, the authors in vivo results conclusively showed a correlation between Ninj1 expression in aortic macrophages and the extent of human and mouse atherosclerotic lesions. Ninj1-deficient macrophages promoted pro-inflammatory gene expression by activating mitogene-activated protein kinase, or MAP kinase, and inhibiting the phosphoinositide 3-kinase signaling pathway. Whole-body and BM-specific Ninj1 deficiencies significantly increase monocyte recruitment and macrophage accumulation in atherosclerotic lesions through elevated macrophage-mediated inflammation. Now, in addition and secondly, macrophage Ninj1 was directly cleaved by MMP9 to generate a soluble form that exhibited anti-atherosclerotic effects, as assessed both in vitro and in vivo. Treatment with the sNinj1-mimetic peptides, ML56 and PN12, reduced proinflammatory gene expression in human and mouse classically activated macrophages, thereby attenuating monocyte transendothelial migration. Moreover, continuous administration of mPN12 alleviated atherosclerosis by inhibiting the enhanced monocyte recruitment and inflammation characteristics of the disorder in mice, regardless of the presence of Ninj1. So in summary, Carolyn, Ninj1 is a novel MMP9 substrate in macrophages, and sNinj1 is a secreted athero-protective protein that regulates macrophage inflammation and monocyte recruitment in atherosclerosis. Dr Carolyn Lam: Wow, Greg, that was incredibly summarized. Thank you. Let's go through what else there is in today's issue. In cardiology news, Bridget Kuhn talks about how the pandemic intensifies the push for home-based cardiac rehabilitation options. There's a white paper by Dr Ho and colleagues, including me, describing the diagnostic dilemma of HFpEF. There's a Research Letter by Dr Gill talking about the cardiometabolic trait sepsis and severe COVID-19, a Mendelian randomization investigation. There's also a Research Letter by Dr Wu on the atlas of exosomes microRNAs secreted from human iPSC-derived cardiac cell type. Dr Greg Hundley: Carolyn, this issue is just packed with articles, because I've got five more to tell our listeners about. First, it's a research letter from Professor G. Hovingh, entitled, Inclisiran Durably Lowers LDLC and PCSK9 Expression in Homozygous Familial Hypercholesterolemia, The ORION-2 Pilot Study. Next, there's an ECG challenge from Dr Jason Gilge relating to AV conduction during atrial flutter. Next, Dr Keith Churchwell has a nice piece related to the importance of those involved in cardiovascular care and participating in their civic duties, including voting. Next, Professor Karthikeyan has nice On My Mind related to overestimation of stroke risk and rheumatic mitral stenosis and the implications for oral anticoagulation. And finally, Carolyn, another research letter, from Dr Pieter van Paassen, entitled, Neutrophils and Contact Activation of Coagulation as Potential Drivers of COVID-19. Well, Carolyn, how about we get on to our feature discussion and review in older patients, which antiplatelet therapy may be safest? Dr Carolyn Lam: Let's go! Dr Greg Hundley: Well, listeners, now we're turning to our feature discussion, and today we'll talk about antiplatelet therapy. And then we have with us, Dr Karolina Szummer from Karolinska Institutet, and our own Associate Editor, Dr Manos Brilakis from the Minneapolis Heart Institute. Welcome to you both, and Karolina, let's start with you. Could you describe for us your hypothesis and some of the background information that led you to perform this study? Dr Karolina Szummer: Thank you so much for having me here and for sharing the ideas behind our study. Current recommendations recommend that we use high-potent antiplatelet agents for treating myocardial infarctions, and in particular, elderly patients are not included. So we decided to do an observational study to look at patients in our Swedish registries treated for myocardial infarctions who were 80 years and older. Dr Greg Hundley: Very nice. Can you tell us a little bit more about your study design? And also the study population? Dr Karolina Szummer: The startup populations are all patients who were admitted to an acute coronary care unit for treatment of myocardial infarctions, and they were all 80 years and older, and they were included from 2010 to 2017. So this encompasses the period during which treatment with ticagrelor was introduced. So we are comparing to ticagrelor versus clopidogrel for the outcomes during the year, following the myocardial infarction. Dr Greg Hundley: And how many patients did you enroll in the study? And what were your study results? Dr Karolina Szummer: We enrolled, in total, 14,000 patients, and these consisted of non-STEMI and of STEMI patients. The majority, about two thirds, were non-STEMI patients. We show, in this study, elderly patients have a lower risk of readmission for myocardial infarction or stroke, but they have a higher risk of having readmission for bleeding and death. So the risk-benefit ratio seems to be skewed towards having, probably, more harm with ticagrelor being more risky than clopidogrel in this study population of elderly. Dr Greg Hundley: And was this true for both men and for women? Dr Karolina Szummer: Yes. So this was true for both men and women. And we did a sensitivity analysis. We looked closer at those who are younger than 80 years old, and in this patient population, the results selected in the same way as for our cohort of elderly, they actually did have the same benefit with a low risk of MI, stroke, and death, and high risk of bleeding. But in the elderly, we noticed a signal towards harm with an increased risk of death. Dr Greg Hundley: It sounds like with ticagrelor, did we have a lower risk of death and a slightly lower risk of myocardial infarction and stroke, but a higher risk of bleeding? Was that the findings? Dr Karolina Szummer: So for the elderly, there was a high-risk of death and bleeding with ticagrelor compared to clopidogrel, but a lower risk of ischemic component of MI and stroke. Dr Greg Hundley: And then with those under 80, those were the ones that had the lower risk of death, lower risk of MI and stroke, but the higher risk of bleeding? Dr Karolina Szummer: Yes, that's correct. So really the end point that differs most is that there is sustainment towards higher mortality in the elderly, because in both younger and elderly, the risk of readmission for bleeding was elevated in both. Dr Greg Hundley: Now, let's turn to our own Associate Editor, Manos Brilakis. Manos, can you help us put these results into perspective, relative to other studies that evaluate the efficacy of antiplatelet therapy, post myocardial infarction? Dr Emmanouil (Manos) Brilakis: I would like to start by congratulating Dr Szummer. It's a wonderful paper, and, I think, provide some new insights on how to use the medications in the ACS patients. And going on the background, if we look at the guidelines, both the European guidelines, as well as the American guidelines, what they say is that both ticagrelor, as well as prasugrel, are preferred and recommended for patients with ACS, both non-ST elevation ACS, as well as ST segment elevation myocardial infarction. And actually, European guidelines say that clopidogrel should only be used when prasugrel or ticagrelor are not available or are contraindicated. And this is based on two trials. One is the PLATO trial, and the other is the TRITON-TIMI 38, that both showed, actually, more benefit with the more intensive P2Y12 inhibitors. And this is what is extrapolated to all patient populations. But as you've heard before, there was only a minority of elderly patients that were included in those trials, about 13% to 15%, and that is why the present study is important, because it suggests that maybe we should look more carefully into the patient's age and potentially other characteristics like frailty or other comorbidities, that might actually alter the risk-benefit ratio. And maybe those medications should not be routinely given to all patients, but perhaps, elderly patients, or at least some of them, might not require, and actually be better off with clopidogrel. Dr Greg Hundley: Let's turn back to Karolina. Karolina, the study was observational. What do you see as, perhaps, a next study to follow up the results that you've brought to us with this study? Dr Karolina Szummer: So the next step would definitely be to do a randomized control trial in the elderly to explore this topic further, to really know for sure what the safety and efficacy is, and what's the best treatment would be for these patients. Dr Greg Hundley: Very good. And Manos, do you have anything to add? Dr Emmanouil (Manos) Brilakis: One more thing. So, there was actually a trial that compared ticagrelor as well as prasugrel with clopidogrel in elderly patients that was called the POPUlar AGE trial that was published last year. And actually this one, published earlier this year, and actually this trial randomized a thousand patients who were more than 70 years old, to either more-intensive or less-intensive. And the results were actually very similar to the findings from Dr Szummer's study from SWEDEHEART, showing that there was more bleeding without any ischemic benefit. And didn't show actually higher mortality but didn't show any significant benefit. So that actually adds to the data that maybe the elderly patients, the selection of antiplatelet agent should be taken into account. And I think for me, this also extrapolates the high bleed risk, higher risk of bleeding, based on criteria, which we currently use mainly for duration. We say, for example, if you're precise DAPT score, which is a score for determining risk of bleeding, is high, you should consider shorter duration of DAPT, but it doesn't say anything about the type of DAPT. And for me, this makes sense that the high bleeding risk, and age is one of the main risk factors for high bleeding risk, should be taken into account also for determining the type of P2Y12 inhibitor. Dr Greg Hundley: Well listeners, we've had a great discussion with Karolina Szummer from Karolinska Institutet, and our own Manos Brilakis from the Minneapolis Heart Institute, really reviewing the utility of ticagrelor versus clopidogrel in older individuals, above the age of 80, that have sustained myocardial infarction, and identifying that ticagrelor is associated with a higher risk of death and bleeding, as opposed to clopidogrel, opening the question up as to whether further studies in older individuals need to be performed to examine the efficacy of antiplatelet therapy. So, on behalf of Carolyn and myself, we wish you a great week and look forward to catching you On the Run next week. This program is copyright the American Heart Association, 2020.

GEN MedCast #44 - Renato Lopes - Resultados do estudo BRACE CORONA

Play Episode Listen Later Oct 7, 2020 9:44

No podcast de hoje o Dr. Renato Lopes, professor livre-docente da Divisão de Cardiologia da Escola Paulista de Medicina (UNIFESP) e da Duke University (EUA), nos fala sobre os resultados do estudo BRACE CORONA. Imperdível!

corona brace resultados estudo divis imperd cardiologia escola paulista medcast renato lopes

BRACE CORONA: Continuing vs. Suspending ACE Inhibitors and ARBs in COVID-19 with Dr. Renato Lopes

CRTonline Podcast

Play Episode Listen Later Sep 11, 2020 12:29

Drs. Ron Waksman and Renato Lopes discuss the results of the BRACE CORONA study, which was presented as a late-breaking trial at the European Society of Cardiology virtual congress. The study examined the difference between continuing or suspending ACE inhibitors and angiotensin receptor blockers in COVID-19 patients. Dr. Lopes provides insights into the top-line findings, which is that there were no significant differences between the two treatment regimens. Watch the interview on CRTonline

covid-19 corona brace drs lopes cardiology suspending european society arbs ace inhibitors renato lopes

Treatment for Patients with Stable Ischemic Heart Disease and Heart Failure

CRTonline Podcast

Play Episode Listen Later Sep 11, 2020 10:57

Drs. Ron Waksman and Renato Lopes discuss the results of a study presented as a late-breaking trial at the European Society of Cardiology 2020 virtual congress. This study examined whether medical therapy or more or an invasive strategy was better for patients with intermediate heart failure (ejection fraction of 35% to 45%) and stable ischemic heart disease. When compared with patients with ischemia but without heart failure, stable ischemic patients with heart failure saw a benefit from invasive intervention. Watch the interview on CRTonline

patients treatments drs stable heart disease cardiology heart failure european society ischemic renato lopes ischemic heart disease

Cloroquina: as respostas que os cientistas ainda procuram

Ao Ponto (podcast do jornal O Globo)

Play Episode Listen Later Jul 27, 2020 24:17

Na última semana, o periódico científico americano The New England Journal of Medicine publicou os resultados do maior estudo feito no Brasil que mostra a ineficácia da hidroxicloroquina em pacientes hospitalizados com Covid-19. Assinado por 35 médicos, ligados a quatro hospitais de ponta e dois institutos de pesquisa que formam a Coalizão Covid-19, o levantamento não revelou diferença na evolução do quadro dos doentes com sintomas classificados entre leves e moderados, divididos em três grupos: pacientes que usaram a hidroxicloroquina; que usaram o remédio em combinação com o antibiótico azitromicina; e que não usaram nenhuma das drogas. São resultados que corroboram outros estudos, feitos no exterior. No entanto, há ainda perguntam sem resposta sobre a eficácia do medicamento, especialmente nos pacientes que não precisaram de internação. No Ao Ponto desta segunda-feira, dois dos líderes da Coalizão Covid-19, o cardiologista Renato Lopes, presidente do Instituto Brasileiro de Pesquisa Clínica (BCRI) e professor da Universidade Federal de São Paulo, e a intensivista Flávia Machado, presidente da Rede Brasileira de Pesquisa em Terapia Intensiva (BRICnet) e também professora da Unifesp, analisam os resultados até agora obtidos e discutem a relevância dos estudos que ainda não foram concluídos.

Circulation March 03, 2020 Issue

Play Episode Listen Later Mar 2, 2020 23:59

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Dr Greg Hundley, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. You know that problem we have with the development of calcification of the aortic valve, the aorta, etcetera with hemodialysis? Well, our feature is going to talk about the results of a randomized phase 2B study to address this. But first, how about if you get us started with a couple of your papers? Dr Carolyn Lam: In fact, it is a couple of papers and they're both related to hypertension. So in the first one, we know that exercise is associated with a lower incidence of hypertension, but what's the association of excessive levels of exercise in the incidence of hypertension? This question was examined by Dr Andersen from Uppsala University Hospital and colleagues, who compared the incidence of hypertension among almost 207,000 participants in a long-distance cross-country skiing event and more than 505,500 persons randomly sampled from the general population who are matched to the skiers on age, sex, and place of residence. Dr Greg Hundley: I love skiing! I want to be in the match group. Tell me, now, how long was this distance that they had to cover? Dr Carolyn Lam: Ah ha. Now the long distance event was really long. It was the Vasaloppet. I hope I pronounced that right, but it's a 45 to 90 kilometer skiing race. So participation, I'm sure you want to hear this, participation was associated with a 41% lower incidence of hypertension over the next eight years, compared to non-participation. And the better the performance in terms of percent of winning time, the lower the incidence of hypertension. If the observed associations are causal, it really adds to the list of beneficial effects of high, or even very high physical fitness. I can see you smiling, Greg. Dr Greg Hundley: This is your confirmation that the AHA wants to send us to Norway to do one of these recordings. Dr Carolyn Lam: Well, this next paper asked the question, what is the association of cumulated blood pressure exposure from young adulthood to midlife with gait and cognitive function in midlife. This is from Dr Mahinrad from Northwestern University Feinberg School of Medicine and colleagues who included 191 participants from the coronary artery risk development in young adults’ study, which is a community-based cohort of young individuals followed over 30 years. Cumulated blood pressure was calculated as the area under the curve for baseline up to year 30 exam and gait and cognition were assessed at the year 30 exam. Cerebral white matter hyperintensity was available at year 30 in a subset of participants who underwent MRI. Dr Greg Hundley: I heard that MRI word. So what did they find Carolyn? Dr Carolyn Lam: They found cumulative exposure to higher blood pressures from young adulthood to midlife, even at levels below the clinical definition of hypertension, was associated with worse gait and worse cognitive function in midlife. The impact of cumulative levels of blood pressure exposure was independent of other vascular risk factors during a follow-up period of over 30 years, and the higher burden of midlife cerebral white matter hyperintensity on MRI, Greg, moderated the association of cumulated blood pressure exposure with gait but not with cognitive function. Dr Greg Hundley: You've got me convinced we now have to go to Norway. But what did the authors think were the clinical implications of their study? Dr Carolyn Lam: Well, here it is. The deleterious effect of elevated blood pressure on brain structure and function may begin during early adulthood and this really emphasizes the need for all primordial, if you may, prevention of high blood pressure. But also reconsidering individual levels of blood pressure for the diagnosis of hypertension. Furthermore, gait may be an earlier measure of hypertensive brain injury than cognition. Now these issues are discussed an editorial by Angela Jefferson from Vanderbilt University Medical Center. Dr Greg Hundley: Very nice, Carolyn. Well, I'm going to take another sort of twist on hypertension. My paper is from Dr Thomas Thum from the Hanover Medical School and is really looking at the relationship between cardiac fibrosis and diastolic dysfunction. So the study sought to identify anti-fibrotic drug candidates by functional screening of 480 chemically diverse natural compounds found in human cardiac fibroblasts. Dr Carolyn Lam: Ooh, interesting. And what did they find? Dr Greg Hundley: What they found is using multiple in vitro fibrosis assays and stringent selection algorithms, the authors identified the steroid bufalin, also seen in Chinese toad venom, and the alkaloid lycorine, from the Amaryllidaceae species, to be effective anti-fibrotic molecules, both in vitro and in vivo, leading to improvement in diastolic function in two hypertension dependent rodent models of cardiac fibrosis. In addition, administration of these agents at effective doses did not change plasma damage markers, nor the morphology of the kidney and liver. And therefore, it's kind of an early first toxicological safety study. Dr Carolyn Lam: Fascinating. Not just in the findings and the methods, and who knew we'd be talking about Chinese toad venom on this podcast, Greg? Okay. But let me tell you about what's more in this issue. So, there is a research letter by Dr Djoussé, and it is entitled Supplementation with Vitamin D and/or Omega-3 Fatty Acids and the Incidence of Heart Failure Hospitalization. And this one is a letter from the VITAL-Heart Failure ancillary study of the parent VITAL trial. I'm sure I've got everyone's attention. (You) Got to read that letter. The next is an On My Mind, by Dr Joe Hill, and is entitled, very intriguingly, Can HFpEF and HFrEF Co-exist? Basically accumulating evidence has revealed that the pathophysiologic mechanisms driving HFrEF and HFpEF are distinct, but this On My Mind paper asks can they coexist? Is it possible to identify subjects who harbor pathophysiological elements of both syndromes simultaneously, and if so, we may find that targeting specific pathways is beneficial and in depth characterization of specific subsets of patients might help overcome the limitations of an ejection fraction driven approach. Dr Greg Hundley: Very interesting, Carolyn. I've got some letters from the mailbox, and the first letter is regarding SGLT2 inhibitors in cardiac hypertrophy and the corresponding author is Professor Kazushi Tsuda from Kansai University of Health Sciences. Another letter, from the corresponding author Dr Renato Lopes from Duke University Medical Center in Durham, evaluates stent thrombosis in patients with atrial fibrillation undergoing coronary stenting from the AUGUSTUS trial. And our own Tracy Hampton provides an update on cardiology news features. And John Warner, from UT Southwestern, the prior American Heart Association president, discusses his journey through healthcare reform. And then finally, our own Sarah O'Brian provides highlights from other journals in the Circulation family related to high points in cardiovascular disease. Well, Carolyn, how about on to dialysis and calcification? Dr Carolyn Lam: Can't wait. Let's go. Our feature discussion today, we will be focusing on patients with end-stage kidney disease. And we know that in these patients, the high cardiovascular morbidity and mortality could partially be due to extensive cardiovascular calcification. Well, our feature paper today is the first double blind placebo-controlled phase 2B trial that tests intravenous myo-inositol hexaphosphate, a novel strategy to inhibit the formation and growth of hydroxyapatite and therefore reduce calcification in these patients. I won't tell you more. I'll leave that to the corresponding author, Professor Paolo Raggi, from University of Alberta, and I'm also so pleased to have with us our editor for digital strategies and associate editor Dr Amit Khera from UT Southwestern. So Paolo, please tell us about SNF472 and your very novel trial. Prof Paolo Raggi: As you correctly stated, patients with end stage renal disease have phenomenally high morbidity and mortality, particularly cardiovascular, and they also manifest extreme calcification on the cardiovascular system. Both the valves and the vessels are very heavily calcified. There's a very clear impression throughout the literature that calcification contributes, no doubt, to the high morbidity mortality with these patients. SNF472 is a derivative of a natural product that is only present in nature in sub molecular quantities and essentially is administered intravenously and the mechanism of action is quite simple. It keeps calcium and phosphorous molecules separate. In other words, it doesn't allow crystallization of calcium and phosphate into what we call hydroxyapatite, or amorphous calcium crystals. This, hopefully, was developed, this product was developed, to inhibit the final step of calcification. Everything comes down, no matter what the promoting event is, to crystallization of calcium and phosphorus. Therefore, if we were able to stop the final event, hopefully you will be able to inhibit further calcification, and that's what we tested in this particular article, in this particular study. Dr Carolyn Lam: Oh Paolo, I just love the way you described that. Very, very crystal clear, if you don't mind the pun. But could you please let us know, so a phase 2B trial, does that mean a surrogate outcome, duration of treatment, number of patients? How about telling us a little bit about the trial? Prof Paolo Raggi: So, the trial involved recruiting three different groups of patients. One would be treated with placebo and two other cohorts would be treated with either 300 milligrams of SNF472 three times a week or 600 milligrams of SNF472 three times a week. The product is injected intravenously into the dialysis line. Therefore, the patients do not have to remember to take a pill or inject themselves. Actually, it's perfect, if you will, compliance because all they have to do is come to their dialysis session and they receive it during dialysis. The study therefore, it was a relatively small study, but enough to prove our point. Three groups were recruited, about 90 patients each, and the two treatment arms at 300 milligrams and the 600 milligrams, were combined as a single group for the purpose of reporting the primary results. The follow up was at one year, so these patients were submitted to CT scanning of the chest without contrast for measurement of calcification only at baseline and then again at 52 weeks. In the intention to treat group, patients were included if they had a baseline scan and at least one follow-up scan at some point during the study. These are very sick patients and sometimes are referred for transplant. Sometimes they withdraw from studies. So, we asked everybody to have a second scan if they needed or wanted to withdraw before the 12 month mark was reached. That's for the intention to treat analysis. And then we need some confirmatory analysis on patients who actually did have the baseline in an actual 12 months scan and received the entire year treatment with these two drugs, with a drug or placebo. Dr Carolyn Lam: That's great and please tell us the results. Prof Paolo Raggi: The results were, in our minds, very exciting. And let me first say, that in all the literature that looked at what is the average progression of calcification in the general population, it's anywhere between 10 to 15% per year. For the person with calcium in the coronary arteries, there's an expected progression about 10 to 15%. All the publications in patients with renal failure and undergoing dialysis, show the progression of anywhere between 25 and 35%, so these people are not only more calcified, these patients also progressing very fast. In the particular trial that we reported in Circulation, we demonstrated on average, a progression of 20% in the group receiving placebo and about 11% in the group receiving SNF472. So, there was about a 45% slowing of progression in the treated group compared to the placebo group. Interestingly enough, we saw a slower progression unusual in the placebo group. As of today, many more treatments are available to patients with end stage renal disease that were not available when the original studies that I mentioned earlier were conducted. So, the 25 to 35% progression that we saw 15 years ago, it's now slowed, you notice, to a 20% progression in these patients, but SNF472 was even more effective at further slowing that progression. Dr Carolyn Lam: Well, congratulations first and foremost on a very successful and really striking and novel results. Well, Amit there's so much to discuss I don't even know where to start. But first, maybe can I bring you in by saying, so what, is Circulation now publishing renal papers? Dr Amit Khera: The answer is absolutely yes. So first I want to congratulate Dr Raggi on a fantastic paper. This was a concomitant late breaking science at the American Heart Association Sessions; so, we always try to think of timely and exciting topics and appreciate working so closely with this group to bring this across the finish line. At Circulation, one thing we've been working on is something called Bridging Disciplines, where purposefully we appreciate the heart is not in isolation and not in a box by itself, but within a larger system, a body system. So, we really enjoy these types of papers that cross disciplines and there's an outstanding editorial by Susan Hedayati, from UT Southwestern who's a nephrologist, who weighed in here as well. So we certainly really value these types of papers in Circulation. Prof Paolo Raggi: I have to say, working with Circulation was amazing. You know, you get a great job and so fast. It was an incredible, actually. Dr Amit Khera: Obviously, the results speak for themselves that the study was positive, and we certainly see this diminishing the vascular classification and certainly you've been, for decades now, an expert in vascular calcification and coronary imaging. And you know, the question that always comes up is, what are the implications here? Now, on one side, especially with the coronaries, you think this would be favorable, you get less obstructive disease, perhaps less ischemic heart disease. But there's always been this debate if calcium's a good or bad thing in terms of plaque stabilization, so what are your thoughts on what ends up being the clinical ramifications of this down the road? Prof Paolo Raggi: Well of course, as we clearly stated in the paper, this has to be followed by some sort of clinical outcome study. So, it is only speculating at this point as to what the benefit might be. But more specifically about your question, I think that there is a misinterpretation of what calcification means in general. And honestly, I would prefer not to have calcification in my cardiovascular system if I had the choice. Many believe, and it's possibly true to a degree, that calcification comes in to repair the plaque and there's some sort of repair mechanism, but we have shown very clearly that the greater the calcification burden, the higher the probability of cardiovascular morbidity mortality. And therefore, it is not benign to have cardiovascular calcification in general. In the case of the patients with end stage renal disease, calcification is not limited to the atherosclerotic plaque. It extends to the thickness of the entire vessel wall and it's well known that patients with end stage renal disease have severe calcification of the media as well as the intima. This obviously causes a series of other problems, such as stiffening of the vessels and therefore reduce compliance and in the long run, many profusion issues to multiple organs, even in the absence of luminal stenosis. A stiff vessel does not comply with what it's supposed to be doing. It is not allowing proper profusion of an end organ and many have demonstrated that also increases the work of the heart, pumping against very rigid plumbing, if you want to put it that way and simply, and therefore may induce left ventricular dysfunction in the long run, arrhythmias if a patient develops left ventricular hypertrophy and fibrosis. So, I think that there's a cascade of events that goes beyond and above just the single plaque, atherosclerosis, calcification. I think that calcification in general, and especially in patients with end stage renal disease, is a whole marker, very high risk of complications. Dr Amit Khera: Thanks for that clarification. I think first and foremost, it's so helpful to think beyond just isolated luminal stenosis and sort of all the maladaptive aspects of vascular calcification in patients with end stage renal disease. And that leads to the next thing in your paper, which I thought was also really interesting, which was the aortic valve calcification. We certainly appreciate that focus on aortic stenosis as of late with the new therapies, but you know particularly in patients with end stage renal disease, it becomes a very complex issue. And you saw some abating of this vascular calcification in the aorta as well. Tell us a little bit about what you think the implications of that would be. Prof Paolo Raggi: So first, a word of caution that the trial was not powered to demonstrate specifically an effect on aortic valve. However, we did demonstrate a beautiful effect on the slowing of the aortic valve calcification as well. It's exciting! I think that it's something that needs to be pursued further and I hope future studies, and definitely is the first time that anything has demonstrated an effect on aortic valve calcification. I'm very well aware of other studies that have attempted, for example, use of statins to slow the progression of valvular calcification and in essence, were completely negative. Patients with end stage renal disease, very severe valvular abnormalities, very, very severe, very important valvular dysfunction as a consequence of massive calcification on the annulus and the leaflets more so of the aortic valve, but also the mitral valve. So this could definitely be a signal for an excellent potential and unexpected if you will, a secondary outcome of this treatment. I believe that in affecting valvular calcification in patients with end stage renal disease would be, could have potentially a massive effect from the point of view of lowering the cardiovascular event rate. Dr Carolyn Lam: May I chime in with a quick question? What were adverse effects like? Prof Paolo Raggi: This particular drug actually was associated with the same exact rate of adverse effect as placebo. In other words, we didn't see anything at all that was alarming. There was one patient that had been reported by the investigator as potential side effect of the drug. They reported something, I think it was like acute hepatic failure, but when the case was clearly analyzed by the DMV, we actually assessed dictation as being a case of cholecystitis had been incorrectly labeled, we believe. And except for that one case, there essentially were no side effects, no adverse effects from treatment. In fact, although it was not powered for those outcomes, there was a lower morbidity and mortality with the SNF472 and then with placebo. Dr Carolyn Lam: I really like that and was really struck by your pointing out a little bit earlier, the ease of administration as part of hemodialysis. That was very nice. Amit, I'm going to give you the final words and questions if I may. Dr Amit Khera: As expected, this has been an exciting podcast and as much as I've read this paper and looked at it in detail, I learned a lot more as I had anticipated. My question for you, Paolo, now, is what's the next step? This is a phase 2B study. What's the next step in the development or evaluation of this compound and where are you going with this? Prof Paolo Raggi: There are a few sub analysis that we haven't yet looked at in this particular study that we just reported. One of the things that we are definitely interested in is to evaluate the effect on bone. As you can imagine, it is true that this particular drug has a wonderful effect on vascular calcification, but the next question is, did it do anything adverse to the bone? It's a logical question but I feel that most likely the answer is going to be a resounding no. But, besides that, the further development of this drug is obvious in my mind. It will have to be addressed in a proper, randomized clinical trial to address some of the clinical questions that we all have. Is this reducing the cardiovascular events? Be it when we need, we will decide together what those cardiovascular events would look like. But obviously myocardial infarction, congestive heart failure, admission for unstable angina, cardiovascular deaths in general, those are going to be very important questions to be answered in a further step. Before we get there, there are a few other questions that we have for the drug itself from this particular 2B study that we can still look at. Dr Amit Khera: Excellent. Looking forward to those subsequent analyses. Dr Carolyn Lam: Thank you and we look forward to the next publication on Circulation. Dr Amit Khera: Absolutely. Dr Carolyn Lam: I'm sure the audience is actually looking forward to more such discussions as these. Remember, you've been listening to Circulation on the Run. Dr Greg Hundley: This program is Copyright The American Heart Association 2020.

Episode 83: The Medically Ill Patients in AUGUSTUS

patients medically michael gibson renato lopes

Play Episode Listen Later Dec 4, 2019 3:07

C. Michael Gibson discusses the AUGUSTUS trial with Renato Lopes.

Circulation December, 03, 2019 Issue

qual novo conversa o melhor renato lopes

Play Episode Listen Later Dec 2, 2019 26:34

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Dr Greg Hundley, associate editor from the Pauley Heart Center in Richmond, Virginia, from VCU Health. Dr Carolyn Lam: You know what, Greg, I may have a hoarse voice today and I'm a little bit scratchy, but my goodness, I couldn't be more excited about this issue. It's the TCT issue. Dr Greg Hundley: Well Carolyn, I cannot wait to discuss with our listeners the feature article that compares Apixaban and a P2Y12 inhibitor without Aspirin, versus regimens with Aspirin in patients with AFib who have ACS, whether managed medically or with PCI, or also those undergoing elective PCI that experience regimens that include vitamin K antagonists, aspirin, or both, but more to come later. Carolyn, should I start with my first discussion article and we grab a cup of coffee? Dr Carolyn Lam: You bet, Greg. Dr Greg Hundley: So my first article is from Seung-Jung Park from the Asan Medical Center at the University of Ulsan College of Medicine. So Carolyn, here's our first quiz question. In terms of Ticagrelor, have studies been performed in those from Asia evaluating bleeding risk? Dr Carolyn Lam: You know, I have to admit, Greg, I'm not totally familiar with the literature, but I do know that it's a very important question for us practicing in Asia. We have a perception that the bleeding risk, especially intracranial bleeding, may be higher in Asians. Dr Greg Hundley: Absolutely. Well, in this multicenter trial, 800 Korean patients hospitalized for acute coronary syndromes with or without ST elevation, and intended for invasive management, were randomly assigned to receive in a one to one ratio, Ticagrelor with a 180 milligram loading dose, and then 90 milligrams twice daily, or Clopidogrel with a 600 milligram loading dose and 75 milligrams daily thereafter, and the primary safety outcome was clinically significant bleeding, which was a composite of major bleeding or minor bleeding according to the PLATO outcomes criteria at 12 months. Dr Carolyn Lam: Oh, so what did they find? Dr Greg Hundley: Well Carolyn, at 12 months, the incidence of clinically significant bleeding was higher in the Ticagrelor group than in the Clopidogrel group. So it was 11.7% versus 5.3, and that included major bleeding and fatal bleeding. They were also higher in the Ticagrelor group. The incidents of death from cardiovascular causes, myocardial infarction or stroke, was not significantly different between the Ticagrelor group and the Clopidogrel group, although there was a strong trend toward a higher incidence in the Ticagrelor group with a P value of 0.07. So consequently, Carolyn, these results identified safety concerns regarding bleeding complications of standard dose Ticagrelor in East Asian, Korean patients with acute coronary syndromes, and therefore large adequately powered randomized trials are needed to determine the optimal antithrombotic regimen in this patient population. Dr Carolyn Lam: Very important data for our patients, as is this next paper, which really examines the cost effectiveness of transcatheter mitral valve repair versus medical therapy in patients with heart failure and secondary mitral regurgitation. Now, these are results from the COAPT trial. As a reminder, the COAPT trial demonstrated that edge-to-edge transcatheter mitral valve repair using the MitraClip resulted in reduced mortality and heart failure hospitalizations and improved quality of life when compared with maximally tolerated guideline directed medical therapy in patients with heart failure and three to four plus secondary mitral regurgitation. In the current paper, first author Dr Baron from Lahey Hospital and Medical Center in Burlington, Massachusetts and St. Luke’s Mid America Heart Institute in Kansas City, as well as corresponding author Dr Cohen from University of Missouri, Kansas City, and their colleagues used data from the COAPT trial to perform a formal patient level economic analysis of the COAPT from the perspective of the US healthcare system, and they found that although the follow up costs were lower with the MitraClip compared with guideline directed medical therapy, and lower by more than $11,000 per patient. However, the cumulative two year costs remain higher by about $35,000 per patient with the transcatheter mitral valve repair, and this is all due to the upfront costs of the index procedure. Now when in trial survival, health, utilities, and costs were modeled over a lifetime horizon, transcatheter mitral valve repair was projected to increase life expectancy by 1.13 years, and quality adjusted life years, or QALYs, by 0.82 years at a cost of $45,648, yielding a lifetime incremental cost effectiveness ratio, or ICER, of $40,361 per life year gained, and $55,600 per QALY gained. Dr Greg Hundley: Very interesting. So how do we interpret these results for clinical practice? Dr Carolyn Lam: Ah, good question. So in order to place this in context, perhaps the most comparable case is the use of transcatheter aortic valve replacement, or TAVR. So based on the partner 1B trial, the ICER for TAVR, compared to medical therapy, was $61,889 per QALY gains. So this is very similar to what you just heard as the ICER for the transcatheter mitral valve repair. The cost effectiveness is also comparable for other commonly used treatments such as the implantable cardiac defibrillators for biventricular pacing, and was interestingly substantially more than the cost effectiveness of continuous flow LVADs, for example, and this is really discussed in a beautiful editorial by Dr Bonow, Mark, and O'Gara, and in this editorial, I think it's really important that they say the cost effectiveness projections really need to be placed in the context of continuing uncertainties regarding the interpretation of COAPT compared to that of the MITRA-FR trial, which reported no benefit of transcatheter mitral valve replacement compared to medical therapy, and so they warn that the current cost effectiveness analysis is not a carte blanche for interventional cardiologists to dramatically escalate their use of MitraClip procedure, and the data do support the thoughtful and deliberate use of this potentially life lengthening procedure in carefully selected patients and under very careful circumstances. You've got to read their editorial. Dr Greg Hundley: That sounds excellent, Carolyn. I really like that, putting that editorial that puts that data in perspective. Well, my next study really emanates from the ABSORB III trial, and it's from Dr Dean Kereiakes at the Christ Hospital Heart and Vascular Center. The manuscript addresses the long-term cardiovascular event rates among bioresorbable vascular scaffolds and drug eluting metallic stents. Dr Carolyn Lam: Greg, remind me, what were the results of the original ABSORB trial? Dr Greg Hundley: Right, Carolyn. So the ABSORB III trial demonstrated non-inferior rates of target lesion failure, cardiac death, target vessel myocardial infarction, or ischemia driven target lesion revascularization at one year with the bioresorbable vascular scaffolds compared with cobalt chromium everolimus-eluting stents, but between one year and three years, and therefore the cumulative to 3 year time point, the adverse event rates, particularly for target vessel myocardial infarction and scaffold thrombosis, were increased with this bioresorbable vascular scaffold. Dr Carolyn Lam: Ah, I see. Okay, so this current study evaluated the outcomes from three to five years beyond the implantation? Dr Greg Hundley: Exactly. So what this study did is they looked at an interval of time between three and five years out, and they found reductions in the relative hazards for the bioresorbable vascular scaffolds compared to the common coated stents, and that particularly occurred for target lesion failure, either cardiac death or target vessel MI or ischemia driven target revascularization when compared to the earlier zero to three year time period. So therefore Carolyn, the authors conclude that improved scaffold design and development techniques to mitigate that zero to three year bio resorbable vascular scaffold risk may enhance the late benefits that one sees in this three to five year time point, because of the complete bioresorption. Dr Carolyn Lam: So that's interesting Greg. Well, my next paper is kind of related. It is the first report of a randomized comparison between magnesium based bioresorbable scaffold and sirolimus-eluting stent in this clinical setting of STEMI with one year clinical and angiographic follow-up. So this study is from the Spanish group, Dr Sabaté and colleagues from the Interventional Cardiology Department and Cardiovascular Institute in Barcelona in Spain, and they found that at one year when compared to the sirolimus-eluting stent, the magnesium based bioresorbable scaffold demonstrated a higher capacity of vasal motor response to pharmacological agents, either endothelium, independent or dependent, at one year. However, the magnesium based bioresorbable scaffolds were also associated with a lower angiographic efficacy, a higher rate of target lesion revascularization, but without thrombotic safety concerns. Dr Greg Hundley: Wow, Carolyn, very interesting, and Dr Lorenz Räber and Yasushi Ueki wrote a very nice editorial on this whole topic of bioresorbable scaffolds, and they wonder about some of the unfulfilled prophecies. Great for our readers to put these two articles together. Now, how about in that mailbox, Carolyn? What have you got in there? Dr Carolyn Lam: First there's a research letter by Dr Kimura entitled Very Short Dual Antiplatelet Therapy After Drug-eluting Stent Implantation in Patients with High Bleeding Risk, and that's insights from the STOPDAPT-2 trial. There's another research letter by Dr Lopes entitled The Hospitalization Among Patients with Atrial Fibrillation and a Recent Acute Coronary Syndrome, or PCI, Treated with Apixaban or Aspirin, and that's insights from the AUGUSTUS trial. A very interesting perspective piece by Dr Rob Califf entitled The Balanced Dysfunction in the Health Care Ecosystem Harms Patients, a really, really interesting read, especially those working in the U.S. healthcare system. An ECG challenge deals with fast and slow, long and shorter. I would love to give you a clue to what it is. It's got to do with the atrial ventricular nodes, but I'll let you take a look and test yourself. There’re highlights from the TCT by Drs Giustino, Leon, and Greg Stone, and finally there's Highlights from the Circulation Family of Journals by Sara O'Brien. Dr Greg Hundley: Very nice, Carolyn. Well, I've got just a couple reviews. Richard Whitlock in a primer provides a nice historical review of anticoagulation for mechanical valves. How do we get here in anticoagulating this particular patient population? Next, Dr Mark Brzezinski from Brigham Women's Hospital in the Harvard Medical School in an on my mind piece provides very elegant figures, beautiful figures, demonstrating inadequate angiogenesis within the fibrous cap of atherosclerotic plaques, and indicates this could be a source or thought of as a contributing factor toward plaque rupture. What an issue, and I can't wait to get onto that featured discussion. Dr Carolyn Lam: For our featured discussion today, it is a super-hot topic, and a question that comes up again and again in clinical practice. What is the right antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome, not just those treated with PCI, but also in those treated medically? Well guess what? We're going to have answers right here. I'm so pleased to have with us Dr Renato Lopes, who's a corresponding author from Duke Clinical Research Institute and our associate editor, Dr Stefan James from Uppsala University in Sweden. Wow. Very, very important question here. Renato, could you just start by outlining what is the AUGUSTUS trial? Dr Renato Lopes: The AUGUSTUS trial was basically one of the four trials trying to give an answer, or help answering about the antithrombotic therapy in patients with anti fibrillation and/or NACS and/or PCI. So in other words, this combination of patients undergoing PCI who require antiplatelet therapy and also patients with AFib who requires anticoagulation therapy, and in summary, what the AUGUSTUS trial did was randomize patients to Apixaban versus VKA, or aspirin placebo in a double blind fashion, and this was a two by two factorial design. So these were basically the two questions that we wanted to answer. Is Apixaban better than VKA, and is it safe to drop aspirin from this treatment strategy? Remembering that everybody received a P2Y12 inhibitor for at least eight months. So this was basically the design of the AUGUSTUS trial, trying to answer two questions in the same study, a two by two factorial design. Dr Greg Hundley: Very, very nice. And Renato, if I could, I mean I said it in the intro, but may I make sure I got it right. This is the only trial in the field that included patients with ACS that was managed medically. So that's a very important group of patients that we still don't know what the best regimen is, is that right? Dr Renato Lopes: That is correct. The other trials, the PIONEER, the RE-DUAL PCI and the VPCI, they only included patients undergoing PCI, and when we designed the trial, we thought that it would be important to also include the whole spectrum of ACS, including not only the PCI treated patients, but also the medically managed patients. Dr Greg Hundley: Well, super. So could you tell us now what were the results? Dr Renato Lopes: So first, in terms of the breakdown, we found that the breakdown of the PCI, ACS versus elective PCI, was really nice. We had about 60% of the trial being ACS patients, and about 39%-40% elective PCI, and then within the PCI, I think that our results pretty much reflect practice in a lot of parts of the world, which was about 39% medically managed and about 61% PCI treated patients. So to begin with, I think a very nice breakdown that gives us power to look at these three separate groups: ACS medically managed, ACS PCI treated, and also elective PCI, which allows us to understand the whole spectrum of coronary disease in patients also with AFib, and in summary, what we showed for the primary endpoint, which was clinical major or relevant non-major bleeding. Let's start with the Apixaban versus VKA comparison, and we show that Apixaban was safer than VKA in all three groups, in the ACS medically managed, in the PCI treated patients, and also in the elective PCI patients. There was no significant direction for those three subgroups, although it was borderline 0.052, just showing maybe a little bit less pronounced results in the elective PCI group, but nonetheless, I would say that in general, very consistent, and in terms of Aspirin for the primary endpoint, also no difference, no interaction among those three groups. In other words, as we increase substantially the risk of bleeding about two folds in all the three groups, ACS medically managed, PCI treated patients, and elective PCI patients, with about again, two fold increase in bleeding compared to placebo. If we go to ischemic events, again, that's our hospitalization and other that are ischemic events. In terms of Apixaban versus VKA, the results were very consistent with the overall trial among these three groups, and in terms of as ACS versus placebo, the results also for the ischemic events were also similar among the three groups. So again, reassuring that the main results of the trial were very consistent, regardless how patients were managed in terms of the ACS, medically or through PCI, and also included in the elect PCI group. Dr Carolyn Lam: Thank you for explaining that so well. Stephan, I would love for you to take us under the hood. What were the editors thinking when we saw this paper, why we're highlighting it now, and what do you think are the implications? Dr Stefan James: The AUGUSTUS trial was unique in many aspects. I think Renato highlighted a few of them. As he told, there have been several similar trials without the other DOAX, factor 10A inhibitors and the dabigatran, but the AUGUSTUS trial was larger. It includes, as you mentioned previously, patients with ACS and medical management, and it also was designed as a two by two factorial design. So it actually asks two different questions and made two different randomizations, both anticoagulation with the two different agents, Warfarin versus Apixaban, but also Aspirin versus placebo, and so it's possible from this trial to understand more of the different aspects of treating patients, these complex patients with atrial fibrillation, NACS or PCI, and gave the study group and us an opportunity to better understand all these complexities. So with that, I'd like to turn to Renato and try to, with that background that I just outlaid, and you just try to make us understand what are the clinical implications of these aspects of the trial and the treatment of Apixaban and Aspirin in these patients? Dr Renato Lopes: I think we were in the area that we desperately needed randomized data, because basically until five years ago, the standard of care of treating these patients was the classic triple therapy with Aspirin, Clopidogrel, and Warfarin, and this was based on no randomized trials and all observational data, and we know how problematic this is, and this field has evolved tremendously almost year after year since the PIONEER trial, since the RE-DUAL trial, and this year, we had AUGUSTUS and ENTRUST and I think now, as Mike Gibson used to say, that we have about 2.8 million different combination of antithrombotic strategies to treat these patients because we have different anticoagulants, different anti-platelets, different doses, different durations, different types of stents, which makes it really impossible for physicians or for any guidelines to contemplate all these options. So we really needed a few trials to at least try to give a few options that are evidence based and not just based on low quality of data, and I think now, if you look at the Augustus results, and the totality of the data from all these trials, which now is about almost 11,000 patients all together, actually almost 12,000 patients all together. I think that what we know today is that yes, the initial period in hospital for some time it's important to use Aspirin. I think this is an important point to highlight, Stephan, that Aspirin still needs to be used for the acute treatment, and I would say at least for the first few initial days while patients are still in the hospital, but then by the time of discharge, which sometimes might be five days, six days, seven days, I think that now the totality of data show that it's reasonable to drop Aspirin for most patients. So based on the AUGUSTUS results, what we show is that if you're going to use anticoagulation as Apixaban at the dose that is approved for stroke preventions in atrial fibrillation, combined with a P2Y12 inhibitor without Aspirin after the initial period, you have the best outcomes in terms of lower rates of bleeding, lower rates of hospitalizations, and we don't have to pay a cost in terms of ischemic events when we actually drop Aspirin and keep only the NOAC, in this case was Apixaban, plus a P2Y12 inhibitor, which most of the time was Clopidogrel, and here with AUGUSTUS, we basically show that this is true for patients with AFib and ACS, irrespective of the management with medical managing, with medical therapy, or with PCI. So I think that's an additional piece that that is true irrespective of how we're going to treat your ACS patient, or if the patient basically underwent elective PCI, and I think we learned today that the classic treatment therapy of VKA plus Aspirin plus P2Y12 inhibitor, so in other words, the triple classic triple therapy should generally be avoided. Dr Stefan James: Thank you Renato. I think that that was a very complete answer in this complex arena. I'd like just to mention that of course the AUGUSTUS, as well as the other trials, have their limitations, as all trials. Although it was large, it was powered for safety, for bleeding events, and it was not powered for ischemic events. Having said that, we still want to look at ischemic events and clinical outcomes, and to what degree do you think we can do that? What conclusions can we draw from an ischemic point of view because of the fact that the trial was underpowered for that interpretation? Dr Renato Lopes: That is a great question, Stephan, and in fact, if we look at events like stent thrombosis, they are very rare, and if you really want to attack a significant difference between Aspirin versus placebo in patients having stent thrombosis, we're really going to need a trial with about 30-40,000 people, which would be not feasible and not doable. So we need to be cautious when we analyze those events in the power trial for ischemic events. Nonetheless, there was a signal, if you look at all trials, and even in the meta-analysis that we published recently, that dropping Aspirin probably increased the risk of ischemic events, not in a statistically significant fashion, but nonetheless, this trend exists. The signal exists. So probably keeping Aspirin, add some protection for ischemic events, primarily stent thrombosis and myocardial infarction. The problem is a tradeoff. The problem is that the cost of adding aspirin is too high. So now the question to us, Stephan, is to look further into our data and in the combined data sets that we're trying to work with the other authors and try to identify, okay, Aspirin really increased the risk of bleeding, but is there a group of patients who might benefit from a little bit longer Aspirin? So that's the first question. Who are those patients? May be complex PCI, maybe bifurcation lesions, maybe multiple lesions, multiple stents, and second, if we decide to give Aspirin longer, how much longer should we give? Because again, the cost is very high in terms of bad bleeds. So we are trying now to identify what is the trade off, and who most benefit from keeping Aspirin longer, and for how long in a way the cost might be worth it to pay in exchange of potentially save some ischemic events? And with that, we can further refine the treatment that I think I highlighted before. For most patients, I think what I said before is probably reasonable. We can drop Aspirin by the time of discharge after a few days, but for a few patients, for some patients, it might be wise to keep Aspirin a little bit longer, and we are trying now to identify first, who those patients are and second, form how much longer should we keep Aspirin, since the 40,000 patient trial is very unlikely to happen. Dr Stefan James: I like his interpretation, Renato, although I wanted to highlight that there are limitations, I think this trial is extremely informant for clinicians. We learned a lot how to treat these very complex patients with complex treatments. Dr Carolyn Lam: No, I couldn't have agreed more. I mean quoting Mike Gibson, 2.8 million combinations. Well, at least we've talked about some of them here and had a very clear take home message, although with the caveats that we were discussing. Thank you so much, Stefan and Renato. This was really a great discussion, and thank you audience for joining us today. You've been listening to Circulation on the Run. Don't forget to tune in again next week. This program is copyright American Heart Association 2019.

#51 - qual o melhor novo anticoagulante?

Cardiopapers

Play Episode Listen Later Oct 7, 2019 16:52

Conversa com o Dr Renato Lopes sobre este importante tema

Meeple Vortex #4 - Brass: Birmingham, Ensinar vs Vencer Jogos e muitas jogatinas!

Play Episode Listen Later Sep 17, 2019 86:34

Está no ar o 4º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para este episódio, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Between Two Castles of Mad King Ludwig e Ragusa;Zabu: Whistle Stop e Terraforming Mars Digital;Butilheiro: Teotihuacan: City of Gods com expansão, City of the Big Shoulders e Pipeline. No segundo bloco fizemos a análise de um dos jogos mais bem recebidos do ano passado: Brass: Birmingham Em Brass: Birmingham - um jogo econômico de estratégia e sequência para a obra prima de Martin Wallace, de 2007 - os jogadores são empreendedores concorrentes em Birmingham que deve desenvolver, construir e estabelecer suas indústrias e redes ferroviárias, explorando as demandas de mercado e suas oscilações durante a revolução industrial, entre os anos de 1770-1870. Vence o jogador que conquistar mais pontos de vitória no final da segunda era. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão de Ensinar jogos vs Vencer Jogos. Quais pontos são revelantes nessa discussão? O que te motiva a ensinar jogos: vencer ou ter certeza que todos tenham uma boa experiência? Isso e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Em breve.

Meeple Vortex #4 - Brass: Birmingham, Ensinar vs Vencer Jogos e muitas jogatinas!

Play Episode Listen Later Sep 17, 2019 86:34

Está no ar o 4º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para este episódio, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Between Two Castles of Mad King Ludwig e Ragusa;Zabu: Whistle Stop e Terraforming Mars Digital;Butilheiro: Teotihuacan: City of Gods com expansão, City of the Big Shoulders e Pipeline. No segundo bloco fizemos a análise de um dos jogos mais bem recebidos do ano passado: Brass: Birmingham Em Brass: Birmingham - um jogo econômico de estratégia e sequência para a obra prima de Martin Wallace, de 2007 - os jogadores são empreendedores concorrentes em Birmingham que deve desenvolver, construir e estabelecer suas indústrias e redes ferroviárias, explorando as demandas de mercado e suas oscilações durante a revolução industrial, entre os anos de 1770-1870. Vence o jogador que conquistar mais pontos de vitória no final da segunda era. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão de Ensinar jogos vs Vencer Jogos. Quais pontos são revelantes nessa discussão? O que te motiva a ensinar jogos: vencer ou ter certeza que todos tenham uma boa experiência? Isso e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Em breve.

Episode 8: Apple Heart Study, Wearables, and What Lies Ahead

Rox Heart Radio

Play Episode Listen Later Aug 14, 2019 18:07

Roxana Mehran talks with David Albert, Bray Patrick-Lake, Renato Lopes, and Deepak Bhatt about wearable devices and what’s ahead.

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Meeple Vortex #3 - Teotihuacan: City of Gods, Jogos Clássicos e muitas jogatinas!

Play Episode Listen Later Aug 8, 2019 119:01

Está no ar o 3º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para este episódio, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Star Wars: Outer Rim, Explorers of the North Sea, Invasores do Mar do Norte, Shipwrights of the North Sea e Inis;Zabu: The Golden Ages e Star Wars: Rebellion;Butilheiro: Cartógrafos: Um Conto de Roll Player, Raccoon Tycoon e Jonathan Strange & Mr Norrell: A Board Game of English Magic. No segundo bloco fizemos a análise de um dos recentes lançamentos da escola Italiana de Design: Teotihuacan: City of Gods Em Teotihuacan, volte no tempo milhares de anos para a maior cidade dos astecas. Testemunhe a glória e o crepúsculo da poderosa civilização pré-colombiana, acumule riquezas, ganhe favores dos deuses e se torne o construtor da magnífica Pirâmide do Sol. Desenvolvido por Daniele Tascini, com ilustrações de Odysseas Stamoglou, Teotihuacan é um jogo competitivo, onde cada jogador controla um conjunto de dados de trabalhadores, que são movimentados em torno de um tabuleiro modular para realizar diversas ações e garantir mais pontos de vitória que seus adversários. O jogo é destinado para 1-4 jogadores e com duração de 150-180 minutos, que foi produzido pela NSKN Games em 2018 e distribuído no Brasil pela Bucaneiros Jogos em 2019. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão de como definir, ou tentar definir, o que faz de um boardgame ser considerado um clássico. Quais pontos são revelantes nessa discussão? Seriam os jogos abstratos são mais fáceis de considerar como clássicos? Isso e muito mais nessa discussão! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Scythe, Sid Meier's Civilization: Um Novo Amanhecer, Merchants & Marauders, Star Wars: Imperial Assault, Star Wars: Destiny, Star Wars: Legion, Star Wars: The Queen's Gambit, Fallout, Firefly: The Game, Rolling Ranch, Roll Player, Railroad Ink: Blazing Red Edition, Welcome to..., On Tour, Twilight Imperium (Fourth Edition), Star Wars: Império Vs. Rebelião, Munchkin, Power Grid, Age of Empires III: The Age of Discovery, Clãs da Caledônia, Root, Lords of Hellas, Kemet, Cyclades, London, Cryptid, Tzolk'in: O Calendário Maia, As Viagens de Marco Polo, Anachrony, Trickerion: Legends of Illusion, Dice Settlers, In The Name of Odin, Puerto Rico, El Grande, Gloomhaven, Azul, Zombicide, For Sale, The Resistance, Agricola, Kingsburg, Dune, Sagrada;

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Meeple Vortex #3 - Teotihuacan: City of Gods, Jogos Clássicos e muitas jogatinas!

Play Episode Listen Later Aug 8, 2019 119:01

Está no ar o 3º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para este episódio, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Star Wars: Outer Rim, Explorers of the North Sea, Invasores do Mar do Norte, Shipwrights of the North Sea e Inis;Zabu: The Golden Ages e Star Wars: Rebellion;Butilheiro: Cartógrafos: Um Conto de Roll Player, Raccoon Tycoon e Jonathan Strange & Mr Norrell: A Board Game of English Magic. No segundo bloco fizemos a análise de um dos recentes lançamentos da escola Italiana de Design: Teotihuacan: City of Gods Em Teotihuacan, volte no tempo milhares de anos para a maior cidade dos astecas. Testemunhe a glória e o crepúsculo da poderosa civilização pré-colombiana, acumule riquezas, ganhe favores dos deuses e se torne o construtor da magnífica Pirâmide do Sol. Desenvolvido por Daniele Tascini, com ilustrações de Odysseas Stamoglou, Teotihuacan é um jogo competitivo, onde cada jogador controla um conjunto de dados de trabalhadores, que são movimentados em torno de um tabuleiro modular para realizar diversas ações e garantir mais pontos de vitória que seus adversários. O jogo é destinado para 1-4 jogadores e com duração de 150-180 minutos, que foi produzido pela NSKN Games em 2018 e distribuído no Brasil pela Bucaneiros Jogos em 2019. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão de como definir, ou tentar definir, o que faz de um boardgame ser considerado um clássico. Quais pontos são revelantes nessa discussão? Seriam os jogos abstratos são mais fáceis de considerar como clássicos? Isso e muito mais nessa discussão! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Scythe, Sid Meier's Civilization: Um Novo Amanhecer, Merchants & Marauders, Star Wars: Imperial Assault, Star Wars: Destiny, Star Wars: Legion, Star Wars: The Queen's Gambit, Fallout, Firefly: The Game, Rolling Ranch, Roll Player, Railroad Ink: Blazing Red Edition, Welcome to..., On Tour, Twilight Imperium (Fourth Edition), Star Wars: Império Vs. Rebelião, Munchkin, Power Grid, Age of Empires III: The Age of Discovery, Clãs da Caledônia, Root, Lords of Hellas, Kemet, Cyclades, London, Cryptid, Tzolk'in: O Calendário Maia, As Viagens de Marco Polo, Anachrony, Trickerion: Legends of Illusion, Dice Settlers, In The Name of Odin, Puerto Rico, El Grande, Gloomhaven, Azul, Zombicide, For Sale, The Resistance, Agricola, Kingsburg, Dune, Sagrada;

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Meeple Vortex #2 - Root, Boardgames na mídia e mais Jogatinas!

Play Episode Listen Later Jul 8, 2019 86:01

Está no ar o 2º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para esta edição, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Merlin e Notre Dame;Zabu: Gloomhaven e Ganges.Butilheiro: -- No segundo bloco fizemos a análise de um dos recentes lançamentos: Root Em Root, a nefasta Marquise de Cat se apropriou da grande floresta, com a intenção de colher suas riquezas. Sob o seu governo, as muitas criaturas da floresta se uniram. Esta Aliança procurará fortalecer seus recursos e subverter a regra dos Gatos. Neste esforço, a Aliança pode alistar a ajuda dos vagabundos errantes. Embora alguns possam simpatizar com as esperanças e os sonhos da Aliança, esses vagabundos têm idade suficiente para se lembrar dos grandes pássaros de rapina. Desenvolvido por Cole Wehrle, com Ilustrações de Kyle Ferrin. Root é um jogo de tabuleiro competitivo, assimétrico, inspirado em jogos de Contra-Insurgência, destinado para 2-4 jogadores e com duração de 90 minutos, que foi produzido pela Leder Games em 2018 e distribuído no Brasil pela Meeple BR Jogos em 2019. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão dos boardgames na mídia, como são enxergados os jogos pela pessoas fora do hobby, a ausência de cobertura em portais de cultura pop, presença em séries/filmes e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Vast: As Cavernas de Cristal, Descent: Journeys in the Dark (second edition), Sword & Sorcery: Espíritos Imortais, O Senhor dos Anéis: Jornadas na Terra Média

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Meeple Vortex #2 - Root, Boardgames na mídia e mais Jogatinas!

Play Episode Listen Later Jul 8, 2019 86:01

Está no ar o 2º episódio do MEEPLE VORTEX, podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 (às vezes antes) de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para esta edição, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Merlin e Notre Dame;Zabu: Gloomhaven e Ganges.Butilheiro: -- No segundo bloco fizemos a análise de um dos recentes lançamentos: Root Em Root, a nefasta Marquise de Cat se apropriou da grande floresta, com a intenção de colher suas riquezas. Sob o seu governo, as muitas criaturas da floresta se uniram. Esta Aliança procurará fortalecer seus recursos e subverter a regra dos Gatos. Neste esforço, a Aliança pode alistar a ajuda dos vagabundos errantes. Embora alguns possam simpatizar com as esperanças e os sonhos da Aliança, esses vagabundos têm idade suficiente para se lembrar dos grandes pássaros de rapina. Desenvolvido por Cole Wehrle, com Ilustrações de Kyle Ferrin. Root é um jogo de tabuleiro competitivo, assimétrico, inspirado em jogos de Contra-Insurgência, destinado para 2-4 jogadores e com duração de 90 minutos, que foi produzido pela Leder Games em 2018 e distribuído no Brasil pela Meeple BR Jogos em 2019. E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão dos boardgames na mídia, como são enxergados os jogos pela pessoas fora do hobby, a ausência de cobertura em portais de cultura pop, presença em séries/filmes e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Vast: As Cavernas de Cristal, Descent: Journeys in the Dark (second edition), Sword & Sorcery: Espíritos Imortais, O Senhor dos Anéis: Jornadas na Terra Média

dark brasil cat notre dame root neste sword telegram conhe board games vortex produ extras sob embora o senhor alian gatos deathmatches jornadas ganges marquise ilustra meeple desenvolvido terra m leder games cole wehrle jbg ludopedia descent journeys renato lopes jogatinas meeple br jogos jogatina bg

Ficha do Jogador #22 - Renato Lopes (Tábula Quadrada)

Play Episode Listen Later Jun 28, 2019 41:30

Seja bem vindos ao 22º episódio do podcast FICHA DO JOGADOR - e nessa edição, eu {zabuzeta} recebi a presença ilustre de Renato Lopes (rejolope) diretamente do Tábula Quadrada, para bater um papo sobre Produção de Conteúdo, Jogos do Feld, Choro na mesa, Jogatinas e muito mais!! Confiram! Conheça mais sobre o Tábula Quadrada e os trabalhos do Renato e equipe: Site: http://www.tabulaquadrada.com.br Facebook: https://www.facebook.com/tabulaquadrada/ Ludopedia: https://ludopedia.com.br/canal/tabula... Instagram: https://www.instagram.com/tabulaquadrada Twitter: https://twitter.com/tabulaboard COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ JOGOS/LINKS COMENTADOS - Dungeons & Dragons 5e: Essentials Kit - Odd Wolrd - Dungeon World Roleplaying Game - Vampiro: A Máscara - Mago: A Ascensão - Ludo - Damas - Xadrez - Banco Imobiliário - Jogo da Vida - Cara a Cara - Combate - A Guerra dos Tronos: Board Game - Munchkin - Zombicide - Zombicide: Green Horde - Kemet - Cyclades - Catan - O Jogo - Scythe - Trajan - Clãs da Caledônia - Lorenzo il Magnifico - Orléans - Great Western Trail - Root - Vast: As Cavernas de Cristal - Brass: Birmingham - SeaFall Legacy - Glass Road - Myrmes - Vanuatu - Citadels - Masmorra de Dados REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

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Ficha do Jogador #22 - Renato Lopes (Tábula Quadrada)

Play Episode Listen Later Jun 28, 2019 41:30

Seja bem vindos ao 22º episódio do podcast FICHA DO JOGADOR - e nessa edição, eu {zabuzeta} recebi a presença ilustre de Renato Lopes (rejolope) diretamente do Tábula Quadrada, para bater um papo sobre Produção de Conteúdo, Jogos do Feld, Choro na mesa, Jogatinas e muito mais!! Confiram! Conheça mais sobre o Tábula Quadrada e os trabalhos do Renato e equipe: Site: http://www.tabulaquadrada.com.br Facebook: https://www.facebook.com/tabulaquadrada/ Ludopedia: https://ludopedia.com.br/canal/tabula... Instagram: https://www.instagram.com/tabulaquadrada Twitter: https://twitter.com/tabulaboard COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ JOGOS/LINKS COMENTADOS - Dungeons & Dragons 5e: Essentials Kit - Odd Wolrd - Dungeon World Roleplaying Game - Vampiro: A Máscara - Mago: A Ascensão - Ludo - Damas - Xadrez - Banco Imobiliário - Jogo da Vida - Cara a Cara - Combate - A Guerra dos Tronos: Board Game - Munchkin - Zombicide - Zombicide: Green Horde - Kemet - Cyclades - Catan - O Jogo - Scythe - Trajan - Clãs da Caledônia - Lorenzo il Magnifico - Orléans - Great Western Trail - Root - Vast: As Cavernas de Cristal - Brass: Birmingham - SeaFall Legacy - Glass Road - Myrmes - Vanuatu - Citadels - Masmorra de Dados REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

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JBG NEWS #60 - Origins Awards, Kinderspiel, Kronos, Redbox, melhores campanhas no KS e mais!

Play Episode Listen Later Jun 27, 2019 36:08

E começa mais um turno do seu podcast quinzenal de notícias, o JBG NEWS, nesta 60ª edição o Renato Lopes (rejolope) do Tábula Quadrada e Zabuzeta (eu) aqui do JBG comentam as principais notícias e destaques no período 13 à 26 de Junho de 2019, confiram! Confiram como foi a gravação: Extra: - Conheça o Tábula Quadrada - Escute o Meeple Vortex COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ NOTÍCIAS E DESTAQUES BRASIL - Live da Grok sobre o status da parceira com Kronos e mais. - Skytear - Comunicado da RedBox MUNDO - Clank! Expeditions: Temple of the Ape Lords - Toy Story: Obstacles and Adventures - Dead of Night - Mais de 1 milhão de decks de Keyforge - Catan: Starfarers - Kinderspiel des Jahres 2019 - Spiel der Spiele 2019 - Origins Awards 2019 DESTAQUES DO KICKSTARTER - Endeavor: Age of Expansion - ThunderQuest: New Horizon - Eternal Adversary EVENTOS - 4º Desplugadamente em Fortaleza-CE no dia 29/06 - Lady Lúdica no Rio de Janeiro-Rj no dia 06/07 - 17º Board Brothers em Sapucaia do Sul-RS no dia 06/07 __________________________ REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

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JBG NEWS #60 - Origins Awards, Kinderspiel, Kronos, Redbox, melhores campanhas no KS e mais!

Play Episode Listen Later Jun 27, 2019 36:08

E começa mais um turno do seu podcast quinzenal de notícias, o JBG NEWS, nesta 60ª edição o Renato Lopes (rejolope) do Tábula Quadrada e Zabuzeta (eu) aqui do JBG comentam as principais notícias e destaques no período 13 à 26 de Junho de 2019, confiram! Confiram como foi a gravação: Extra: - Conheça o Tábula Quadrada - Escute o Meeple Vortex COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ NOTÍCIAS E DESTAQUES BRASIL - Live da Grok sobre o status da parceira com Kronos e mais. - Skytear - Comunicado da RedBox MUNDO - Clank! Expeditions: Temple of the Ape Lords - Toy Story: Obstacles and Adventures - Dead of Night - Mais de 1 milhão de decks de Keyforge - Catan: Starfarers - Kinderspiel des Jahres 2019 - Spiel der Spiele 2019 - Origins Awards 2019 DESTAQUES DO KICKSTARTER - Endeavor: Age of Expansion - ThunderQuest: New Horizon - Eternal Adversary EVENTOS - 4º Desplugadamente em Fortaleza-CE no dia 29/06 - Lady Lúdica no Rio de Janeiro-Rj no dia 06/07 - 17º Board Brothers em Sapucaia do Sul-RS no dia 06/07 __________________________ REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

rio spiel spiele melhores junho redbox grok kronos campanhas kinderspiel confiram fortaleza ce janeiro rj sul rs origins awards lady l jbg renato lopes sapucaia zabuzeta not iacute

WaxWarrior Show LIVE - w/guest Renato Lopes - June 13th, '19

WaxWarriors

Play Episode Listen Later Jun 17, 2019 172:35

As aired June 13th, '19 Also available as videocast here: http://bit.ly/WWshowRELOvid DL link: https://we.tl/t-gv5FMlktUx Check us out in iTunes as well: http://bit.ly/WWshowITUNES

show live renato lopes

WaxWarrior Show LIVE - w/guest Renato Lopes - June 13th, '19

WaxWarriors

Play Episode Listen Later Jun 17, 2019 172:35

As aired June 13th, '19 Also available as videocast here: http://bit.ly/WWshowRELOvid DL link: https://we.tl/t-gv5FMlktUx Check us out in iTunes as well: http://bit.ly/WWshowITUNES

show live renato lopes

JBG NEWS #59 - Série de Magic no Netflix, Fim do Doff RJ e mais!

Play Episode Listen Later Jun 13, 2019 28:27

E estamos de volta com mais um turno do seu podcast quinzenal de notícias, o JBG NEWS, nesta 59ª edição o Renato Lopes (rejolope) do Tábula Quadrada e Zabuzeta (eu) aqui do JBG comentam as principais notícias e destaques no período de 29 de Maio à 12 de Junho de 2019, confiram! Confiram como foi a gravação: Extra: - Conheça o Tábula Quadrada - Escute o Meeple Vortex COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ NOTÍCIAS E DESTAQUES BRASIL - O fim do DOFFRJ - HQ brasileira virando boardgame - Zurvivors MUNDO - Série de Magic no Netflix - Marquesas - Cities Skylines board game - Falecimento de James Mathe - UK Games Expo Awards 2019 - Indicados ao Spiel Portugal 2019 DESTAQUES DO KICKSTARTER - Trouble in Templetown - Company of Heroes board game - Batman Gotham City Chronicles Season 2 - Altar Quest EVENTOS - 5º Amigos do Tabuleiro em Porto Alegre /RS no dia 20/06 __________________________ REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

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JBG NEWS #59 - Série de Magic no Netflix, Fim do Doff RJ e mais!

Play Episode Listen Later Jun 13, 2019 28:27

E estamos de volta com mais um turno do seu podcast quinzenal de notícias, o JBG NEWS, nesta 59ª edição o Renato Lopes (rejolope) do Tábula Quadrada e Zabuzeta (eu) aqui do JBG comentam as principais notícias e destaques no período de 29 de Maio à 12 de Junho de 2019, confiram! Confiram como foi a gravação: Extra: - Conheça o Tábula Quadrada - Escute o Meeple Vortex COMPRE SEUS BOARDGAMES E ACESSÓRIOS NA BRAVO JOGOS: → https://www.bravojogos.com.br/ _________________________ NOTÍCIAS E DESTAQUES BRASIL - O fim do DOFFRJ - HQ brasileira virando boardgame - Zurvivors MUNDO - Série de Magic no Netflix - Marquesas - Cities Skylines board game - Falecimento de James Mathe - UK Games Expo Awards 2019 - Indicados ao Spiel Portugal 2019 DESTAQUES DO KICKSTARTER - Trouble in Templetown - Company of Heroes board game - Batman Gotham City Chronicles Season 2 - Altar Quest EVENTOS - 5º Amigos do Tabuleiro em Porto Alegre /RS no dia 20/06 __________________________ REDES SOCIAIS - Telegram: Grupo de ouvintes Canal do JBGNews Grupo do Mercadinho - Twitter: Siga @jogatinabg Siga @jogatinabgnews (notícias quentes agora no twitter) - Instagram: Siga @jogatinabg - Discord: Entre no nosso servidor! https://discord.gg/VF5A6JP - Youtube: Inscreva-se no nosso canal ____ Edição: Zabuzeta ™

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Os desafios de liderar um estudo internacional

Conversa de médico

Play Episode Listen Later Jun 13, 2019 13:14

Mais de 4,5 mil pacientes, em 492 centros espalhados por 33 países e apenas uma pessoa liderando este esforço de pesquisa. Neste podcast gravado durante o encontro anual do American College of Cardiology (ACC), o Dr. Renato Lopes, Ph.D., brasileiro e pesquisador do Duke Clinical Research Institute (DCRI), em Durham, na Carolina do Norte (EUA), fala ao Dr. Luís Fernando Correia sobre os desafios de liderar um estudo internacional multicêntrico.

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Meeple Vortex #1 - Wingspan, Propriedades Intelectuais em Boardgames, e outras Jogatinas!

Play Episode Listen Later Jun 10, 2019 82:07

Está no ar o primeiro episódio do MEEPLE VORTEX, novo podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para a primeira edição, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Empires of the Void II e Bora Bora;Zabu: Vast: As Cavernas de Cristal e A Guerra dos Tronos: Board Game (com expansão Dança dos Dragões);Butilheiro: Teotihuacan: City of Gods e Lignum (second edition). No segundo bloco fizemos a análise de um dos recentes lançamentos: Wingspan Em Wingspan, os jogadores são entusiastas de pássaros - pesquisadores, observadores de pássaros, ornitólogos e colecionadores - que procuram descobrir e atrair as melhores aves para o seu aviário. Desenvolvido por Elizabeth Hargrave, com Ilustrações de Natalia Rojas, Ana Maria Martinez Jaramillo e Beth Sobel. Wingspan é um jogo de tabuleiro competitivo, de peso médio, com a mecânica de engine building (construção de motores) destinado para 1-5 jogadores e com duração de 40-75 minutos, que foi produzido pela Stonemaier Games e distribuído no Brasil pela Grok Games. Artigos sobre Wingspan fora do hobby: - https://www.nature.com/articles/d41586-019-01503-0 - https://www.theguardian.com/science/2019/apr/20/board-games-turning-science-into-playtime - https://www.nytimes.com/2019/03/11/science/wingspan-board-game-elizabeth-hargrave.html - https://www.nexojornal.com.br/expresso/2019/05/27/Por-que-este-jogo-sobre-pássaros-é-um-dos-melhores-de-2019 E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão do uso de Propriedades Intelectuais oriundas de livros, filmes, séries de TV, jogos eletrônicos, etc. nos boardgames, os seus aspectos positivos e negativos, os casos de sucessos e de fracassos e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Merchants & Marauders, Root, Tzolk'in: O Calendário Maia, Newton, Coimbra The Castles of Burgundy, La Isla, Trajan, Carpe Diem, Forum Trajanum, The Castles of Burgundy: The Card Game, The Great Zimbabwe, Terraforming Mars, Gizmos, Lorenzo il Magnifico, Dungeons & Dragons, Carcassonne: Star Wars, Game of Thrones: O Trono de Ferro, Cosmic Encounter, A Game of Thrones: The Card Game (second edition), O Senhor dos Anéis: Card Game, StarCraft: The Board Game, Forbidden Stars, World of Warcraft: The Boardgame, O Hobbit: o Jogo de Tabuleiro, Magic: The Gathering, A Guerra do Anel, A Batalha dos Cinco Exércitos, O Hobbit: o Jogo de Cartas, Harry Potter: Hogwarts Battle, Thanos Rising: Avengers Infinity War, Villainous, Marvel Dice Masters: Avengers vs. X-Men, Quarriors!, Legendary: A Marvel Deck Building Game, XCOM: The Board Game, Battlestar Galactica: The Board Game, Star Wars: Rebellion, Star Wars: Imperial Assault, This War of Mine: The Board Game, Star Wars: Star Battle, Dark Souls: The Board Game, Bloodborne: The Board Game, Batman: Gotham City Chronicles, The Pillars of the Earth, A Column of Fire, World Without End, Teenage Mutant Ninja Turtles: City Fall, Bill & Ted's Excellent Boardgame, Planet of the Apes, The Godfather - Império Corleone, Narcos: The Board Game, God of War: The Card Game, Conan, Sentinelas do Multiverso, The 7th Continent; - Links: Banished (steam)

god tv game world earth war fire gods game of thrones planet brasil dragons root xmen telegram guerra drag pillars dungeons newton conhe conan god of war board games planet of the apes world of warcraft apes magic the gathering vortex produ cartas jogo outras extras continent castles ferro merchants batalha column carpe diem o senhor burgundy la isla card game deathmatches multiverso marauders wingspan villainous corleone bora bora anel ilustra terraforming mars magnifico artigos trajan gizmos tabuleiro stonemaier games meeple desenvolvido star wars rebellion propriedades cosmic encounter o hobbit elizabeth hargrave world without end great zimbabwe intelectuais harry potter hogwarts battle tzolk star wars imperial assault quarriors batman gotham city chronicles lignum forbidden stars jbg sentinelas ludopedia renato lopes forum trajanum legendary a marvel deck building game xcom the board game cinco ex jogatinas void ii beth sobel burgundy the card game battlestar galactica the board game thrones the card game starcraft the board game dark souls the board game thanos rising avengers infinity war mine the board game jogatina bg marvel dice masters avengers thrones o trono

Meeple Vortex #1 - Wingspan, Propriedades Intelectuais em Boardgames, e outras Jogatinas!

Play Episode Listen Later Jun 10, 2019 82:07

Está no ar o primeiro episódio do MEEPLE VORTEX, novo podcast sobre boardgames idealizado pelos canais Deathmatch, Tábula Quadrada e Jogatina BG! Um novo episódio de Meeple Vortex será publicado todo dia 10 de cada mês no feed do JBG, e será constituído de três blocos: jogatinas recentes, análise de um título escolhido e um tópico de discussão. E para a primeira edição, você vai conferir: No primeiro bloco nós comentamos quais foram os boardgames que estiveram em nossas jogatinas: Renato: Empires of the Void II e Bora Bora;Zabu: Vast: As Cavernas de Cristal e A Guerra dos Tronos: Board Game (com expansão Dança dos Dragões);Butilheiro: Teotihuacan: City of Gods e Lignum (second edition). No segundo bloco fizemos a análise de um dos recentes lançamentos: Wingspan Em Wingspan, os jogadores são entusiastas de pássaros - pesquisadores, observadores de pássaros, ornitólogos e colecionadores - que procuram descobrir e atrair as melhores aves para o seu aviário. Desenvolvido por Elizabeth Hargrave, com Ilustrações de Natalia Rojas, Ana Maria Martinez Jaramillo e Beth Sobel. Wingspan é um jogo de tabuleiro competitivo, de peso médio, com a mecânica de engine building (construção de motores) destinado para 1-5 jogadores e com duração de 40-75 minutos, que foi produzido pela Stonemaier Games e distribuído no Brasil pela Grok Games. Artigos sobre Wingspan fora do hobby: - https://www.nature.com/articles/d41586-019-01503-0 - https://www.theguardian.com/science/2019/apr/20/board-games-turning-science-into-playtime - https://www.nytimes.com/2019/03/11/science/wingspan-board-game-elizabeth-hargrave.html - https://www.nexojornal.com.br/expresso/2019/05/27/Por-que-este-jogo-sobre-pássaros-é-um-dos-melhores-de-2019 E no terceiro bloco, trouxemos para a nossa mesa de discussão a questão do uso de Propriedades Intelectuais oriundas de livros, filmes, séries de TV, jogos eletrônicos, etc. nos boardgames, os seus aspectos positivos e negativos, os casos de sucessos e de fracassos e muito mais! Conheça mais sobre os nossos canais: Deathmatch: Medium, Ludopedia e Instagram; Tábula Quadrada: Site, Ludopedia, Instagram, Youtube e Facebook; Jogatina BG: Site, Ludopedia, Youtube, Instagram, Facebook, Twitter e Telegram. Produção: Anderson Butilheiro, André Luis e Renato Lopes. Edição e Pós-produção: André Luis (@zabuzeta) Extras: - boardgames citados durante o podcast: Merchants & Marauders, Root, Tzolk'in: O Calendário Maia, Newton, Coimbra The Castles of Burgundy, La Isla, Trajan, Carpe Diem, Forum Trajanum, The Castles of Burgundy: The Card Game, The Great Zimbabwe, Terraforming Mars, Gizmos, Lorenzo il Magnifico, Dungeons & Dragons, Carcassonne: Star Wars, Game of Thrones: O Trono de Ferro, Cosmic Encounter, A Game of Thrones: The Card Game (second edition), O Senhor dos Anéis: Card Game, StarCraft: The Board Game, Forbidden Stars, World of Warcraft: The Boardgame, O Hobbit: o Jogo de Tabuleiro, Magic: The Gathering, A Guerra do Anel, A Batalha dos Cinco Exércitos, O Hobbit: o Jogo de Cartas, Harry Potter: Hogwarts Battle, Thanos Rising: Avengers Infinity War, Villainous, Marvel Dice Masters: Avengers vs. X-Men, Quarriors!, Legendary: A Marvel Deck Building Game, XCOM: The Board Game, Battlestar Galactica: The Board Game, Star Wars: Rebellion, Star Wars: Imperial Assault, This War of Mine: The Board Game, Star Wars: Star Battle, Dark Souls: The Board Game, Bloodborne: The Board Game, Batman: Gotham City Chronicles, The Pillars of the Earth, A Column of Fire, World Without End, Teenage Mutant Ninja Turtles: City Fall, Bill & Ted's Excellent Boardgame, Planet of the Apes, The Godfather - Império Corleone, Narcos: The Board Game, God of War: The Card Game, Conan, Sentinelas do Multiverso, The 7th Continent; - Links: Banished (steam)

god tv game world earth war fire gods game of thrones planet brasil dragons root xmen telegram guerra drag pillars dungeons newton conhe conan god of war board games planet of the apes world of warcraft apes magic the gathering vortex produ cartas jogo outras extras continent castles ferro merchants batalha column carpe diem o senhor burgundy la isla card game deathmatches multiverso marauders wingspan villainous corleone bora bora anel ilustra terraforming mars magnifico artigos trajan gizmos tabuleiro stonemaier games meeple desenvolvido star wars rebellion propriedades cosmic encounter o hobbit elizabeth hargrave world without end great zimbabwe intelectuais harry potter hogwarts battle tzolk star wars imperial assault quarriors batman gotham city chronicles lignum forbidden stars jbg sentinelas ludopedia renato lopes forum trajanum legendary a marvel deck building game xcom the board game cinco ex jogatinas void ii beth sobel burgundy the card game battlestar galactica the board game thrones the card game starcraft the board game dark souls the board game thanos rising avengers infinity war mine the board game jogatina bg marvel dice masters avengers thrones o trono

Circulation May 14, 2019 Issue

Play Episode Listen Later May 13, 2019 22:53

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Greg Hundley, Associate Editor of Circulation from the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr Carolyn Lam: Are NOACs, or non-vitamin K antagonist oral anticoagulants, safe and efficacious in patients with extremely high or very low body weight? Very interesting paper and discussion coming right up. Greg, I hear that you've got a couple of papers you'd like to highlight first. Dr Greg Hundley: You bet, Carolyn. My two papers today both focus on ventricular dysrhythmia. The first one, from Yuki Komatsu from Tsukuba, Japan, researches the efficacy of catheter ablation of refractory ventricular fibrillation storm after myocardial infarction. VF storm attributed to focally triggered VF after MI is recognized as a distinctive, lethal, arrhythmogenic syndrome that differs from scar mediated monomorphic VT. This study investigated the acute and long-term outcomes of catheter ablation for the treatment of last resort in a large series of consecutive patients with post-MI VF storm refractory to medical therapies. In the study, investigators enrolled 110 patients averaging about sixty-five years in age. Ninety-two were men, and their average ejection fraction was approximately 31%. VF storm occurred in the acute phase of MI, about four and a half days after MI-onset, during the index hospitalization in about 39% of the patients. It was sub-acute (that is greater than 1 week later) in 44% of patients. It was remote (greater than 6 months later) in 17% of patients. And the focal triggers were found to originate from the scar border zone in 80% of the individuals. Dr Carolyn Lam: And what did the study show? Dr Greg Hundley: So Carolyn, during in hospital stay after ablation, VF storm subsided in 84% of patients and overall, 27% of in-hospital deaths occurred. The duration from the VF occurrence to the ablation procedure was associated with in-hospital mortality, with a P-value of 0.008. During follow-up after discharge from the hospital, only one patient developed recurrent VF storm. Of note though, 36% of the patients died, with a median survival of 2.2 years. And the long-term mortality was associated with a low EF (less than 30%), New York Heart Association class greater than 3 Heart Failure, a history of atrial fibrillation or chronic kidney disease. So in summary Carolyn, the results of this study show that in patients with MI presenting with focally-triggered VF storm, catheter ablation of the culprit triggers is life-saving and appears to be associated with short and long-term freedom from recurrent VF storm. The overall mortality for these patients is associated with the severity of their underlying cardiovascular disease, and those associated co-morbidities. Now my next paper is from one of our associate editors, Sami Viskin from Tel Aviv University. He's looking at a new form of polymorphic VT. Now as we think about polymorphic VT, I always think about the long QT interval syndromes associated with Torsades de Pointes. We have specific management strategies for those long QT syndromes, but Carolyn, there's a second category of polymorphic VT that's not related to QT prolongation. This second category involves patients without structural heart disease, who have genetic disorders like Brugada or patients that may have experienced hypothermia. There is also a third category of individuals with structural heart disease, during acute ST elevation MI. What Sami has discovered is there's now a fourth category of non-QT prolongation, which includes those with coronary artery disease but without evidence of ischemia. Dr Carolyn Lam: So how did they show or find this fourth category? Dr Greg Hundley: Well, this is a longitudinal cohort that he identified, and they basically followed forty-three individuals who developed polymorphic VT within days of an otherwise uncomplicated MI or coronary revascularization procedure. The in-hospital mortality was 17% with these patients with arrhythmic storm and the patients were treated with quinidine invariably survived to hospital discharge, just like the other categories of non-QT prolongation polymorphic VT. During long term follow-up of five and a half years, 16% of patients discharged without quinidine developed recurrent polymorphic VT and there were no recurrent arrhythmias in those individuals that were receiving quinidine therapy long term. So Carolyn, although quinidine therapy is usually considered contraindicated in patients with organic heart disease who develop ventricular arrhythmias, this therapy may be life-saving for patients with coronary disease developed arrhythmic storms due to polymorphic VT. Polymorphic VT storms may be a transient phenomenon. It's unclear for how long quinidine should be continued in these responsive patients. Dr Carolyn Lam: Wow, neat! Well, for my two papers I'm going to start off with a basic paper and, in fact, a quiz for you this time, Greg! So, what do cilia have to do with the heart? All right, you get to ask me, do you remember what cilia are? Dr Greg Hundley: Aren't cilia on prokaryotes? I mean, I think of bacteria. Dr Carolyn Lam: All right, let me set us straight. The primary cilium is a cellular organelle and it's formed by a protrusion of the plasma membrane that functions as a signaling platform in eukaryotic cells and is found in many cells including neurons, pre-adipocytes and kidney tubular cells, where they have been reported to be involved in a variety of cellular functions such as proliferation, differentiation, cell cycle regulation as well as mechano-chemical sensing of diverse stimuli. Now, the importance of these cilia is highlighted by the role in several diseases, known as ciliopathies. Polycystic kidney disease is one such disorder with, by the way, numerous cardiovascular manifestations. Whereas ciliated cells have been described in the developing heart, a role for primary cilia in the adult heart has not been reported. It was therefore the aim of these authors and those co-corresponding authors Dr Hill from UT Southwestern and Dr Lavandero from University of Chile, who aimed to identify cells in the adult heart harboring a primary cilium and to determine whether these primary cilia play a role in disease-related remodeling. Dr Greg Hundley: Carolyn, this is so interesting. I had no idea about these cilia. So what did they find? Dr Carolyn Lam: So, in a series of elegant experiments, these authors identified for the first-time primary cilia in mouse, rats, and human hearts, specifically and exclusively in cardiac fibroblasts. Now these ciliated fibroblasts were enriched in areas of myocardial injury. Transforming Growth Factor beta-1 signaling and SMAD3 activation were impaired in fibroblasts that were depleted of the primary cilium. Extra cellular matrix protein levels and contractile function were also impaired. And in vivo depletion of PC1 inactivated fibroblasts after myocardial infarction impaired the remodeling response. Dr Greg Hundley: So how do we use this clinically, and what does it mean for us? Dr Carolyn Lam: These findings point to a pivotal role of cilia and PC1 in disease related pathological cardiac remodeling and suggest that some cardiovascular manifestations of autosomal dominant polycystic kidney disease, for example, derive directly from myocardium autonomous abnormalities. The findings also uncover novel fibrosis regulators and raise the prospect that this pathway may emerge as a target with therapeutic relevance. Dr Greg Hundley: Wow, very interesting! Dr Carolyn Lam: Thanks! And the next paper is also very interesting, in dilated cardiomyopathy and providing insights in how specific viral function may be involved in the development of dilated cardiomyopathy. Looking at the Group B enteroviruses, which are a common cause of acute myocarditis and can be a precursor of chronic myocarditis and therefore dilated cardiomyopathy leading to heart transplantation. In fact, enterovirus-induced dilated cardiomyopathy represents a third of idiopathic dilated cardiomyopathy cases. So these authors, led by corresponding author Dr Andreoletti from University of Reims, Champagne-Ardenne and Dr Semler from University of California, performed deep sequencing of viral RNA from cardiac tissue from patients with enterovirus related end stage dilated cardiomyopathy and then trans-factored viral RNA clones, mimicking the viral genomes found in patient tissues into primary human cardiac cells to assess their replication activities and impact on cardiomyocyte function. They found that the major persistent viral forms are composed of B-type enteroviruses harboring 5' terminal deletion in their genomic RNAs. These viruses alone, or associated with full length populations of helper RNAs, could impair cardiomyocyte function by viral enterovirus proteinase 2A activities in these enterovirus-related dilated cardiomyopathy cases. Dr Greg Hundley: Very interesting, Carolyn. So what are the clinical implications of this viral infection of the heart? Dr Carolyn Lam: Well, the findings seem to imply that it would be important for us to develop specific inhibitors of enterovirus proteinase 2A activity that might prevent viral replication and inhibit the shut-off of host cell translation as well as the disruption of dystrophin. Furthermore, in early diagnosed enterovirus induced dilated cardiomyopathy, the use of such protease inhibitors could potentially decrease and stop the chronic pathological process of dilated cardiomyopathy and therefore reduce the need for heart transplantation in this end-stage. Very interesting, but requires more work. So, that wraps up our summaries Greg. Shall we move to our feature discussion? Dr Greg Hundley: Absolutely. Dr Greg Hundley: Today we have Renato Lopes from Duke University in Durham, North Carolina and Brian Olshansky, Professor Emeritus from Iowa now in clinical practice in Waterloo and Mason City, Iowa. We're going to talk about our non-vitamin K oral antagonists, or NOACs, safe and efficacious in patients in extremely high (greater than 120 kg) or extremely low (less than 60kg) of body weight. Renato, welcome to our podcast in Circulation on the Run. Can you give us a little overview of your study, why you performed it and what results did you experience? Dr Renato Lopes: The idea behind this study was to provide more data into the use of NOACs in these extreme body weight patients, where we don't have a lot of information. Some guidelines actually caution against the use of NOACs in patients with extreme body weight because of the lack of data. We had the opportunity to look at the Aristotle database, which was a large, randomized trial comparing apixaban versus warfarin for patients with atrial fibrillation, over 18 000 patients. We took advantage of this database to try to look at the extreme body weight and how those patients at weight more than 120 kg, more than 140 kg and less than 60 kg, performed in terms of the treatment effect of apixaban versus warfarin. This was the rational, to try to provide more data so people could gain additional confidence in using apixaban in clinical practice in those extreme body weight patients. What we showed was, in general the treatment effect of apixaban versus warfarin for the efficacy outcomes CHOKE, systemic embolism and all cause death and myocardial infarction was very consistent across the weight spectrum and preserved. Apixaban was superior to warfarin and this was consistent regardless of the weight category. For the low body weight patients less than 60 kg, we also found that apixaban results in terms if efficacy was preserved. So, going out to the bleeding and safety endpoints, apixaban was safer than warfarin across different spectrums of weight. Surprisingly, in patients less than 60 kg we saw an even greater relative risk reduction in bleeding, in patients treated with apixaban compared to warfarin. The main message was for efficacy, apixaban was better than warfarin - the same results as the Aristotle main trial. For bleeding and safety endpoints, we also saw the same results and consistent results with apixaban- in particular with patients below 60 kg, which is always a concern that people might have in clinical practice. It seems that apixaban was even safer with an even greater treatment effect. Dr Greg Hundley: Very nice. Can you tell us a little bit about some of the sites where you enrolled patients and did you identify any variation in age, sex or region specific factors? Were there any differences in your findings related to race? Dr Renato Lopes: That is a very interesting question because we know that these variables play an important role in body weight. We enrolled patients from thirty-nine countries in Aristotle, in over a thousand sites all over the world. Interestingly, I can tell you that the heaviest weight we had in our study was 205 kg, a patient from the United States. The lightest weight that we had was 39 kg, from the Philippines. You lose trading the variation that regions of the world can play out and how patients can perform. We haven't seen any major difference in these analogies. There were prior analogies that look at different BMIs, and we know that the treatment effect might be attenuated depending on race and sex. In this analogy, we did not find any significant difference according to race, region of the world or even sex. Dr Greg Hundley: Just getting back to your body weight measurement, you mentioned percentage of individuals were above 120 kg and briefly mentioned some were above 140 kg. What percentage of your study cohort was that extra-large size, above 140 kg? Do you think more work needs to be done in that area or do you think the results were sufficient for that very heavy body weight? Dr Renato Lopes: This is a very important question. If we look at the breakdown, we had about 11% of the entire trial in the low spectrum of weight, less than 60 kg in weight - almost 2000 patients. A good number of patients. In extreme weight more than 120, we have about 980 patients. That was 5.5% of the overall trial. When you look at greater than 140 kg, we had 258 patients, 1.4% of the overall trial population and about 25% of this category greater than 120. I think as we start getting greater than 140 kg, we had 258 patients. It is not a large number of patients. It is some information and it is good to have some data on these patients. Before that, we had no data on apixaban in this level of weight. What we are seeing is that above 140 kg, the death rate are very low. There is a trend to better bleeding endpoints and better bleeding profile with apixaban, similar to what we have seen in the entire spectrum of weight when we look at weight as a continuous variable. We also saw that trend in patients greater than 140 kg for bleeding. This is reassuring. I don't think we can say it is definitive, it is only 260 patients that we are talking about. It is reassuring that we now have data in patients more than 140 and up to 205 kg, and we didn't seem to see any major concern or any difference in the curves in terms of the direction of efficacy and safety of apixaban. For the majority of patients it is reassuring and gives us extra confidence that the dose we use in clinical practice five milligrams twice daily should also work in those heavy weight and the heaviest body weight patients. Dr Greg Hundley: Very good. Brian you've done an excellent editorial and I wonder if you could help us put this study in perspective with what we know about NOACs and managing patients with atrial fibrillation? Dr Brian Olshansky: It really is a fascinating study. Obesity is as growing problem for us here in the mid-west and probably throughout the world. It effects a variety of things including drug pharmakinetics, volume of distribution, drug clearance etc. So knowing how NOACs work at the extremes of body weight, either the massively obese or the vanishingly frail, it becomes important to understand the safety and efficacy of the use of NOACs in these individuals. There are guidelines that caution us against use of NOACs at extremes of body weight, particularly those patients who are over the 120 kg mark. The one point I would like to make is, at least here in the mid-west, 120 kg is becoming almost the norm. We are having people that are becomingly massively obese and this is really the question then in my mind, is what to do with those patients who are over 140 kg or even way more than that. This gets to points that I would like to make about some the issues we need to consider about this study and where we are with our understanding about the use of NOACs in the extremes of body weight. One thing to keep in mind is, in this analysis, this was a retrospective group analysis. That is one important point. We don't have prospective data that look at an entire large population, a very frail, a very low body weight population. Another issue is that weight is not a static measure. We only have assessment at the baseline. Variability in weight or body mass index may be important in terms of its relationship to the development of atrial fibrillation and sequelae. The other issue here to consider is that there are comorbidities that are associated with those who are at the extremes of body weight and there was a significant variation in this study in age composition, sex dominance, the region of enrollment, the presence of comorbidities between the different weight groups that could contribute to results we have seen. Those with low body weight had more comorbidities and a higher mean CHADSVASC score, and had the biggest difference between apixaban and warfarin. We have quite a bit to learn about how to understand these data, and when we consider the individuals who are over 140 kg, indeed there are concerns about the volume of distribution of a NOAC and its efficacy. We would like to rely on this data. The problem is that the number of individuals that are a part of this retrospective analysis at the very high body weight and very low body weights was a rather small number and so to project from that number, what we should do with all of our patients becomes somewhat of a concern. Although these are interesting and provocative data, what we really need is to have some well-designed large prospective randomized controlled trials that specifically address those individuals at the extremes of body weight because this is becoming more and more of a problem as time goes on. We are seeing more individuals that are at the extremes of body weight. While I have not specifically noticed a difference in my own clinical practice, what we need is a better understanding about the dosing of and potential risks and benefits of the NOACs for the extremes of body weight. Dr Greg Hundley: On behalf of Carolyn and myself, we really appreciate you listening. Have a great week. We look forward to seeing you next week. Dr Carolyn Lam This program is Copyright American Heart Association 2019.

Episode 65: SECURE-PCI: Impact of Timing of Atorvastatin Loading Dose

timing secure dose loading pci michael gibson renato lopes

Play Episode Listen Later Apr 3, 2019 4:58

Does timing of an atorvastatin loading dose make a difference in PCI for ACS? C. Michael Gibson and Renato Lopes discuss.

Dr Renato Lopes fala sobre o AUGUSTUS diretamente do ACC'19 em entrevista ao Dr Alexandre Quadros

SBHCI Podcast

Play Episode Listen Later Mar 21, 2019 15:27

O AUGUSTUS, um dos mais importantes estudos que avaliou angioplastia coronária em pacientes com fibrilação atrial, analisou a segurança e eficácia da apixabana versus os antagonistas dos inibidores da vitamina K em regimes diferentes de antiagregação plaquetária, foi apresentado no American College of Cardiology 2019. O investigador principal, Dr Renato Lopes, fala com exclusividade par o nosso podcast, em entrevista ao Dr Alexandre Quadros. Não percam este e todos os outros episódios, assinando e seguindo o SBHCI Podcast. Compartilhem! #Augustus #PCI #AF #APIXABAN #NOAC #cardiologiaintervencionista

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Circulation February 12, 2019 Issue

Play Episode Listen Later Feb 11, 2019 21:58

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: And I'm Dr Greg Hundley, director of the Pauley Heart Center from VCU Health in Richmond, Virginia. Dr Carolyn Lam: Is income volatility a new cardiovascular risk factor? You have to stay tuned to hear all about that. But for now, join Greg and I over a nice little coffee chat, because we're picking up the journal right here and I'm going to tell you about our two top picks this week. Greg, you go. Dr Greg Hundley: Well my top picks, Carolyn, is really pertaining to senescence and senescent cardiomyocytes. Remember that? Senescence is a situation where there's a mismatch between energy demand and supply and so that facilitates the cells transitioning toward failure. They lose their ability to function. In other parts of the body, they lose their ability to divide. And these investigators assessed altered calcium transfer from sarcoplasmic reticulum to the mitochondria, because that's being casually linked to the pathophysiology of aging in heart failure. Because the advanced glycation end products or AGEs accumulate through life, the authors thought that maybe this intracellular glycation would be occurring in aged cardiomyocytes and their impact on the sarcoplasmic reticulum and mitochondria. So, their study, they investigated both mice and humans and the found that ryanodine receptor glycation was associated with more pronounced calcium leak in mice and also interfibrillar mitochondria directly exposed to sarcoplasmic calcium release from aging mice had increased calcium content, compared to those with younger ones. Now we're starting to implicate a mechanism by where senescence could be important in these mice. But of course, in Circulation in these wonderful basic science papers that we have, they also cover a translational human component. And what these group found is that there were higher levels of advanced glycation end products and reduced glyoxalase 1 activity present in left atrial appendages, from those patients that underwent surgery greater than 75-years-of-age, compared to individuals that were younger. And also, elderly patients exhibited hyper glycation and increased mitochondrial calcium content that was associated with reduced myocardial aerobic capacity due to less respiring mitochondria. Dr Carolyn Lam: Wow Greg, that was a huge summary and how nice to link aging or senescence with AGE or advanced glycation end products. Seriously, that was new to me. Okay look, bring it home. What are the clinical implications? Dr Greg Hundley: What these investigators have done is now identified a previously unknown pathophysiological mechanism that may facilitate the transition from healthy, towards failing cardiomyocytes and the implication is that if you could disrupt that process, maybe you could halt the aging of cardiomyocytes. You got to be careful though I think with senescence, just as we know from the general literature. Senescence is a defense mechanism in cancer therapy, but it's a protagonist if you will, in aging. More to come in this field, but very exciting research. So Carolyn, tell me about your first paper. Dr Carolyn Lam: Happily, Greg. I'm going to take us to the cath lab and talk about functional assessment of epicardial coronary artery disease. This paper from Dr Koo and colleagues of Seoul National University Hospital, is the first to validate the physiological relevance and prognostic implication of all available novel resting pressure derived indices of coronary stenosis. This includes indices like resting full cycle ratio or RFR and diastolic pressure ratio or DPR, and they compared this to instantaneous wave free ratio or IFR and fractional flow ratio or FFR. What they looked at was more than a thousand vessels in 435 patients and showed that all the resting ... Just the resting. Not hyperemic but resting pressure divide indices, closely correlated with each other and showed excellent agreement and the same discriminatory ability for no FFR. All the indices also showed a similar pattern of changes to different anatomical and hemodynamic stenosis severity, regardless of the target vessels and importantly showed similar diagnostic performance for myocardial ischemia, defined by gold standard PET derived CFR and hyperemic myocardial blood flow. And finally, they showed that all these indices showed significant association with the two year vessel oriented composite clinical outcomes. Dr Greg Hundley: So, do we still need to do adenosine infusions in the cath lab? Dr Carolyn Lam: That's exactly what they're trying to drive at, because the major advantage of these resting indices, for example RFR over IFR, is that IFR doesn't require identification of a specific landmark or a specific time point during diastole. They may be simpler to perform and this first study showing their physiologic relevance and prognostic implication may enhance adoption of invasive physiologic assessment in daily clinical practice, which we know is important and a clinical benefit. Dr Greg Hundley: Excellent. I tell you, it would sure save time if we could use indices like that. Let me tell you about my next paper. This is from Renato Lopes, from Duke University Medical Center, in Durham. Also, one of your affiliates. In all of our cardiovascular/metabolic clinical trials today, cardiovascular death is a very important outcome. But what happens when, in doing a study like that and you have an undetermined cause of death, the US Food & Drug Administration Guidance indicates that deaths due to undetermined causes should be rare in well-run clinical trials. And so what this group did is they looked at 127,049 enrolled participants from nine trials and they looked at how deaths were adjudicated. And across nine clinical cardiovascular trials, in different therapeutic areas, the proportions of deaths adjudicated as related to undetermined cause ranged from 7-to-22% and overall, had an average of 16%. Interestingly, in multi-variable analysis, death due to undetermined cause, was associated with the therapeutic area and the year of publication of the study, and then also several patient factors including: gender, age, the region of enrollment, and time from enrollment to death. Dr Carolyn Lam: Gosh, this is so enlightening. Greg, having been on CECs and struggle with the adjudication, I really like this paper as well. But please, tell us all, why should we be concerned about this? Dr Greg Hundley: Great question, Carolyn. First we might think about, if you're reading a study, the proportion of deaths due to undetermined cause should really fall within this range. And have a mean of maybe 16%. Second, what if there are higher rates due to undetermined cause? Well, that may indicate there are issues with the trial quality. And then finally, researchers, whenever they're doing a study, should really report on the proportion of deaths where cause was unable to be determined. And there was a great editorialist, David Morrow, from Brigham and Women's Hospital, and really pointed out, you've got a couple factors here that lead to why there's undetermined cause of death. Maybe the documents are missing, or you're in a clinical situation where a subject lives alone, found dead, there's no autopsy. Uncertain duration. Sometimes there are limits on the study personnel; their ability to actually go out and acquire the data so that the team, like what you're on, can actually adjudicate the information. And a point that's made is really ... He used the word, doggedness, but with which he consistently worked toward and tried to get those medical records and pursue them, because that is very important. When we think, well what's the importance of a study like this? It's valuable to those that perform studies, because as we're working with our study coordinators, we need to make that information known to them. If we don't collect the exact cause of death in these important cardiovascular interventional studies, we may end up with an improper result. And also, for the investigative team. A really important study I think, providing guidance for the first time now about what we should expect in undetermined cause of death, when we're looking at cardiovascular trials. Dr Carolyn Lam: Indeed, and from talking about doing the trials to talking about a very important trial, I want to take you to The Partner 2 Trials and talk about the cost-effectiveness of Transcatheter Aortic Valve Replacement, or TAVR, compared to surgical aortic valve replacement, in patients at intermediate surgical risk. Now we already know that TAVR is cost-effective, although not cost-saving. But cost-effective compared to surgical aortic valve replacement in those at high surgical risk. But this paper refers to intermediate surgical risk. And the analysis is from Dr Cohen and colleagues from Saint Luke's Mid-America Heart Institute, and it's an analysis of the Partner 2A Randomized Trial and the SAPIEN 3 Intermediate Risk Registry. In summary, they found that TAVR was projected to lower total costs by $8,000.00 to $10,000.00. And to increase quality adjusted survival by 0.15 to 0.27 years, compared to surgical aortic valve replacement over a lifetime horizon. Dr Greg Hundley: Wow! Carolyn, I've got two questions for you. First of all, how does TAVR save those costs? And number two, was this true for everyone? Were there any caveats or special subgroups that this was really applied to? Dr Carolyn Lam: The cost savings in a TAVR cohort looked like they were driven by both a shorter length of stay during the index hospitalization, as well, as less resource utilization during follow-up. And that would be in the form of fewer hospital days, as well as fewer rehabilitation and skilled nursing facility days. As for the caveats, you see that the authors did acknowledge that the long-term durability of the valves involved like the SAPIEN XT and the SAPIEN 3 valves is still unknown, and so lifetime costs associated with TAVR, may be higher than we assumed, owing to the need of more frequent repeat valve procedures for example. Now if though, the long-term data demonstrate comparable late mortality with TAVR, and the surgical aortic valve replacement, these findings are really significant, because they suggest that TAVR may become the preferred treatment strategy for patient populations. Not only based on clinical outcomes, but even based on economic considerations. Dr Greg Hundley: It looks like that long-term information is going to be really critical here, so we'll look for more in this area. Dr Carolyn Lam: For sure. Wish we could keep chatting, but I think we need to move to the featured discussion. Dr Greg Hundley: And now to the very fun segment of our discussion this week at Circulation on the Run. This is Greg Hundley, from VCU Health. Director of The Pauley Heart Center. And today we have a fantastic paper from Adina Zeki Al Hazzouri from Miami, transitioning to Columbia University. And also, our Associate Editor, Dharam Kumbhani from the University of Texas, Southwestern. Today's paper, Adina is going to discuss is, Associations of Income Volatility with Incident Cardiovascular Disease and All-Cause Mortality in a US Cohort. And what she's done is worked with the Coronary Artery Risk Development in Young Adult Study, we also know that as, CARDIA. And it's really a prospective cohort conducted in urban centers, in Birmingham, Alabama, Chicago, Illinois, Minneapolis, Minnesota, and Oakland, California. The goal here was to asses a block of individuals, younger, aged 23-35 years, identified in the time window of 1990-to-2005 and then followed subsequently to look at income volatility. Adina, we're so excited to have you here. And can you tell us a little bit more about your study. Dr Adina Zeki Al Hazzouri: Sure, the motivation for the study is the fact that we know that income volatility is on the rise. And what I mean by, income volatility, is the sudden and unpredictable change in income. And in the health researcher, we actually do not know as much, what is the effect or the influence of income volatility on health outcomes, and it is really common, most of us do experience these sudden or unpredictable changes in income. Whether they're little dips or little jumps in income. So they are really common, and I think it's really important to try to understand what would be their effect on health outcomes. We were really interested in specifically understanding their effect on all-cause mortality and incidents of cardiovascular disease events, so we took advantage of an ongoing perspective cohort study. The cardio study that you just mentioned. And what is really nice about this study is they were really relatively young back in 1990 when we first had the measure of income. They were between ages 23-and-35. And they were followed for over 20-years, so we had repeatedly over 10-years, or 15-years, repeated measures of income. And then we were able then to look in the subsequent 10-years for incident events, cardiovascular events and all-cause mortality, and what is also interesting in this study is that these individuals, given that their age range, so that they are in the peak of their working years, which makes it even more interesting in terms of applicability and inference of those findings that we're making in this study. We looked at, as I said, income volatility and we defined it basically as what is the standard deviation of these percent changes in income that you experience between the different visits in the study, which were on average, five years apart. And once we defined that, then we looked at it with outcome and what we really found was that those who experienced high volatility had around a two-fold increased risk of cardiovascular disease, as well as all-cause mortality. We also looked at another measure of income volatility which is the number of income drops, so how many times you've dropped significantly, which we defined as a drop of more than 25%. And that is lower than your average income throughout the study period. And we found similar results. Dr Greg Hundley: Adina, what could be the cause of this? What do you think as an investigative group, is the mechanism behind this finding? Dr Adina Zeki Al Hazzouri: There could be various mechanisms playing roles here. Stress is obviously one of the important mechanisms. If you think about the instability of income, that instability in income could result in daily stresses, maybe inability to pay for bills. Also, that resulting in inflammation in all the stress pathway. Also, you could think potentially having this instability could also maybe hinder access to care, maybe coping mechanisms related to stress could alter adherence to treatment. Whether maybe someone has to take daily medications, having those dips or changes, sudden changes in income, could alter your adherence to those medications and then subsequently influence your risk for cardiovascular disease. Also, you could think access to health insurance. The social support, though it's not very well evidenced, but maybe if you've had always stable income, or low income, you're more likely to have more resilience. However, when you have these unpredictable changes, or sudden changes in income, you may not have that coping mechanism or support ready for you to deal with those sudden changes. These are some of the pathways that we think of that could potentially be playing a key role here. Dr Greg Hundley: Very good. Now let's turn to Dharam, our Associate Editor, from University Texas, Southwestern. Dharam, boy, surprising findings. A young cohort. I mean, they were 23-to-35 and in the next 10-years of their life they start to experience hard cardiovascular events. I mean, fatal and non-fatal myocardial infarction, and also, all-cause mortality. How do you put this in perspective, related to the workforce, and what do you think this means for this young population moving forward? Dr Dharam Kumbhani: At the outset we obviously want to congratulate Adina and her group, for this really, very interesting study in cardiovascular EPY and broadly intersects in health economics and health policy, as well for obvious reasons. Very interesting construct as you pointed out and what does this mean for younger subjects who experience these income volatility very early in their life. I think, just like any other EPY study, I think the perspective is helpful, because although the hazard ratio for these income volatility is two or higher, the absolute incidents rates are, again putting that in perspective is important, and so the absolute incident rates for example is somewhere between two-to-five, per 1,000 persons. So overall that impact, that's just helpful to understand what effects this would have. Hopefully, that helps. But obviously, very interesting analysis and brings up a lot of questions. I think one thing I may add to what was just mentioned is ... And this was highlighted very nicely by the editorialist, Dr Spatz, and her colleague from Yale. About how this is globally in the financial toxicity space, and there are a number of these indicators that are now being carefully studied like in this study, such as wealth shock and as I said, financial toxicity. And how they actually have an impact on cardiovascular outcomes. One of the feelings when you read a paper like this or when you read studies like this, and in fact this was one of our initial concerns as well, is to what extent you may have a component, or significant component of reverse causality. Your, "Patients who are sicker in some way," or have those culpabilities, be the ones that have these events is their relationship with other socio-economic indicators such as employment and how that would affect income volatility as well. I think the authors have done a really terrific job responding to that. And again, it shows an association obviously we know that, that doesn't imply that it's cause[owed], but it's a very interesting association. And that it's helpful to speculate both on the mechanisms, which were just outlined, and also what this means from a health policy standpoint. What that would mean for researchers in the cardiology community, or policy makers, things like that. So I think this is a very nice analysis and definitely brings up a lot of discussion points. Dr Greg Hundley: And a very important paper on multiple fronts. One, we've identified an issue in young, healthy individuals that could significantly contribute to adverse cardiovascular events. And then number two, I really liked your point on how this could impact public health policy, and maybe even how we need to think about reducing stress and how we design aspects of the workforce moving forward, so individuals don't suffer from these conditions. I want to thank, Adina Zeki Al Hazzouri, from Columbia. And our Associate Editor, Dharam Kumbhani, for these excellent comments. We look forward to seeing you next week. Dr Carolyn Lam: This program is copyright, American Heart Association, 2019.

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