Cardiovascular diseases (CVD) remain the leading cause of morbidity and mortality in women worldwide. Especially for women, traditional risk factors fail to explain most cases, deaths, and disability-adjusted life years (DALYs) from CVD. Risk factors inherent to the female sex and psychosocial aspects play an essential role in the development of CVD in women. Efforts need to be made to narrow the gap in diagnosis and treatment among women, especially younger ones, among whom CVD prevalence is increasing worldwide. 1 Ischemic heart disease (IHD) remains a major threat to public health, and the overall burden is increasing globally. The GBD 2019 Study estimated 126.5 (95% UI, 118.6-134.7) million prevalent cases of IHD in 2019 globally. Agestandardized rates for DALYs, deaths, and prevalent cases declined from 1990 to 2019, probably due to population growth and aging. 2 In addition, IHD was the leading cause of death and DALYs in Brazil in 2019 for both males (12.22% of total death -95% UI, 11.5%-12.77%; annual percent change -0.022) and females (12.03% of total death -95% UI, 10.66%-12.88%; annual percent change 0.07). It is important to note that there has been an increase in the annual percent change in mortality from IHD in women in recent years (Figure 1). 3 The GBD 2017 estimated 1736 (95% UI, 1689-1779) DALYs lost per 100 000 individuals due to IHD, with lower rates for females (1127; 95% UI, 1084-1163) than for males (2153; 95% UI, 2067-2216), in 2017 in Brazil. From 1990 to 2017, there was a decline in DALYs lost for both males (-47%) and females (-52%) in all Brazilian Federative Units (Figure 2). 4In addition, the GBD 2017 estimated 84 events of IHD per 100 000 inhabitants in 2017 in Brazil. The age-standardized incidence was 104 per 100 000 inhabitants for males and 58 per 100 000 for females. 4 The GBD 2017 estimated a prevalence of IHD in 2017 of 2229 (95% UI, 2098-2372) and 1008 (95% UI, 938-1081) per 100 000 inhabitants for males and females, respectively. The IHD prevalence increased in both sexes from 1990 to 2017 (Figure 3). 4 Mortality due to myocardial infarctionMyocardial infarction (MI) is the leading cause of death in Brazil nowadays. The MI mortality rate decreased between 1996 and 2019, in both sexes, especially among females, being more relevant in the state capitals than in the inner areas. 4 According to the Brazilian Unified Health System (SUS) Department of Information Technology (DATASUS), there were 142 982 hospital admissions for MI in 2018, with inhospital mortality of 11%. In 2018, the DATASUS registered 10 811 primary angioplasties for MI, with in-hospital mortality of 6.3% and a mean length of hospital stay of 5.1 days. In 2018, the total amount reimbursed for coronary

Fundamento: Instantaneous Wave-Free Ratio (iFR) é um método de avaliação funcional invasiva sem necessidade de droga vasoativa para indução de hiperemia máxima. Objetivo: Analisar a contribuição do iFR na terapêutica das lesões coronarianas com ausência ou discrepância entre os métodos diagnósticos não invasivos para isquemia e a angiografia coronária. Método: Foram estudados pacientes consecutivos com 18 anos ou mais, ambos os sexos, no período de maio de 2014 a março de 2018, com lesões coronarianas classificadas, por medição da porcentagem de diâmetro da estenose através de estimativa visual, em estenoses moderadas (41-70%) ou graves (71%-90%). O iFR ≤ 0,89 foi considerado positivo para isquemia. Empregou-se regressão logística com elastic net, tendo como variável desfecho o emprego de stent, e variáveis independentes: idade, sexo, hipertensão arterial, diabetes, dislipidemia, tabagismo, história familiar, obesidade e infarto agudo do miocárdio (IAM) prévio. Foram construídas Árvores de Classificação, Curva Roc, e gráficos Box Plot com o software R. O valor de p < 0,05 foi considerado significativo. Resultados: Foram avaliados 52 pacientes com 96 lesões obstrutivas (56 moderadas, 40 graves). O ponto de corte do iFR de 0,87 apresentou sensibilidade de 0,57 e 1-especificidade de 0,88, demonstrando boa acurácia para a reclassificação das lesões. Diabetes mellitus, dislipidemia, e presença de lesão moderada, com iFR < 0,87 foram preditores do implante de stents. Foram empregados stents em 32% das lesões de portadores de doença arterial coronariana estável e IAM com e sem supra de ST (lesões não culpadas). Conclusão: O iFR contribui para a reclassificação das lesões e diminuição do emprego de stents, auxiliando na abordagem das lesões moderadas e severas. (Arq Bras Cardiol. 2019; [online].ahead print, PP.0-0) Palavras-chave: Isquemia Miocárdica; Reserva Fracionada de Fluxo Miocárdico; Stents; Doença da Artéria Coronariana; Estenose Coronária; Fatores de Risco; Intervenção Coronária Percutânea.

Evolução Temporal da Análise de Resultados do Emprego do iFR Temporal Evolution of the iFR (Instantaneous Wave-Free Ratio) Employment Results Analysis

Degenerative aortic stenosis is currently a public health problem. Affecting the elderly population, this pathology has been showing an increasing prevalence as a direct result of the population aging. In this context, women have a greater life expectancy, corresponding to most of the population with degenerative aortic stenosis. Specific characteristics of this pathology in females are present in the diagnosis, pathophysiology, anatomical aspects, imaging and in therapeutic approach. Women present a more severe disease with less valve calcification than men, more concentric ventricular remodeling, higher transvalvular gradients, and less myocardial fibrosis. Less evident symptoms mean that these patients are referred later for surgical or percutaneous therapeutic treatment. The greater comorbidity presented by females and possibly due to the smaller body surface, bring specific aspects that affect the surgery results, leading to higher mortality rates and, more often, the prosthesis-patient mismatch. Percutaneous valve implantation is a good alternative, with better results in females, when compared to surgery, both in the treatment of native valves and in the treatment of a previously implanted bioprosthesis' dysfunction. The challenges encountered for the treatment of aortic stenosis in women and their possible solutions are described in this article, focusing on the observed difference of aortic stenosis in females and their possible solutions.