Cardiovascular Diseases/complications – ABC CARDIOL

IJCS

Editorial

Safety of Dental Anesthesia in ICD Recipients

Ricardo Alkmim Teixeira

Some anesthetic agents administered during general anesthesia can cause heart rhythm disorders, mainly associated with autonomic imbalance. Off-target cardiac sodium channel blockade is considered the canonical mechanism behind cardiotoxicity.

Lidocaine, the most common local anesthetic, produces a transient loss of sensory, motor, and autonomic function when the drug is injected or applied close to neural tissues; furthermore, it has a good safety margin before reaching toxic blood levels. However, care must be taken to keep track of the total dose given to minimize its systemic toxicity. In addition to direct nerve toxicity, systemic toxicity affecting the brain and/or cardiac muscle can also occur. Cardiovascular toxicity usually appears as tachycardia and hypertension; however, with increasing toxicity, bradycardia and hypotension can occur. Ventricular arrhythmias and cardiac arrest also have been described. Because of its potential effects upon the heart, it is also commonly used as an antiarrhythmic agent to depress ventricular arrhythmias in controlled doses.

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Original Article

9p21 Locus Polymorphisms: Risk and Severity Factors of Coronary Artery Disease in Venezuelan Patients

Susana Blanco Sobrino et al. Eva Salazar Alcalá Asdrúbal Alfonzo Reyes Jesus Flores-Soler … Romina Leras Mirabal Yettana Luti Ingrid Márquez Mercedes Teresita Fernandez Mestre

Abstract

Background:

The 9p21 region is the most relevant locus associated with coronary heart disease in different populations. However, there are no studies that prove that this region is a risk factor in the Venezuelan population.

Objectives:

To analyze whether or not the 9p21 rs1333049 polymorphism is a risk factor for acute myocardial infarction (AMI) in Venezuelan patients, as well as to investigate its correlation with cardiovascular risk factors (CVRF), age of occurrence, type and severity of infarction, and the correlation of the rs10757274 polymorphism with severity of coronary artery disease.

Methods:

This was an association study, including 487 unrelated Venezuelan individuals, grouped in 354 patients with AMI and 133 controls. The rs1333049 and rs10757274 polymorphisms were determined using the polymerase chain reaction (PCR) technique with sequence-specific primers. The analysis of association was determined using the SNPStats tool. The continuous variable description and the correlations were performed using the SPSS statistical software. Significance was established at p<0.05.

Results:

A positive correlation was observed between the rs1333049 polymorphism and the presence of hypertension ( r: 0.145, p: 0.006), and between hypertension and heart infarction ( r: 0.318, p: <0.0001). A positive correlation was found between the rs10757274 polymorphism and the number of coronary vessels that presented obstructive lesions in patients aged ≤ 55 years ( r: 0.276, p: 0.0078).

Conclusion:

The rs1333049 polymorphism at the 9p21 locus is correlated with hypertension in Venezuelan patients, while the rs10757274 polymorphism is associated with the progression of coronary atherosclerosis, suggested by the correlation with the number of coronary vessels that presented significant obstructive lesions.

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Editorial

Cause or Consequence? What is the Relationship between Cardiac Injury and COVID-19 Severity?

Claudio Tinoco Mesquita

In most patients, coronavirus disease-2019 (COVID-19) causes minor respiratory symptoms or even no symptoms. SARS-CoV-2 infection can also cause extrapulmonary manifestations and complications. COVID-19 is more severe and fatal among patients with pre-existing cardiovascular risk factors or diseases. Increases in cardiac troponin (cTn) are indicative of myocardial injury and frequently found in patients with COVID-19. The Chinese Center for Disease Control and Prevention published a survey demonstrating that among patients diagnosed with COVID-19, 13% had hypertension, 5% had diabetes mellitus, and 4% had a history of cardiovascular disease. However, in this same cohort, among patients who had not survived, 40% had hypertension, 20% had diabetes, and 22% had pre-existing cardiovascular disease. Patients with cardiovascular disease had the highest case fatality rate (10.5%).

In this issue of the International Journal of Cardiovascular Sciences, Rocha et al. , studied 192 patients admitted with COVID-19 in a quaternary care cardiac hospital in Rio de Janeiro, Brazil. Mortality rate was 28%. Multivariate analysis demonstrated that elevated cTnI levels (OR=9.504; 95% CI=1.281–70.528; P=0.028) upon admission and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360–923.706; P=0.012) were independent predictors of death during hospitalization. The main limitations of the study are a sample from a single Brazilian metropolitan region and a short follow-up period. However, these limitations do not invalidate the main message of the study: the measurement of cardiac troponin at hospital admission may be useful for identification of high-risk patients infected by SARS-CoV-2.

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Case Report

Cardiac Manifestations Associated With Coronavirus Disease: A Case Report

Gabriela Ribeiro Prata Leite Barros et al. Raphaela Tereza Brigolin Garofo Bernardo Noya Alves de Abreu Adriano Camargo de Castro Carneiro André Luiz Esteves Mendonça

Abstract

This study presents a 47-year-old female patient, with a history of diabetes, who contracted SARS-CoV-2 and exhibited cardiovascular complications.

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Case Report

Commotio Cordis Secondary to Aggression

Luisa Gonçalves et al. Inês Pires João Santos Joana Laranjeira Correia … Davide Moreira Inês Almeida

Case report

A 35-year-old man was admitted following a recovered cardiorespiratory arrest. He was attacked by another man with multiples blunts by a wood stick in the chest and head. An eyewitness statement indicated that the victim had lost consciousness and collapsed after being hit in the chest. He was in cardiac arrest, and a nearby healthcare professional provided first aid with cardiopulmonary resuscitation. The first electrocardiogram (ECG) rhythm strip, fifteen minutes later, identified ventricular fibrillation (VF) (). Sixteen electrical shocks were delivered, always with VF, before restoration of sinus rhythm and circulation. A 12-lead-ECG revealed sinus rhythm without ST deviations and a corrected QT interval of 414 msec. On admission, he was under ventilatory support, with a heart rate of 80 beats per minute, blood pressure of 121/70mmHg, and no signs of shock. There was no previously known medical condition, besides being an active smoker and a binge drinker, and no family history of early coronary disease, cardiomyopathy, or sudden death. He was under the influence of alcohol, as was confirmed by blood tests (blood alcohol level of 1.31g/L), and had a discretely elevated cardiac troponin-T of 0.9ng/ml (normal range, 0 to 0.08 ng/ml). The remaining analyzes, cranial and cervical CT scan, chest X-ray, and abdominal eco FAST were normal. An initial echocardiogram in the emergency department demonstrated normal-sized chambers and global ventricular systolic dysfunction explained by a prolonged cardiac arrest. He was admitted to the intensive care unit for post-resuscitation care with therapeutic hypothermia and temporary ventilatory support. At 48 hours of admission, there was a normalization of systolic function with a normal ejection fraction by echocardiogram (). Coronary angiography excluded coronary disease (). Serial electrocardiograms were not suggestive of an arrhythmogenic substrate (). The sudden cardiac arrest was assumed secondary to a commotio cordis (CC), and for this reason, the patient was not proposed for an implantable cardioverter-defibrillator (ICD). The clinical outcome was favorable, and the patient was discharged. He remained asymptomatic during three years of follow-up, with normal ECG, echocardiogram with strain-rate imaging, exercise stress test, and 24-hour-Holter. During mid-term follow-up, a cardiac magnetic resonance imaging (MRI) showed normal-sized chambers, global and regional function, and no myocardial edema or myocardial scar by late focal hyperenhancement (-).

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Case Report

Beyond Atherothrombotic Disease in Acute Coronary Syndrome

Mayra Alejandra Mora et al. Manuela Molano-Perez Cristian Orlando Becerra-Gonzalez Kenny Buitrago-Toro … Silvana Jimenez-Salazar Carlos Ortiz

Abstract

Half of the global population over 20 years of age will be affected by cardiovascular disease. Cardiovascular events in young people is challenging. Spontaneous coronary artery dissection is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an uncommon and underdiagnosed cause of acute myocardial infarction predominately found in young women. Medical management has been more widely accepted, with percutaneous and surgery treatment reserved for precise indications. Optimal control of individual risk factors is essential in order to avoid recurrences.

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Original Article

Relationship between Discordance of Low-Density Lipoprotein and Non-High-Density Lipoprotein Cholesterol and Risk Stratification in Acute Myocardial Infarction

Murat Eren et al. Ozge Kurmus Turgay Aslan Kursat Akbuga Hatice Tolunay

Abstract

Background:

Sizeable proportion of patients have discordant low-density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (NHDL-C). It has been shown that discordance of LDL-C and NHDL-C either underestimates or overestimates coronary risk.

Objectıve:

We assessed whether this discordance has an impact on GRACE and TIMI risk scores in patients with acute myocardial infarction (AMI).

Methods:

We retrospectively evaluated the data of 198 consecutive patients with AMI. Fasting serum lipid profiles were recorded, GRACE and TIMI scores were calculated. Patients were divided into 3 groups according to LDL-C and NHDL-C percentiles: Discordant group: LDL-CNHDL-C (n=48). GRACE and TIMI scores, mortality and cardiovascular events (heart failure, non-fatal myocardial infarction and angina) at sixth month were compared between these three groups. Differences between these groups were analyzed with One-way ANOVA or Kruskal-Wallis rank test, and with chi-square for percentages. Also, post hoc LSD or Conover-Iman’s non-parametric multiple comparison test were used. A p value <0.05 was accepted as statistically significant.

Results:

TIMI risk score didn’t differ between discordant or concordant groups. Mean GRACE (death) and GRACE (death and MI) scores were higher in group with LDL-CNHDL-C (p=0.029 and 0.008, respectively). Cardiovascular events and mortality at sixth month were not different among groups (p=0.473 and p=0.176, respectively).

Conclusion:

GRACE score was higher in discordant group with LDL-C<NHDL-C, but there is no difference regarding TIMI scores between discordant and concordant groups in AMI patients.

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Case Report

Linear and Nonlinear Heart Rate Variability Analysis in Gonadal Dysgenesis (Swyer Syndrome): A Case Report

Valdelias Xavier Pereira et al. Tatiana Dias de Carvalho Marcos Antonio Marinovic Junior Alex Rey Norberto … José Maria Soares Júnior Vitor Engrácia Valenti Isabel Cristina Esposito Sorpreso

Abstract

Swyer syndrome is one of the disorders of sexual differentiation. Previous studies have demonstrated increased sympathetic activity with heart rate variability (HRV) analysis with decreasing estradiol levels. One patient presented a pure 46, XY gonadal dysgenesis with female phenotype. Cardiac autonomic modulation was assessed through HRV analysis while at rest. This research analyzed linear and nonlinear indexes. HRV analysis showed reduced parasympathetic and global modulation with an apparent increase in sympathetic tone and a loss of HR fractal dynamics toward correlated behavior, characterized by low entropy and high determinism of time series.

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Editorial

Home-Based Resistance Training in Heart Diseases: Don't Stop the Music, your Muscles are still Listening

Gabriel Dias Rodrigues et al. Pedro Paulo da Silva Soares

Cardiovascular diseases (CVDs) are a well-known cause of death and physical incapacity worldwide. Heart failure (HF) is a common disease resulting from multiple etiologies that contribute to decreasing physical capacity and quality of life (QOL).^, Not long ago physical exercises were discouraged in CVDs, but evidence-based exercise programs augment QOL, reduce mortality and hospital readmission in HF². Strength training is an important component of a cardiac rehabilitation program due to its close relationship with improvements in functional capacity reverberating in activities of daily living and QOL.

Unfortunately, supervised-rehabilitation programs in fitness centers are not widely available for the majority of patients with heart disease. Nevertheless, home-based rehabilitation programs could be more accessible to most patients, because of its relatively low cost and feasibility. Especially during COVID-19 pandemic lockdown, many opportunities to exercise were suspended, including cardiac rehabilitation services and community health programs. Also, social distancing increased sedentarism numbers and several position statements have encouraged people to stay active at home, trying to reverse or counterbalance the additional impact of social distance on physical inactivity.^, In a practical perspective, resistance training is conventionally performed through free weights or weight machines that usually require extensive physical space and outside facilities (i.e., gym or rehabilitation centers). Thus, resistance exercises, in particular, are not easily adopted at home and could be omitted from home-based cardiac rehabilitation. To underscore, a question that must be made: How patients remain strong at home?

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Original Article

Cardiovascular Risk Factors in Patients with Chronic Kidney Disease Under Conservative Treatment

Cássia Oliveira et al. Priscila Moreira de Lima Pereira Iris Teixeira Soares Melina Gabriela Monteiro … Marcus Gomes Bastos Ana Paula Carlos Cândido

Abstract

Background

Cardiovascular disease (CVD) is commonly associated with chronic kidney disease (CKD). These diseases have a significant impact on life expectancy. Individuals with CKD are more likely to die from CVD than to progress to end-stage kidney disease.

Objective

To assess cardiovascular risk factors of patients with CKD under conservative treatment.

Methods

This was an observational, cross-sectional study. Socioeconomic, anthropometric, biochemical, and physical inactivity data were assessed, and 10-year risk for CVD were estimated using the Framingham Score in patients with CKD under conservative treatment. For statistical analysis, the Student’s t-test and Pearson’s chi-square test were performed.

Results

A total of 172 individuals were evaluated, 57% of whom were male, with an average age of 68.85 ± 11.41 years. The prevalence of hypertension and diabetes were 87.2% and 53.5%, respectively; 62.2% were physically inactive; 9.9% of men were smokers and 12.8% consumed alcohol. According to BMI, 82.4% of adults <60 years old and 60.6% of those older than 60 years were overweight. High waist circumference and a high waist-hip ratio were highly prevalent in females (91.9% and 83.8%, respectively) and males (64.3% and 39.8%, respectively); 92.4% had a high body fat percentage and 73.3% high uric acid levels. According to the Framingham score, 57% have a medium or high risk of developing CVD in 10 years.

Conclusion

There was a high prevalence of cardiovascular risk factors in the population studied. The assessment of cardiovascular risk factors in patients with CKD makes it possible to guide the conduct of health professionals to prevent mortality from cardiovascular causes. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Viewpoint

Severe Cardiovascular Complications of COVID-19: a Challenge for the Physician

Nathalie Cristina Crivelari et al. Gisele Queiroz de Oliveira Clarice Hyesuk Lee Park Gregorio da Cruz Riemma … Isabela Bispo Santos da Silva Costa Marcus Vinícius Guimarães de Lacerda Glaucia Maria Moraes de Oliveira Francisco Carlos da Costa Darrieux Luciana Sacilotto Ludhmila Abrahão Hajjar

Introduction

Since December 31, 2019, when China reported the appearance of cases of acute respiratory failure caused by a new species of coronavirus, SARS-CoV-2, which causes the disease called COVID-19, almost 20 million cases were confirmed, causing 726 thousand deaths worldwide. In Brazil, on August 8^th, 2020, there was approximately 3 million cases and 100 thousand death by the disease.

Its rapid spread, its high potential for hospitalization, and its high lethality, especially in the most fragile groups such as geriatric patients and those with comorbidities, particularly cardiovascular ones, make this pandemic a challenge never faced by modern medicine. To date, we have no specific medication that has effective and safe results for the treatment of COVID-19. The scientific community has sought to research drugs with therapeutic plausibility, and controlled and randomized studies are underway. Many therapeutic proposals are based on in vitro experiments. The medications used are described in case records, with no solid scientific evidence for their use, and with a high probability of causing damage due to their adverse effects alone or in combination.

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Original Article

Self-reported HIV/HAART-associated Lipodystrophy and Modifiable Risk Factors for Cardiovascular Disease

Thiago Veiga Jardim et al. Rodrigo de Castro Cardoso Annelisa Silva e Alves de Carvalho Santos Marianne de Oliveira Falco Erika Aparecida Silveira

Abstract

Background

Patient self-report is the most common diagnostic tool in the literature to detect HIV/HAART-associated lipodystrophy. However, data on the association of cardiovascular risk factors with HIV/HAART-associated lipodystrophy assessed by self-report are still missing.

Objectives

To determine the prevalence of self-reported HIV/HAART-associated lipodystrophy and to identify independent associations between traditional modifiable cardiovascular risk factors and self-reported lipodystrophy.

Methods

We conducted a retrospective observational study at an outpatient infectious disease clinic in the Central-West of Brazil to identify the association between traditional modifiable cardiovascular risk factors and self-reported lipodystrophy. Sedentary lifestyle, smoking status, family history of cardiovascular disease, hypertension, diabetes, dyslipidemia, increased waist circumference and overweight were the cardiovascular risk factors assessed. Self-reported HIV/HART-associated lipodystrophy was categorized as: mild (noticeable by patients’ close inspection), moderate (easily noticeable by patient and physician) or severe (readily noticeable by a casual observer). Prevalence ratio (PR) and 95% confidence interval (CI95%) were calculated. Multivariate Poisson’s regression was used to analyze factors associated to HIV/HAART-associated lipodystrophy assessed by self-report considering a significance level of 5%.

Results

A total of 183 patients were included, with a mean age of 39.3±10.9 years. Most of the sample were male (77.6%), non-white (50.8%) and single (53.0%). The overall prevalence of HIV/HAART-associated lipodystrophy was 52.5% (95% CI 44.96 – 59.88). Severe lipodystrophy was observed in more than half patients (55.2%). No traditional modifiable cardiovascular risk factor was independently associated with lipodystrophy. Female sex (PR 1.49; 95% CI 1.15 – 1.95; p =0.003), time of HIV infection diagnosis of 1-3 years (PR 1.83; 95% CI 1.09 – 3.08; p =0.002) and a positive family history of CVD (PR 1.62; 95% CI 1.11 – 2.36; p <0.001) were independently associated with lipodystrophy.

Conclusion

HIV/HAART-associated lipodystrophy assessed by patient self-report was not associated with traditional modifiable cardiovascular risk factors. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Original Article

Prevalence of Malnutrition and Its Association with Clinical Complications in Hospitalized Cardiac Patients: Retrospective Cohort Study

Natally Gonçalves de Ávila et al. Juliana Umbelino Carneiro Fernanda Donner Alves Izabele Vian da Silveira Corrêa Juliana Paludo Vallandro

Abstract

Background

Malnutrition can affect the clinical course of hospitalized patients, increasing hospital stay, infections, mortality, and hospital costs. Among heart disease patients, the malnutrition prevalence ranges from 25 to 51.9%.

Objective

To assess the prevalence of malnutrition and its association with clinical complications in cardiac patients admitted to a cardiology hospital.

Method

Retrospective cohort study with patients evaluated within 48 hours of admission to the ward of a referral center for cardiology in Porto Alegre, Brazil. Patients were aged 18 years or older. Malnutrition was assessed by Subjective Global Assessment. Length of hospital stay, transfer to the intensive care unit (ICU), hospital discharge and in-hospital death were collected from medical records. Statistical analysis was performed using the SPSS 22.0 program. Comparisons between groups with and without malnutrition were made by unpaired Student’s t-test and chi-square test with adjusted residuals, and multivariate Poisson regression used for analysis of outcomes. The significance level considered was 5%.

Results

We evaluated 130 patients aged 63 ± 13 years, 63% were male, and the most frequent cause of hospitalization was angina (25%). The prevalence of malnutrition was 27% and, after statistical adjustment for age, malnutrition was positively associated with ICU transfer and length of hospital stay longer than seven days.

Conclusion

The prevalence of malnutrition found in this sample was 27% and this nutritional diagnosis was positively associated with ICU transfer and length of hospital stay longer than seven days. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Viewpoint

Heart Failure with Preserved Ejection Fraction and COVID-19: a Pernicious Relationship

Evandro Tinoco Mesquita et al. Antonio Jose Lagoeiro Jorge Humberto Villacorta Luiz Claudio Danzmann Wolney de Andrade Martins

Introduction

The ongoing pandemic of Severe Acute Respiratory Virus-2 (SARS-CoV2) infection was first recognized in China in 2019 and brought significant health and economic threats around the world. On January 31, 2020, the World Health Organization (WHO) declared the disease caused by SARS-CoV2 an international public health emergency and on March 11, 2020, the WHO declared it a pandemic.^, Three months after the initial WHO declaration, there are more than 5 million confirmed cases worldwide and 300,000 deaths. In Brazil, in the same time interval, there were more than 850,000 cases and 43,000 deaths, with an upward trend.

The epidemiological and clinical severity of the pandemic by COVID-19 was initially supported by 4 alarming elements: (a) respiratory transmission with a high infectivity rate; (b) high lethality in specific subgroups; (c) high demand for intensive care and mechanical ventilation; and (d) no effective vaccine or specific treatment. Given the magnitude of the problem and the scarcity of resources, there was a recommendation for hospitalizing critically ill patients and providing them with supportive treatment and, above all, mitigation via social isolation aimed at flattening out the epidemic curve.^–

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Editorial

COVID-19: A Matter Close to the Heart

Gláucia Maria Moraes de Oliveira et al. Fausto J. Pinto

The world is facing a new challenge, the novel coronavirus disease 2019 (COVID-19), caused by a betacoronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), phylogenetically identical to the SARS-CoV (severe acute respiratory syndrome coronavirus) and the MERS-CoV (Middle East respiratory syndrome coronavirus) responsible for innumerable deaths in China in 2003 and in the Middle East in 2012, respectively.

On March 11, 2020, the COVID-19 outbreak was characterized as a pandemic by the World Health Organization (WHO). Twenty-three days after that announcement, the cases reported reached 1,056,777 in 182 countries, with 55,781 deaths, most of which occurring in Italy, Spain, France, China and Iran. So far, Brazil has registered 8,195 cases and 335 deaths, while Portugal, 9,886 cases and 246 deaths, figures that have increased steeply since the beginning of the pandemic.

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