Morbidity

IJCS

Original Article

Sociodemographic Profile of Acute Myocardial Infarction in Rio De Janeiro, Brazil (2010-2019)

Abstract

Background

Cardiovascular Diseases (CVDs) are the main cause of mortality in Brazil, which includes acute myocardial infarction (AMI). In 2017, 12% of deaths caused by infarction in Brazil occurred in the state of Rio de Janeiro, characterizing it as an important “hotspot” in the country.

Objectives

This study aimed to characterize the population affected by AMI over the past decade within the state so as to guide future public policies related to CVDs.

Methods

Secondary data of patients affected by AMI between 2010 and 2019 were obtained by DATASUS. In-hospital case-fatality rates, mortality rates, and proportional mortality were calculated using information gathered by the Mortality Information System (SIM) and demographic statistics produced by the Brazilian Institute of Geography and Statistics (IBGE).

Results

The main results showed that in-hospital case-fatality rates were higher in women, patients aged 60 years and over, the black color/race, and the state’s Northwest region. The mortality rate was higher among men, especially in the South-central region and those over 50 years of age. People aged 40-49 years presented a considerable risk of death by infarction. The major categories of data classified as “ignored” in hospital admissions and death certificates were those related to race and education level.

Conclusions

Prevention should not only focus on the elderly, but also on people over 40, especially men. The incompleteness of electronic public data systems can affect the use of race/color or education level as epidemiological variables. New studies should be conducted to understand why the South-central region is so heavily affected by infarction.

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IJCS

Original Article

Overview of Cardiovascular Disease Risk Factors in Adults in São Paulo, Brazil: Prevalence and Associated Factors in 2008 and 2015

Jaqueline L. Pereira et al. Michelle A de Castro Jean M. R. S. Leite Marcelo M. Rogero … Flavia M. Sarti Chester Luís Galvão César Moisés Goldbaum Regina M. Fisberg

Abstract

Background

Cardiovascular diseases (CVDs) are the main cause of morbidity and mortality in Brazil.

Objective

To provide population-based data on prevalence and factors associated with CVD risk factors.

Methods

Individuals aged ≥20 years from two editions of the cross-sectional Health Survey of São Paulo focusing on Nutrition (ISA-Nutrition), performed in Sao Paulo city in 2008 (n=590) and 2015 (n=610), were evaluated for: obesity, central obesity, waist/height ratio, high blood pressure (HBP), dyslipidemia, diabetes, and number of CVD risk factors ≥3. Prevalence was estimated according to complex survey procedures. Factors associated with cardiovascular risk factors were assessed using logistic regression, with statistical significance of p<0.05.

Results

Obesity and older age were associated with higher odds of all cardiovascular risk factors investigated, except for dyslipidemia. HBP was positively associated with being Black/Brown and negatively associated with being physicaly active in leisure time. Women were more likely to have increased adiposity indicators and three or more cardiovascular risk factors than men. Those with higher education had lower chances of having diabetes, HBP and dyslipidemia, and those with higher income had higher chances of having three or more risk factors. Former smokers had higher odds of diabetes, obesity, and high waist/height ratio, and smokers had higher odds of high non-HDL cholesterol levels. From 2008 to 2015, there was an increase (p<0.001) in the prevalence of diabetes (6.9% to 17.3%), HBP (31.9% to 41.8%), dyslipidemia (51.3% to 67.6%), and number of CVD risk factors ≥3 (18.9% to 34.1%).

Conclusion

This study shows increasing prevalence of CVD risk factors in adult population in Sao Paulo and may support the definition of target groups and priority actions on CVD prevention and treatment.

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IJCS

Original Article

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

Júlia Lasserre Moreira et al. Pedro Henrique Andrade Araújo Salvatore Barletta José Augusto Baucia

Abstract

Background

Although cardiovascular disease is the leading cause of death in women, few data exist on risk factors and treatment of these diseases in women. This leads to a delay in the institution of appropriate therapies and worse outcomes in this population.

Objective

We aimed to identify predictors of morbidity and mortality in women undergoing isolated mitral valve replacement.

Methods

This was a retrospective cohort study with 104 women who underwent isolated mitral valve replacement at a referral hospital for treatment of cardiovascular diseases, performed from January 2011 to December 2016. Data were obtained from medical records. Statistical analysis was performed to calculate odds ratio, unpaired Student’s t-test, and binary logistic regression. P values <0.05 were considered statistically significant.

Results

Mean age of patients was 43.73 (±13.85) years. Most patients had a diagnosis of rheumatic disease prior to surgery (76%; N=79). Mortality rate was 4.9% (N = 5). There was a statistically higher risk of death among patients with reduced ejection fraction (EF) (<50%) (OR = 14.833, 95% CI 2.183 – 100.778, P=0.001) and older age (P = 0.009). There was an inverse association between a previous diagnosis of rheumatic disease and death (OR = 0.064, 95% CI 0.007 – 0.606, P=0.002). Logistic regression showed reduced EF at preoperative evaluation as a predictor of death and a diagnosis of rheumatic disease as a protective factor.

Conclusion

Older age and reduced EF were associated with postoperative mortality. Reduced EF was a predictor of death, and rheumatic disease was associated with better surgical outcomes.

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IJCS

Editorial

Risk Prediction Systems: One for all or all for Some

Jorge Paiter et al. Gláucia Maria Moraes de Oliveira

Cardiovascular diseases (CVD) are the main cause of death in Brazil and worldwide, determining an increase in morbidity and disability-adjusted life years (DALYs). The prevalence of CVD increased from 271 million (95% uncertainty interval [UI]: 257–285) in 1990 to 523 million (95% UI: 497–550) in 2019, and the number of deaths steadily grew from 12.1 million (95% UI: 11.4–12.6) in 1990 to 18.6 million (95% UI: 17.1–19.7) in 2019 in the 21 world regions analyzed by the Global Burden of Disease (GBD) 2019 study. The prevalence of CVD is likely to increase in Northern Africa and Western Asia, Central and Southern Asia, Eastern and Southeastern Asia, and Latin America and the Caribbean due to population growth and aging.

Ischemic heart disease (IHD) is part of this heterogeneous group of disorders, in which an acute coronary event is the first manifestation in approximately half of the cases.^, The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170-194) DALYs and 9.14 million (95% UI: 8.40-9.74) deaths in 2019. The GBD 2019 study has estimated 197 million (95% UI: 178-220) prevalent cases of IHD in 2019.

[…]

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IJCS

Original Article

Prognosis of Heart Failure with Preserved Ejection Fraction in Primary Care by the H2FPEF Score

Antonio Jose Lagoeiro Jorge et al. Maria Luiza Garcia Rosa Wolney de Andrade Martins Adson Leite … Dayse Mary da Silva Correia Maria Auxiliadora Nogueira Saad Humberto Villacorta Sergio Chermont Ronaldo Altenburg Gismondi Breno Macedo Almeida Evandro Tinoco Mesquita

Abstract

Background:

Primary care physicians have difficulty dealing with patients who have HF with preserved LVEF(HFpEF). The prognosis of HFpEF is poor, and difficult to predict on primary care.

Objective:

The aim of the study is to apply the H2FPEF score to primary care patients and verify its power to assess the risk of death or hospitalization due to cardiovascular disease.

Methods:

This longitudinal study included 402 individuals, with signs or symptoms of HF, aged≥45 years and, underwent an evaluation which included clinical examination, BNP and echocardiogram. The diagnosis of HFpEF was confirmed by the criteria of the European Society of Cardiology. After five years, the patients were reassessed as to the occurrence of the composite outcome, death from any cause or hospitalization for cardiovascular disease. H2FPEF used six variables: body mass index, medications for hypertension, age, pulmonary artery systolic pressure, atrial fibrillation and E/e’ ratio ranged from 0 to 9 points. The level of statistical significance was p<0.05.

Results:

HFpEF was diagnosed in 58(14.4%). Among patients with H2FPEF≥4, 30% had HFpEF and in those with a score≤4, HFpEF was present in 12%. Patients with HFpEF and H2FPEF≥4 had 53% of outcomes, whereas patients with HFpEF and a score ≤4 had a 21% of outcomes. BNP values were higher in patients with HFpEF compared to those without HFpEF(p<0.0001).

Conclusion:

H2FPEF≥4 indicated a worse prognosis in patients with HFpEF assisted in primary care. H2FPEF may be a simple and useful tool for risk stratification in patients with HFpEF at the primary care.

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Editorial

Lung Ultrasound in COVID 19 Outbreak: Can we Reduce the Burden from the Overloaded CT Departments?

Filipe Penna de Carvalho et al. Alex dos Santos Felix

Since the first descriptions on the use of lung ultrasound (LUS) for bedside evaluation of critically ill patients, important publications have underscored the utility of LUS for the detection of a wide array of pulmonary and pleural diseases, as well as for the differential diagnosis of acute respiratory failure, proving to be an important tool for a point-of-care based examination and an extended resource for examining critical patients, cited by many as the “new stethoscope”.^,

The coronavirus disease-2019 (COVID-19) outbreak has emerged as a global health burden since late 2019, challenging healthcare systems around the world due to the constant need for intensive care support and isolation of patients, many of whom evolve with severe hemodynamic involvement, leading to high morbidity and mortality. This critical scenario highlights the importance of appropriateness and best appliance of all diagnostic and therapeutic resources. In this regard, the use of point-of-care ultrasound (POCUS) is proving to be a cost-effective tool for the management of these potentially critical patients, from the initial presentation (triage) to in-hospital management and post-discharge follow-up.

[…]

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IJCS

Review Article

Transcatheter Aortic Valve Implantation: Where are we in 2020?

Rogerio Sarmento-Leite et al. Gilberto Eder de Oliveira Junior

Abstract

Aortic stenosis is an insidious disease of rapid progression after the onset of symptoms. Aortic valve replacement surgery is a well-established therapy that reduces symptoms and increases survival rates. However, the procedure may be associated with high operative mortality rates and promote comorbidity. Depending on the local reality, the prevalence of patients considered inoperable (due to medical comorbidities and age) may achieve 30%. For these patients, transcatheter aortic valve implantation (TAVI) was initially indicated; over time, the method has advanced technologically and been simplified, and become an alternative therapy for patients at low and intermediate surgical risk also, and considered one of the major advances of modern medicine.

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IJCS

Original Article

Reliability between Cardiovascular Risk Assessment Tools: A Pilot Study

Rodrigo Conill Marasciulo et al. Ana Maria Nunes de Faria Stamm Guilherme Thomé Garcia Antônio Carlos Estima Marasciulo … Ariel Córdova Rosa Alexandre Augusto de Costa Remor Cristian Battistella

Abstract

Background

The prevention of cardiovascular disease (CVD) is important in clinical practice due to its high morbidity and mortality. Different guidelines have recommended the use of different cardiovascular risk assessment tools, which may have implications on therapeutic decisions.

Objective

To evaluate the agreement rate between the Framingham risk score (FRS) and the Systematic Coronary Risk Evaluation (SCORE) tool on CVD risk assessment in disease-free subjects.

Methods

Cross-sectional study with a sample of 51 subjects treated at the outpatient clinic of a university hospital in Brazil between January 2014 and January 2015. The FRS and two versions of the European SCORE (SCORE-High and SCORE-Low) were used to assess CVD risk; patients were classified as low/moderate risk (< 20% and <5%, respectively) or high risk (≥ 20% and ≥5%, respectively). The agreement rate was evaluated using kappa statistics, a test for interrater reliability that ranges from -1 to 1, and results above 0.6 represent a high agreement rate.

Results

The FRS classified a higher proportion of subjects as high risk for CVD (35.3% [18/51] vs. 23.5% [12/51] with the SCORE-High and 13.7% [7/51] with SCORE-Low). However, there was a high agreement rate between FRS and SCORE-High (k=0.628). The agreement between FRS and SCORE-Low was poor (k=0.352).

Conclusions

There was a high agreement rate between FRS and SCORE-High in cardiovascular risk assessment in the study sample. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Editorial

Oral Contraceptives and Cardiovascular Risk: Adding Clinical Evidence to the Pathophysiology

Daniel Arthur B Kasal et al. Andrea De Lorenzo

Women cardiovascular health is an important and often neglected issue. Cardiovascular diseases (CVDs) are the main cause of death in women, in Brazil and worldwide. Oral contraceptives are the main method used for contraception in Brazil. The issue of oral contraceptives and cardiovascular risk has been raised since the first descriptions of this class of pharmaceuticals, in the 1960s. The development of low-dose combined oral contraceptives (COCs) containing ethinyl estradiol and different progestins has reduced, albeit not eliminated, cardiovascular morbidity in women taking these medications. The main side effects associated with COCs are procoagulant effects. Therefore, the use of COCs is associated with increased risk of developing acute myocardial infarction, venous thromboembolism and stroke. In addition, adverse changes in the lipid profile and glucose tolerance have been described. Clearly, ageing and exposure to other risk factors, mainly smoking and obesity, play an important role in the development of adverse outcomes related to COCs. In addition, formulations with different progestins may produce distinct effects on circulation.

Another important side effect associated with COCs is the development of hypertension. A meta-analysis including 24 studies and over 250,000 participants found a significant association between the duration of oral contraceptive use and risk of hypertension. Studies regarding the pathophysiology of this association have revealed a number of different and complementary mechanisms. These include oxidative stress, endothelial dysfunction and the activation of the Renin-Angiotensin-Aldosterone system (RAAS). In this issue, Oliveira et al., published an interesting clinical observational study, with young volunteers using low-dose COCs for at least one year, compared to women not using the medication. The authors found higher plasma renin levels in women using COC, with a strong correlation with plasma C-reactive protein (CRP). Additionally, although they did not reach the level of hypertension, systolic arterial pressure measurements of COC users were higher than those of non-users. This finding suggests that RAAS activation, if sustained, could eventually shift blood pressure in women using this medication into the hypertension range. The increase of inflammatory pathways, which is associated with RAAS activation, is also shown by the positive correlation with CRP. While the study was restricted to young and healthy participants, and COC use included five different formulations, the results add clinical evidence linking RAAS activation to oral contraceptive use, inflammation and even hypertension development, in a Brazilian sample.

[…]

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Editorial

The Challenge of Controlling Resistant Hypertension

Marcus Vinicius Bolivar Malachias

Hypertension is the main risk factor for cardiovascular disease, stroke, disability and death. Despite the accumulated knowledge about hypertension and many treatment options, some hypertensive patients do not achieve the recommended blood pressure goals even receiving non-pharmacological treatment and three antihypertensive drugs. These individuals have the so-called “resistant hypertension” and are at increased risk of involvement of target organs, higher morbidity and mortality.

Several international scientific societies, including the Brazilian Society of Cardiology, have dedicated to publishing evidence-based guidelines for the management of arterial hypertension,^, and specific position statements on resistant hypertension have also been produced.^, The Department of Hypertension of the Brazilian Society of Cardiology is about to issue an updated statement on the subject.

[…]

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Original Article

Heart Failure: An Overview of Morbidity and Mortality in Rio Grande do Sul

Carolina Zenilda Nicolao et al. Juliana Bischoff Ferreira Adriana Aparecida Paz Graciele Fernanda da Costa Linch … Marciane Rover Emiliane Nogueira de Souza

Abstract

Background:

Heart failure (HF) is the final pathway of most cardiac diseases. Although the prevalence of HF has increased, due to the ageing of the population, more comprehensive data have shown a reduction in the percentage of HF hospital admissions over the last years.

Objective:

Assess the morbidity and mortality of HF patients in Brazil, Rio Grande do Sul and Porto Alegre.

Method:

The study is a retrospective analysis of data from the Brazilian Unified Health System’s (Sistema Único de Saúde [SUS]) Department of Informatics (DataSUS). We evaluated the incidence of HF hospital admissions, the average length of stay, hospital costs and sex ratio, during a ten-year period (2007 to 2016). Due to availability of the system, mortality rate and age range, the total duration of the study was nine years.

Results:

Within this period, the percentage of hospitalizations for HF decreased. On the other hand, the length of stay increased in all regions studied. Mortality rates were in decline in all regions. Hospital costs showed an increase of 110.8%. HF was more prevalent in patients between the seventh and eighth decades of life, with men being more affected than women, except in Rio Grande do Sul.

Conclusion:

We conclude that, in spite of the high costs of HF to healthcare providers, hospitalizations and mortality rates have shown a significant decline over the last years, which results from the advances in the treatment of this disease, through initiatives to improve patient education, engagement and planning in health care and self-care.

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