2007;88(6) – ABC CARDIOL

Artigo Original

Gender-related associations of increased body mass index with clinical and laboratory variables in individuals with no evidence of heart disease

Fernando Araújo et al. Alice Tatsuko Yamada Marcello Ricardo Paulista Markus Ivana Antelmi … Maria do Rosário Dias de Oliveira Latorre Alfredo José Mansur

BACKGROUND: In clinical practice, the patients we care for display a wide range of body mass indices, from lean to obese. This finding may be the sole apparent clinical abnormality. OBJECTIVE: To evaluate clinical and laboratory variables that might be associated with increased body mass index in asymptomatic men and women with no evidence of heart disease, to provide data to substantiate medical recommendations in a study sample from our everyday practice. METHODS: The subjects aged 14 to 74 years (mean 40.6 years), 295 men (43.1%) and 389 women (56.9%) The associations between body mass index stratified by gender and clinical and laboratory variables were analyzed using the Spearman correlation coefficient and multiple linear regression. RESULTS: The mean body mass index (BMI) did not differ significantly between women (26.15 Kg/m²) and men (26.33 Kg/m²). In the multiple linear regression model, the ratios of total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) (beta = 1.1320; p < 0.001) and serum glucose (beta= 0.0233; p = 0.023) were independently correlated with body mass index in women. In men, the variables independently correlated with BMI were the TC/HDL-C (beta = 0.793; p < 0.001) and age (beta = 0.0464; p = 0.030). CONCLUSION: In men and women with no evidence of heart disease, TC/HDL-C increased with body mass index in both genders. Other indices associated with BMI included serum glucose in women and age in men. Clinical and laboratory variables associated with body mass index may differ in relation to gender.

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Artigo Original

Spontaneous respiratory modulation improves cardiovascular control in essential hypertension

Carlos Hermano da Justa Pinheiro et al. Renato Antônio Ribeiro Medeiros Denise Gonçalves Moura Pinheiro Maria de Jesus Ferreira Marinho

BACKGROUND: Recent studies show that controlled breathing improves baroreflex and heart rate variability and lowers blood pressure in hypertensive patients. OBJECTIVE: To evaluate the effects of slow breathing training on cardiorespiratory system modulation of patients (n=10, men and women, ages ranging from 45 to 60) with essential hypertension seen in an outpatient setting. METHODS: According to the study design, each patient was used as his/her own control, and data were collected before and after the intervention. The following parameters were assessed: heart rate variability (HRV), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), respirometry, chest expansion measurement, and statistical data analysis. Respiratory training was performed in 30-minute sessions held twice a week over one month using slow breathing exercises. RESULTS: Our results were as follows: a reduction in SBP, DPB, and MAP (p < 0.05 vs control); an increase in heart rate variability, as evidenced by greater RR interval variation and SDNN index; a decline in respiratory rate (p < 0.01 vs control); and an increase in tidal volume (p < 0.01 vs control) and thoracic expansibility (p < 0.01 vs control). CONCLUSION: Respiratory retraining using the slow breathing technique appears to be a useful adjunctive for cardiorespiratory control in hypertensive patients.

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Clinicoradiological Session

Case 3/2007: a three-month-old male infant with criss-cross heart, atrioventricular discordance, and double-outlet right ventricle, without pulmonary stenosis

Edmar Atik

CLINICORADIOLOGIAL SESSION

Case 3/2007 A three-month-old male infant with criss-cross heart, atrioventricular discordance, and double-outlet right ventricle, without pulmonary stenosis

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Artigo Original

Ventricular resynchronization: comparing biventricular and bifocal right ventricular pacemakers

Eduardo Arrais Rocha et al. Tatiana Pereira Gondim Sebastião Abreu Roberto Farias … Vera Marques Almino Rocha Demóstenes Ribeiro Ricardo Pereira Pedro Negreiros Carlos Roberto M. Rodrigues José Nogueira Paes Júnior

OBJECTIVE:To analyze the conventional biventricular pacing (BV) and the bifocal (BF) right ventricular (RV) pacing, and to perform a comparative analysis of these two techniques in relation to clinical, functional and echocardiographic parameters in a population without the exclusion criteria of the major studies. METHODS:A prospective non-randomized analysis of 36 patients undergoing surgery for multisite pacemaker implantation due to QRS > 130 ms, severe left ventricular dysfunction, and NYHA functional class III or ambulatory class IV congestive heart failure was performed. RESULTS: Favorable results of resynchronization were obtained with both techniques, with no significant differences in the comparison of the two groups, except for a higher QRS narrowing in the BV group, and a trend of a lower number or hospital admissions in the BV group. When the groups were analyzed separately and compared before and after the procedures, we observed that improvement was much more significant in the biventricular group, as were the more statistically relevant rates. CONCLUSION: Cardiac resynchronization therapy proved to be an efficient therapy in both groups analyzed, although with more significant outcomes in the biventricular group.

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Revisão

Mechanisms and treatment of resistant hypertension

Eduardo Pimenta et al. David A. Calhoun Suzanne Oparil

REVIEW ARTICLE

Mechanisms and treatment of resistant hypertension

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Artigo Original

Influence of cardiopulmonary bypass on the plasma concentrations of atenolol

Fátima da Silva Leite et al. Luciana Moraes dos Santos Wanderley Wesley Bonafé Andréia Zago Chignalia … Maria José Carvalho Carmona Mariana Junqueira Suyama Luiz Marcelo Sá Malbouisson José Otavio Costa Auler Jr Silvia Regina Cavani Jorge Santos

BACKGROUND: Betablockers are used in the treatment of angina pectoris and others ischemic coronary diseases, reducing mortality and cardiovascular events. Atenolol is a hydrophilic betablocker which is characterized by gastrointestinal absorption, small extent of distribution and renal function-dependent elimination. OBJECTIVE: The study objective was to determine the inter-individual variability of atenolol in coronary patients. METHODS: Plasma atenolol was quantified in six blood samples collected during the preoperative period from seven patients with coronary insufficiency and surgical indication, chronically treated with atenolol PO 25 to 100 mg/day. All patients presented a normal or slightly reduced renal function. RESULTS: All enrolled patients presented normal or slightly reduced renal function as a result of age and underlying disease. Atenolol plasma concentrations showed a monoexponential decline, confirming the first-order pharmacokinetics at the doses employed for the control of coronary insufficiency (mean ± SD): 123 ± 56, 329 ± 96, 288 ± 898, 258 ± 85, 228 ± 79 and 182 ± 73 ng/ml at times zero, 2, 4, 6, 8 and 12h after dose administration. The investigated group showed a small inter-patient variability of atenolol administrated at multiple regimens due to the hydrophilic characteristic of the drug. Furthermore, accumulation of atenolol administered chronically was greater in coronary patients, compared to healthy subjects. CONCLUSION: In view of its cardio-selectivity and low-variability, atenolol should be used as the first-choice drug for the treatment of acute coronary syndrome and other cardiovascular diseases.

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Case Report

Percutaneous retrieval of intracardiac foreign body with a novel technique

Estêvão Carvalho de Campos Martins et al. Guilherme Brenande Alves Faria

We report on the case of a patient with a long term vascular catheter embolized into the right ventricle. This case had unique characteristics since both ends of the catheter were inaccessible for snare, which made it difficult to capture them using conventional techniques. We describe a new method to retrieve the foreign body through its mid-point portion, using a single catheter with two independent snare and hook systems.

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Artigo Original

Evaluation of heart failure prognostic factors in patients referred for heart transplantation

Cleópatra Medina Noronha Areosa et al. Dirceu Rodrigues Almeida Antônio Carlos C. de Carvalho Angelo A. V. de Paola

OBJECTIVES: To evaluate the survival of patients with heart failure submitted to cardiac transplantation screening as well as identify poor prognostic factors using a risk score to identify patients with higher death risk. METHODS: 330 male and female patients aged 12 to 74 years old, referred for heart transplantation from January 1986 to November 2001 were evaluated. Clinical, laboratory, electrocardiographic, Holter monitoring, echocardiographic and radionuclide ventriculography data were analyzed. RESULTS: The median follow up period was 5 years; patients’ survival rate was 84.5% in the first year, 74.3% in the second year, 68.9% in the third year and 60.5% in the fifth year. The prognostic variables selected through the univariate analysis were: age, Chagas’ disease etiology for cardiomyopathy, NYHA functional classes III and IV, orthopnea, systolic blood pressure, mean blood pressure, pulse pressure, plasma urea, sodium, glucose, albumin, bilirubin, hemoglobin, and mean heart rate. The prognostic variables at the multivariate analysis were: ejection fraction, blood urea, and hemoglobin. The risk score: RR=exp[(-0.0942401 x ejection fraction) + (0.0105207 x blood urea) + (-0.2974991 x hemoglobin) + (-0.0132898 x age) + (-0.0099115 x blood glucose)] discriminated the population with a higher death risk. CONCLUSION: Patients’ survival was satisfactory despite heart failure severity, suggesting they can be maintained on optimized clinical treatment until persistent clinical deterioration takes place. Ejection fraction, ventricular diameters, and clinical functional class alone should not be used as an indication for heart transplantation. The risk score could help discriminate the population with the poorest prognosis.

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Artigo Original

A risk score for predicting peripheral arterial disease in individuals 75 years or older

Marcia Makdisse et al. Luiz Roberto Ramos Frederico Moreira Anderson Oliveira … Otavio Berwanger Alcione Moscardi Virginia Junqueira Evandro Rodrigues Antonio Carlos Carvalho

BACKGROUND: The prevalence of peripheral arterial disease (PAD) in the elderly is high. Most are asymptomatic and the sensitivity of the physical exam is low. In Brazil, little is known in regard to PAD risk factors in the elderly. OBJECTIVES: To identify risk factors for PAD among elderly individuals (> 75 years) in the community and to develop a prediction score. METHODS: Cross-sectional, prospective, community-based study nested within a cohort study (“Epidoso”). A total of 176 individuals were assessed. PAD was defined as an ankle-brachial index <0.9. Risk factors associated with PAD were entered into a multivariate logistic regression model. Statistical modeling was used to formulate a score according to the likelihood of PAD. A p value 18 points defined the “high risk” individuals and yielded sensitivity, specificity, positive predictive value and negative predictive value of 85.9%, 71.4%, 63.2% and 89.9%, respectively. Receiver-operator characteristic analysis yielded area under curve of 85%, indicating excellent discrimination and goodness-of-fit statistics indicated excellent calibration (p=0.639). CONCLUSION: Because of its good performance, the proposed score can become a simple and useful tool to identify elderly community residents at higher risk of PAD who should be considered for further investigation.

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Artigo Original

Prognostic value of left atrial volume index in hemodialysis patients

Silvio H. Barberato et al. Roberto Pecoits Filho

OBJECTIVE: To evaluate the prognostic value of left atrial volume index (LAVi) in the clinical course of hemodialysis (HD) patients, compared with previously established echocardiographic and clinical parameters. METHODS: Echocardiograms were obtained from 118 hemodialysis patients, who were then followed for 19 ± 8 months. Study endpoint was a composite of all-cause mortality and nonfatal cardiovascular events. Cox multivariate analysis was used do assess the independent prognostic value of LAVi. RESULTS: On univariate analysis, LAVi and other clinical and echocardiographic parameters were predictive of prognosis. Multivariate analyses showed that LAVi was an independent predictor of prognosis (hazard ratio 1.03 per ml/m², 95% confidence interval: 1.01 to 1.05, p=0.014), and added incremental information to the model containing traditional predictors of cardiovascular risk, such as left ventricular mass, ejection fraction, and clinical variables (p=0.02). CONCLUSION: LAVi is an independent predictor of prognosis in HD patients, providing incremental information to traditional clinical and Doppler echocardiographic data.

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Point of view

Myocardial remodeling in congenital heart disease

Vera Demarchi Aiello et al. Maria Angélica Binotto

POINT OF VIEW

Myocardial remodeling in congenital heart disease

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Artigo Original

Medial hypertrophy in patients with pulmonary embolism: anatomopathological study

Renato Tambellini Arnoni et al. Fábio Biscegli Jatene Wanderley Marques Bernardo Vera Demarchi Aiello … Tanas Jatene Rosângela Monteiro Lea Maria Macruz Demarchi

OBJECTIVE: To compare the arterial response of cases of acute and chronic embolism, seeking to associate ischemic pulmonary remodeling with progression to chronicity. METHODS: Retrospective analysis of 61 necropsies of patients who died in the Instituto do Coração (31 cases of pulmonary embolism and 30 cases of acute myocardial infarction). Slides of pulmonary tissue were obtained from all cases and analyzed qualitative and quantitatively (medial thickness measurement). RESULTS: Qualitative analysis enabled the differentiation between cases of embolism and the control group, thus characterizing the two groups and defining the adequate choice of the control group. The alterations predominated in patients with embolism (alveolar inflammation and edema, infarction, vasoconstriction, concentric intimal proliferation, presence of thrombus). Quantitative analysis demonstrated higher percent medial thickness in the cases of embolism than in the control group; among the cases of embolism, no differences in intra (acute – 19.74 and chronic – 20.04) and pre-acinar (acute – 18.85 and chronic – 18.68) arteries were observed. CONCLUSION: The lack of difference among the groups with embolism and the higher values of percent medial thickness in the peripheral arteries allow the conclusion that the vascular response is more intense and starts in these arteries.

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Case Report

Use of beta-blockers in the post-operative period of Sano modification of the Norwood procedure with persistent cyanosis

Eli Szwarc et al. Maria H. S. Rodrigues Simone F. Pedra Marcelo B. Jatene … Edson R. Romano Carlos R. Ferreiro

Persistent cyanosis is a frequent complication in the post-operative period of Sano modification of the Norwood procedure. It may be explained by a dynamic proximal shunt stenosis of the synthetic conduit that links the right ventricle to the pulmonary artery, as detected by echo cardiographic study. The use of beta-blockers in the post-operative period has been recently described in order to improve the arterial oxygen saturation. In this report, we describe the use of propranolol in two patients undergoing Sano modification of the Norwood procedure, in whom a gradient reduction in the synthetic conduit, increase in the levels of arterial oxygen saturation, decrease in heart rate, and increase in blood pressure were observed, thus resulting in clinical improvement. We conclude that the use of beta-blockers in these cases was beneficial.