2007;89(5) – ABC CARDIOL

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Artigo Original

Prevalence of coronary risk factors and myocardial perfusion scintigraphy abnormalities in asymptomatic diabetic outpatients

Francisco das Chagas Monteiro Júnior et al. Fhabyula da Silva Cunha Natalino Salgado Filho José Bonifácio Barbosa … João Ribeiro Furtado Pedro Antônio Muniz Ferreira Vinícius Nina Joyce Lages Nilton Santana

OBJECTIVE: To determine the prevalence of coronary artery disease (CAD) risk factors (RF) and myocardial ischemia in a sample of asymptomatic diabetic patients treated on an outpatient basis. METHODS: From 80 type 2 diabetic patients initially recruited at an university outpatient endocrinology clinic, with no symptoms and/or CAD diagnosis, only 61 patients completed the study protocol, being 52,5% females, with a mean age of 56.3 ± 10.9 years. The patients were interviewed searching for RF and underwent electrocardiogram, echocardiogram and perfusional myocardial scintigraphy (PMS) at rest and under stress. According to the PMS results they were divided into two groups: an ischemic and a normal one. RESULTS: The RF identified were: male gender (48%), age > 55 years (51%), family history of premature atherosclerotic disease (16%), history of smoking (46%), hypertension (44%), sedentary lifestyle (62%), overweight / obesity (67%), HDL- cholesterol 100 mg/dl (85%) and triglycerides > 150 mg/dl (54%). Ischemic MPS were diagnosed in 15% of the patients. The variables associated with this diagnosis were: male gender (p=0.007), low HDL levels (p=0.046), history of smoking (p=0.038), left ventricular hypertrophy (LVH) (p=0.043) and left ventricle ejection fraction (LVEF) < 60% (p=0.01). CONCLUSION: A high prevalence of associated RF was observed, as well as a significant prevalence of 15% for myocardial ischemia. The variables identified as predictors of a myocardial ischemia diagnosis were: male gender, low HDL-cholesterol, past smoking, LVH and LVEF < 60%.

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Artigo Original

Coronary artery disease in asymptomatic type-2 diabetic women: a comparative study between exercise test, cardiopulmonary exercise test, and dipyridamole myocardial perfusion scintigraphy in the identification of ischemia

Paola Emanuela Poggio Smanio et al. Antonio Carlos Carvalho Antonio Sergio Tebexreni Anneliese Thom … Filadelfo Rodrigues Romeu Meneghelo Luiz Mastrocolla Alexandre Alves Leopoldo Soares Piegas Angelo Amato de Paola

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality among diabetic individuals. Myocardial ischemia is frequently asymptomatic, thus leading to a late diagnosis and worse prognosis. Diabetic women are known to have a cardiovascular death risk higher than that in men. OBJECTIVE: To assess the prevalence of coronary artery disease (CAD) in asymptomatic diabetic women. To compare the results of exercise test (ET), cardiopulmonary exercise test (CPET), and dipyridamole myocardial perfusion scintigraphy (MPS) with the findings of coronary angiography, (ANGI) in order of identify the most accurate method in the detection of significant CAD. METHODS: A total of 104 diabetic women were assessed with ET, CPET and MPS in the period within two months from the ANGI. MIBI-99mTc scintigraphy was performed using the gated-SPECT technique. Pearson’s chi-square, Student’s t tests were used for the statistical analysis and also the logistic regression analysis. RESULTS: The prevalence of CAD in the group studied was 32.7%. For the ET, an effective test (p=0.045), the chronotropic incompetence (p=0.031), and the exercise time performed (p=0.022) showed a significant association with DAC. For CPET, peak VO2 and HR achieved were associated with CAD (p=0.004 and p=0.025, respectively). Most of the MPS variables showed a significant association with CAD (p=0.001, for all). CONCLUSION: The results obtained may suggest a high prevalence of CAD in diabetic women. Thus, this population should be investigated from the cardiovascular point of view even without cardiac symptom. Of the noninvasive diagnostic methods used, dipyridamole MPS was the one that showed the highest discrimination power in relation to diabetic women with CAD.

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Revisão

Ambulatory blood pressure monitoring and type 2 diabetes mellitus

Cristiane Bauermann Leitão et al. Luís Henrique Canani Sandra Pinho Silveiro Jorge Luiz Gross

Hypertension is one of the main risk factors for the onset and progression of chronic complications in type 2 diabetes mellitus (DM). Ambulatory blood pressure (BP) monitoring (ABPM) provides a better correlation with target organ lesions than BP obtained in the office. Furthermore, it allows the evaluation of distinct BP parameters such as the 24-h, daytime and nighttime systolic and diastolic BP means, BP loads and the absence of nocturnal drop of BP, as well as the identification of white-coat and masked hypertension. DM patients have higher daytime and nighttime BP means than non-DM patients. In addition, one third of normotensive type 2 DM patients have masked hypertension, which is associated with an increase in albuminuria and in left ventricle wall thickness. On the other hand, the prevalence and effect of white-coat hypertension in type 2 DM patients have not yet been properly evaluated. The absence of nocturnal drop of BP does not add information to the 24 h, daytime or nighttime BP measurements, but the nighttime BP means seem to be relevant in DM retinopathy. In conclusion, BP determination by ABPM allows better patient risk stratification for the development of DM chronic complications and is an essential instrument for effective BP control in these patients.

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Artigo Original

Application of noninvasive ventilation in acute respiratory failure after cardiovascular surgery

Vera Regina de Morais Coimbra et al. Rodrigo de Almeida Lara Ériko Gonçalves Flores Emília Nozawa … José Octávio Costa Auler Júnior Maria Ignez Zanetti Feltrim

OBJECTIVE: To examine ventilatory response, oxygenation-related, and hemodynamics of patients with hypoxemic acute respiratory failure (ARF) submitted to noninvasive mechanical ventilation (NIV) during the postoperative phase of cardiovascular surgery in order to identify predictive variables of success, and to compare the different types of NIV. METHODS: Seventy patients with hypoxemic ARF were randomized to one of three modalities of NIV – continuous positive airway pressure (CPAP) and ventilation with two pressure levels (PEEP + SP and BiPAP®). Ventilation, oxygenation-related, and hemodynamics variables were analyzed at pre-application, and 3, 6, and 12 hours after the protocol began. RESULTS: Thirteen patients were excluded. Thirty-one patients progressed to independence from ventilatory support and comprised the success group, and 26 required orotracheal intubation and were considered the nonsuccess group. Age, initial heart rate (HR), and respiratory rate (RR) showed elevated levels in the nonsuccess group (p=0.042, 0.029, and 0.002, respectively). A greater number of intraoperative complications were seen in the nonsuccess group (p=0.025). Oxygenation variables increased only in the success group. Among the NIV types, 57.9% of patients in the ventilator group, 57.9% in the two-pressure levels group, and 47.3% in the CPAP group progressed with success. Oxygenation and RR variables showed improvement only in the groups with two pressure levels. CONCLUSION: Patients with hypoxemic ARF in the postoperative stage after cardiovascular surgery showed better oxygenation, RR, and HR during NIV application. In older patients and those with higher baseline RR and HR values, NIV was not sufficient to reverse ARF. The two-pressure level modes showed better results.

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Point of view

The ecosystem of cardiology guidelines – patrons of the state of the art in cardiology

POINT OF VIEW

The ecosystem of cardiology guidelines – patrons of the state of the art in cardiology – Part I

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Artigo Original

Prevalence of cardiovascular risk factors in adults living in Luzerna, Santa Catarina, in 2006

João Rogério Nunes Filho et al. Daniela Debastiani Alessandra Daros Nunes Karen Glazer Peres

OBJECTIVES: To estimate the prevalence of cardiovascular risk factors in the adult population of Luzerna, in the state of Santa Catarina. METHODS: A cross-sectional study with adults of both genders aged 20 to 59 years (n = 411). The prevalence of hypertension, diabetes, dyslipidemia, obesity, increased waist circumference, and smoking was estimated. Study variables were checked for frequency distribution, and a chi-square test for association was performed. RESULTS: The response rate was 85.9%. The following prevalences were found: hypertension: 14.7%; diabetes: 2.3%; dyslipidemia: 18.7%; obesity: 15.6%; increased waist circumference: 24.1%; and smoking: 15.6%. A total of 52.4% of the subjects had none of the risk factors; 22.4% had one risk factor, and 13.6%, 6.8%, and 4.9% had two, three, and four or more associated risk factors, respectively. CONCLUSION: The study sample showed low prevalence of hypertension and diabetes and less clustering of risk factors in the same individual, as compared with other data reported in the literature.

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Artigo Original

Atrial fibrillation ablation in Brazil: results of the registry of the Brazilian Society of Cardiac Arrhythmias

Guilherme Fenelon et al. Maurício Scanavacca Jacob Atié Leandro Zimerman … Luiz Pereira de Magalhães Adalberto Lorga Filho Henrique Maia Martino Martinelli Filho

BACKGROUND: Aiming to define the profile of curative atrial fibrillation (AF) ablation in Brazil, the Brazilian Cardiac Arrhythmia Society [Sociedade Brasileira de Arritmias Cardíacas] (SOBRAC) created the Brazilian Registry of AF Ablation [Registro Brasileiro de Ablação da FA]. OBJECTIVE: To describe the results of this registry. METHODS: A questionnaire was sent to SOBRAC members asking about data on patients submitted to AF ablation between September 2005 and November, 2006. RESULTS: A total of 29 groups from 13 states completed the forms. Of these, 22 (76%) had performed AF ablations. Between 1998 and 2001, 7 groups (32%) initiated AF ablations and between 2002 and 2006, 15 groups began to perform them (68%). From 1998 to 2006, 2,374 patients were submitted to ablation, 755 (32%) of them during the registry period. Most (70%) were males and 89% presented with paroxysmal or persistent AF. Ancillary imaging methods (intracardiac echocardiography and electroanatomic mapping) were used by 9 groups (41%). During an average five-month follow-up period, total success was 82% and success without use of antiarrhythmic agents was 57%. Nevertheless, 35% of the patients required two or more procedures. There were 111 complications (14.7%) and 2 deaths (0.26%). CONCLUSION: Curative AF ablation has been increasing significantly in our country, with success rates comparable to international indexes, but often more than one procedure is necessary. Despite promising results, AF ablation still results in significant morbidity. Supplementary imaging methods have been used more and more in an effort to increase efficacy and safety of the procedure. These findings should be considered by public and private funding agencies.

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Comunicação Breve

Use of mechanical circulatory support in cases of end-stage acute heart failure

Alexandre Siciliano Colafranceschi et al. Andrey José de Oliveira Monteiro Rodrigo Minati Barbosa Denise Castro de Souza Côrtes … Celso Musa Correa Leonardo Secchin Canale Marcelo Ramalho Fernandes Eduardo Botelho Luiz Antonio de Almeida Campos

BRIEF COMMENTS

Use of mechanical circulatory support in cases of end-stage acute heart failure

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Artigo Original

Exposition to smoking and attitudes: comparison between inquiries applied to adult population in São Paulo City, 1987 and 2002

Luiz Francisco Marcopito et al. Ana Paula Coutinho Dalva Maria de Oliveira Valencich Marco Antonio de Moraes … Rodolfo Brumini Sandra Aparecida Ribeiro

BACKGROUND: Periodic monitoring of tobacco smoking in the population is of public health interest. OBJECTIVES: To compare the prevalence of smoking habits and attitudes toward tobacco smoking from a sample of residents of the City of Sao Paulo, in 1987 and 2002. METHODS: Two random sampling household surveys were carried out among residents of the City of Sao Paulo, in 1987 and 2002, respectively with 1,471 and 2,103 participants aged 15-59 years RESULTS: Age-adjusted prevalence of tobacco smoking dropped from 41.8% (in 1987) to 25.5% (in 2002) among males and, respectively, from 30.6% to 19.8% among females, and such reduction was observed in all education levels. There was a decrease in the mean number of cigarettes smoked a day among men (but an increase among women), There was a growth in the preference for low tar cigarettes, an increase in those who quit smoking in the last 10 years, a growth among those who seriously tried to quit smoking, and an increase in those who believe in that “smoking is dangerous for your health”. CONCLUSION: There was a favorable change in the situation of smoking habits in the City of Sao Paulo from 1987 to 2002.

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Artigo Original

Efficacy of atorvastatin when not administered daily

Antonio Edmond Ghattas et al. João Pimenta

BACKGROUND: Statins are widely used because they reduce cardiac events. Although they are indicated for daily use, some doctorsgive prescriptions for every other day, mainly with the purpose of reducing costs. OBJECTIVE: To evaluate the efficacy of atorvastatin, when not administered everyday, on LDL-cholesterol (LDL-C) levels, and also to evaluate cost reduction. METHODS: A total of 100 patients with hypercholesterolemia in primary (PP) and secondary prevention (SP) were assessed. After a 12-week diet period, atorvastatin was initiated at a dose of 10 mg per day. After six weeks, LDL-C was determined, and if the levels were <80 or <104 mg/dL for SP and PP, respectively, two atorvastatin doses were subtracted per week. If LDL-C remained <80 or <104 mg/dL, a further reduction to three times a week was allowed, and the last determination was performed after six more weeks. The percentage variation in costs was the parameter to evaluate the saving. RESULTS: In 47 out of the 52 patients of this group, a reduction by 32% in LDL-C was observed, and daily atorvastatin was maintained. Forty one patients remained throughout the study and had their weekly dosage reduced. In 25 patients the medication was administered three times a week, and in 16, five times a week, with reductions of 42.4% and 46.1% in LDL-C, respectively. As regards costs, one of the groups had their monthly expense reduced from R$ 106.65 to R$ 74.65, and the other group from R$ 106.65 to R$ 53.33. CONCLUSION: The results suggest that atorvastatin may be administered on a non-daily basis. A cost reduction between 30% and 50% was also observed.

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Artigo Original

Silent myocardial ischemia in patients with stable coronary artery disease receiving conventional antianginal drug therapy

João Fernando Monteiro Ferreira et al. Luiz Antonio Machado César César J. Gruppi Dante M. A. Giorgi … Whady A. Hueb Antonio P. Mansur José A. F. Ramires

BACKGROUND: Few data are available on the behavior of myocardial ischemia during daily activities in patients with coronary artery disease receiving antianginal drug therapy. OBJECTIVE: To study the mechanism generating myocardial ischemia by evaluating blood pressure and heart rate changes in patients with stable atherosclerotic disease receiving drug therapy and with evidence of myocardial ischemia. METHODS: Fifty non-hospitalized patients (40 males) underwent 24-hour electrocardiographic monitoring synchronized with blood pressured monitoring. RESULTS: Thirty five episodes of myocardial ischemia were detected in 17 patients, with a total duration of 146.3 minutes; angina was reported in five cases. Twenty nine episodes (100.3 minutes) occurred during wakefulness, with 11 episodes (35.3 + 3.7 min) in the period from 11 a.m. to 3 p.m. Blood pressure and heart rate evaluation in the three ten-minute intervals following the ischemic episodes showed a statistically significant difference (p< 0.05), unlike that shown for the three intervals preceding the episodes. However, during the ischemic episode, a higher than 10-mmHg elevation in blood pressure and 5 beats per minute in heart rate were observed when compared with the time interval between 20 and 10 minutes before the episode. The mean heart rate at the onset of ischemia during the exercise test performed before the study was 118.2 + 14.0, and 81.1 + 20.8 beats per minute on the 24-hour electrocardiogram (p < 0.001). CONCLUSION: The incidence of silent myocardial ischemia is high in stable coronary artery disease and is related to alterations in blood pressure and heart rate, with different thresholds for ischemia for the same patient.

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Correlação Clínico-Radiográfica

Case 6/2007: a ten-year-old child with mild pulmonary valve stenosis

CLINICORADIOLOGICAL SESSION

Case 6/2007 A ten-year-old child with mild pulmonary valve stenosis

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Artigo Original

Cardiac ventricular weights recorded at the autopsy of healthy subjects who died of external causes

Sérgio Lamêgo Rodrigues et al. Enildo Broetto Pimentel José Geraldo Mill

OBJECTIVE:To establish cardiac ventricular weights recorded during the autopsy of healthy individuals who died of external causes, aiming at determining normality patterns in our population. METHODS:A total of 94 hearts were evaluated at the Forensics Department of the city of Vitória, Espírito Santo. After the heart removal and resection of the atria and epicardial fat, the right ventricle (RV) and the left ventricle (LV), including the septum, were separated and weighed and the mass was indexed by the height. The Kolmogorov-Smirnov test was used to test the normality of the distribution. Data are presented as means± SD. RESULTS:After the exclusion of 12 hearts (possible cardiovascular disease detected post-mortem) 82 hearts were examined (52 males and 30 females, aged 16-68 yrs, 31±12 yrs). The weight of the LV was 181±25 g and 125±15 g, and the weight of the RV was 54±7 g and 38±6 g; the LV mass indexed by height was 105±14 g/m and 78±8 g/m, for males and females, respectively. The P95 of the LV weight was 218 g and 128 g/m in males and 148 g and 88 g/m in females. No significant correlation between ventricular mass and age was observed. CONCLUSION:The weight of the LV in the males from our sample was higher than that reported in the contemporary literature. Our results suggest that the presence of LV hypertrophy can be inferred in the presence of LV mass > 218 g or 128 g/m in males and 148 g or 88 g/m in females.

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Image

Doppler echocardiographic flow pattern of the left internal thoracic artery following myocardial revascularization using a composite graft

Antonio Jorge de Vasconcelos Forte et al. José Glauco Lobo Filho Maria Cláudia A Leitão

IMAGE

Doppler echocardiographic flow pattern of the left internal thoracic artery following myocardial revascularization using a composite graft

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Case Report

Anomalous origin of the right coronary artery: diagnosis and treatment

Antonio Carvalho Leme Neto et al. Roberto Gomes de Carvalho Remulo José Rauen Junior Gilberto Melnick … Gustavo Carvalho Janaine Marchiori

We report the case of a rare anomaly of the right coronary artery (RCA) arising from the left aortic sinus, having a single ostium with the left coronary artery, associated with documented episodes of inferior ischemia, in which surgical treatment with a right internal thoracic artery to RCA bypass graft and the corresponding ligation provided greater stability to the coronary blood flow and good clinical progress.

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