2009;92(3) – ABC CARDIOL

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Artigo Original

Carotid artery structural and functional evaluation in relatives of type 2 diabetic patients

Sônia Silva Prado et al. Mário Luiz Ribeiro Gilberto Perez Cardoso Kelb Bousquet-Santos … Luis Guillermo Coca Velarde Antônio Cláudio Lucas da Nóbrega

In Western countries type 2 diabetes mellitus (DM2) is the leading cause of morbidity and mortality, particularly from cardiovascular causes. Since a family history of diabetes, even in non-diabetic subjects, is regarded as an increased risk of coronary heart disease, the use of approved surrogate markers of early atherosclerosis, specially of ultrasonic measurements of the carotid arteries, is of vital importance. OBJECTIVE: To analyze the structural properties (intima-media thickness) and functional properties (distensibility measurement) of the carotid arteries in subjects with (FH+) a family history of type 2 diabetes, in comparison to subjects without (FH-) a family history of type 2 diabetes, both groups with no known cardiovascular risk factors. METHODS: 32 individuals (male and female, age range, 21-47 years; 19 FH+, 13 FH-) had their right and left common and internal carotid arteries measured, using high-resolution B-mode ultrasonography. Both groups had similar (p>0.05) age, BMI, blood pressure, and fasting blood glucose and insulin, leptin, and C-reactive protein (CRP) levels. RESULTS: The intima-media thickness (IMT) of the left common carotid artery (LCCA) in the FH+ group (0.568±0.107mm) was statistically greater (p=0.029) than in the FH- group (0.477±0.116mm). Multiple regression analysis identified age, overweight and obesity (determined by BMI), CRP, and LDL-cholesterol levels as independent predictors of the IMT in the LCCA. CONCLUSION: FH+ individuals with no metabolic disorders presented greater IMT of the left common carotid artery (structural alteration) than FH- individuals, but normal vessel function. (Arq Bras Cardiol 2009;92(3): 186-192)

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Artigo Original

Combination of amlodipine and enalapril in hypertensive patients with coronary disease

Marcos Rienzo et al. José Francisco Kerr Saraiva Paulo Roberto Nogueira Everli Pinheiro de Souza Gonçalves Gomes … Miguel Antonio Moretti João Fernando Monteiro Ferreira Dikran Armagnajian Antonio de Pádua Mansur José Antonio Franchini Ramires Luiz Antonio Machado César

BACKGROUND: Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE: To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) 110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with χ2, Fischer and analysis of variance, for p< 0.05. RESULTS: Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 ± 13.4) and B (125.3 ± 12.6) (p= 0.45) and DAP, A (74.5 ± 6.7 mmHg) and B (75.5 ± 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION: The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

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Artigo Original

Renal and adrenal tumors with cardiac invasion: immediate surgical results in 14 patients

Rafael Fagionato Locali et al. Priscila Katsumi Matsuoka Tiago Cherbo Edmo Atique Gabriel Enio Buffolo

BACKGROUND: The resection of tumor thrombus of the inferior vena cava (IVC) and right atrium (RA) increases the survival rate of patients with renal/adrenal cancer. OBJECTIVE: To evaluate the surgical procedure in cases of IVC and RA in the treatment of renal and adrenal tumors. METHODS: Fourteen patients undergoing surgical intervention (during the period) between January 1997 and June 2007, for resection of IVC and/or RA thrombus due to renal or adrenal tumors, were retrospectively evaluated. The patients (64.2% male) presented with Wilms’ tumor, clear cell carcinoma and adrenal adenocarcinoma, and had mean age of 4.5, 60.5 and 2.5 years, respectively. Epidemiological characteristics and intra- and postoperative parameters were evaluated. RESULTS: Suprahepatic IVC tumor thrombus were observed in all the patients, and in 62.4% of them the thrombus invaded the RA. Thrombectomy was performed with extracorporeal circulation with deep hypothermia and total circulatory arrest in 85.7%, with mild hypothermia in the remaining cases. The inferior vena cava was ligated in 7.1% of the cases, and reconstruction with suture was performed in 92.9% of the patients. The duration of orotracheal intubation and length of hospital stay were different, according to the tumor type. Two deaths, due to intraoperative cardiorespiratory arrest, were seen among patients with adrenal adenocarcinoma. CONCLUSION: IVC and RA tumor thrombi are more frequent in patients with Wilms’ tumor. More postoperative complications are seen in patients with adrenal adenocarcinoma, and the postoperative prognosis is better for patients with Wilms’ tumor.

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Review Article

Inflammatory markers of cardiovascular disease in the elderly

Adriane M. Ramos et al. Lucia Campos Pellanda Iseu Gus Vera L. Portal

Most information on the role of inflammatory markers as cardiovascular disease predictors concerns only middle-aged individuals. This review aims at evaluating the role of inflammatory markers as cardiovascular disease predictors in the elderly. The Medline (Pubmed) and Cochrane databases were used in the search, using the key words. After adding the following filters: Limits: Aged 65+ years, Humans, Randomized Controlled Trial, Meta-Analysis, Review, Clinical Trials, 554 studies were identified. Of these, 120 were selected and evaluated regarding their power of evidence (classification of the Oxford Centre for Evidence-Based Medicine). In studies with patients older than 65 years, interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and interleukin-10 (IL-10) showed to be good predictors of cardiovascular events. Regarding C-reactive protein (CRP), the data are inconsistent, as it appears to have lower power of prediction in the elderly when compared to middle-aged individuals. Fibrinogen levels seem to be predictors of mortality, although they are non-specific predictors, i.e., not solely of cardiovascular mortality. Additionally, the inflammatory markers are also indicative of functional decline and mortality, regardless of the presence of cardiovascular disease. The current evidence is not sufficient to allow the routine use of inflammatory markers in the elderly, as there are few studies in this age range and most of them are short-term ones with a small number of inflammatory markers. The routine request for these markers must be decided on an individual basis.

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Review Article

Systematic review and meta-analysis of diagnostic and prognostic studies: a tutorial

Marcos R. de Sousa et al. Antonio Luiz P. Ribeiro

Systematic reviews with meta-analysis of studies on diagnostic tests or prognostic factors are research tools that are still being developed. The objective of the present paper is to describe the methodology of systematic review and meta-analysis of this type of studies, step by step. A literature review on the subject was made, the recommendations were compiled and the paper was organized in: a) Introduction, b) Details on the eight steps to be followed, c) Form of publication of a systematic review with meta-analysis, and d) Conclusion. The systematic review methods were thoroughly described with a critical analysis of the methods of statistical compilation of results, with emphasis on the utilization of the Summary Receiver Operator Characteristic curve. References for the details of each statistical technique used were provided in the meta-analysis. We concluded that systematic reviews with meta-analysis of diagnostic tests or prognostic factors are useful in data compilation of various studies on the same subject, since they reduce biases and increase the statistical power of the primary research.

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Artigo Original

Prognostic value of the collagen volume fraction in hypertrophic cardiomyopathy

Edmundo Arteaga et al. Aloir Queiroz de Araújo Mauricio Bernstein Felix J. A. Ramires … Barbara Maria Ianni Fabio Fernandes Charles Mady

BACKGROUND: In hypertrophic cardiomyopathy (HCM), interstitial myocardial fibrosis is an important histological modification that has been associated with sudden death and evolution toward myocardial dilation. OBJECTIVE:To prospectively evaluate the prognostic value of the collagen volume fraction in HCM. METHODS: An endomyocardial biopsy of the right ventricle was successfully performed in 21 symptomatic patients with HCM. The myocardial collagen volume fraction (CVF) was determined by histology. The CVF was also determined in fragments of nine normal hearts from subjects deceased from non-cardiac causes. The patients were divided into above-median CVF and below-median CVF groups, and their clinical and echocardiographic characteristics and survival curves were compared. RESULTS: Among the patients, the CVF ranged from 1.86% to 29.9%, median 6.19%; in normal hearts, from 0.13% to 1.46%, median 0.61% (p <0.0001 between HCM and control). There were no significant correlations between CVF and baseline echocardiographic measures. Patients with CVF 6.19% were compared and no baseline differences were observed. However, after an average follow-up period of 110 months, four deaths occurred (two sudden, two due to heart failure) in the group with increased CVF, whereas the patients of the group with lower CVF were all alive at the end of the period (p = 0.02). CONCLUSION:For the first time, myocardial fibrosis was prospectively associated with a worse prognosis in patients with HCM. Efforts should be directed to the quantification of myocardial fibrosis in HCM, on the premise that its association with the prognosis can aid in the stratification of risk for defibrillator implantation, and in the prescription of drugs that potentially promote myocardial repair.

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Artigo Original

Genetic factors in familial aggregation of blood pressure of portuguese nuclear families

Rogério César Fermino et al. André Seabra Rui Garganta José António Ribeiro Maia

BACKGROUND: Despite of the increase in the prevalence of hypertension in Portugal, the importance of genetic factors in blood pressure (BP) has not been studied extensively in our country. OBJECTIVES: To verify the indirect presence of vertical transmission of genetic factors between parents and children in BP values, and to estimate the magnitude of genetic factors contributing for variation in BP values in the population. METHODS: Sample size comprises 367 individuals (164 parents and 203 children) pertaining the 107 nuclear families participating in “Familias Activas” project, proceeding from different regions of North Portugal. The BP was measured with Omron® model M6 (HEM-7001-E) digital device. SPSS 15.0 was used for data analysis; PEDSTATS was used to verify the structure of each family data. Familial correlations and heritability estimates were computed in FCOR and ASSOC modules of S.A.G.E. version 5.3. RESULTS: For systolic BP (SBP), correlation values were low to moderate (0,21< r <0,35); for diastolic BP (DBP) values were found to be moderate (0,24< r <0,50). Genetic factors explain 43 and 49% of the total variation in SBP and DBP, respectively. CONCLUSION: A moderate amount of the SBP and the DBP is accounted for by genetic factors.

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Case Report

Hypertrophic cardiomyopathy and tachyarrhythmias detected by a pacemaker

Adrian Baranchuk et al. Syamkumar Divakaramenon Sebastian Ribas Carlos A. Morillo

A 56-year-old man came to the Pacemaker Clinic for his regular pacemaker control. He had experienced a syncopal episode in the previous week. He had a previous diagnosis of non-obstructive hypertrophic cardiomyopathy. Due to a previous syncope and documented 2:1 infrahisian block, a dual-chamber permanent pacemaker had been implanted a few years before. The device was interrogated, showing several ventricular high rate episodes. A careful analysis of the stored intracardiac electrograms showed ventricular tachycardia (VT) with 2:1 ventriculoatrial conduction. The following presentation discusses the alternative diagnosis and clinical management in an unusual diagnosis of VT in the presence of non-obstructive hypertrophic cardiomyopathy.

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Case Report

Cardiogenic shock caused by disulfiram

Ana Jerónimo et al. Carla Meira Augusta Amaro Glória Cabral Campello Cristina Granja

Drug intoxication with disulfiram is a rare condition that may lead to severe and potentially fatal cardiovascular manifestations such as cardiogenic shock. We report the case of a female patient with refractory shock after deliberate self-poisoning with disulfiram. Clinical, biochemical and echocardiographic assessment, as well as invasive monitoring confirmed cardiogenic shock associated with this drug. The known mechanisms of action of disulfiram are discussed, and the major collateral effects, especially cardiovascular effects, are described. We underscore the importance of suspecting this diagnosis and of adopting prompt and the most adequate therapeutic approach in this context.

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Página do Presidente

International exchange towards continuing education's and Brazilian cardiology's strengthening

Antonio Carlos Palandri Chagas

THE PRESIDENT’S PAGE

International exchange towards continuing education’s and Brazilian cardiology’s strengthening

[…]

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Artigo Original

Prevalence and variables associated with physical inactivity in individuals with high and low socioeconomic status

Helena França Correia dos Reis et al. Ana Marice Teixeira Ladeia Everton Carvalho Passos Flávio Guilherme de Oliveira Santos … Larissa Tapioca de Wasconcellos Luís Cláudio Lemos Correia Marta Silva Menezes Renata Dáttoli Gouvêa Santos Victor Guerrero do Bomfim Mário de Seixas Rocha

BACKGROUND: Studies that considered only the leisure physical activity found that the physical inactivity is higher among lower-income individuals. There is a possibility that this association shows modifications, when considering transportation, work and domestic activities. OBJECTIVE: To determine whether there is a difference between the prevalence of physical inactivity between individuals of high and low socioeconomic levels. METHODS: The sample consisted of individuals of both sexes, aged 18 or older, from two groups of different socioeconomic levels. The low socioeconomic level (LSEL) group consisted of the parents of students from a public school. The high socioeconomic level (HSEL) group consisted of the parents of students from a private College. The International Physical Activity Questionnaire (IPAQ) was used to determine the level of physical activity. RESULTS: A total of 91 individuals were evaluated in the LSEL group and 59 in the HSEL group. In the LSEL group, 42.9% (39) of the individuals were classified as insufficiently active, compared to 57.6% (34) of individuals in the HSEL group. Taking as a parameter of physical inactivity the time of weekly physical activity < 150 minutes, there was a decrease in the classification of inactivity in both groups, although with the maintenance of higher inactivity among individuals of HSEL (49.2% vs 28.6%; p= 0.01). CONCLUSION: The individuals of HSEL are more sedentary than the individuals of LSEL.

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Artigo Original

B-type natriuretic peptide assessment in the diagnosis of rejection after pediatric heart transplant

Cristina de Sylos et al. Estela Azeka Luis Kajita Luis Benvenutti … Célia Cassaro Strunz Klébia Castello Branco Arlindo Almeida Riso Carla Tanamati Marcelo Jatene Miguel Barbero-Marcial

BACKGROUND: Rejection is one of the major causes of mortality following pediatric heart transplant. B-type natriuretic peptide (BNP) has been studied as a method for the diagnosis of acute rejection, especially in adult patients undergoing heart transplant. OBJECTIVE: To correlate serum BNP levels with acute rejection as diagnosed by endomyocardial biopsy in patients of the pediatric heart transplant group. METHODS: A total of 50 BNP samples were collected from 33 children in the postoperative period of heart transplant, and data on age, gender, skin color, blood group, immune panel, follow-up time after transplant, functional class, immunosuppressive regimen used and number of rejections were analyzed. RESULTS: Thirty three children with median age of 10.13 years were analyzed; of these, 54% were females and 78% were Caucasians. BNP levels were determined at a mean time from transplant of 4.25 years. Nine episodes of rejection were diagnosed in eight patients (27%) by means of endomyocardial biopsy; of these, three were grade 3A, five were grade 2, and one had humoral rejection. At the moment of biopsy, most patients were asymptomatic. The mean serum BNP level was 77.18 pg/ml, with 144.22 pg/ml in the group with rejection and 62.46 pg/ml in the group without rejection, with p = 0.02. CONCLUSION: Asymptomatic children can present acute rejection in the postoperative period of heart transplant. Serum BNP levels show a statistically significant difference in the group with rejection and thus can be an additional method in the diagnosis of cardiac rejection.

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Artigo Original

Evaluation of baroreflex function in young spontaneously hypertensive rats

Vitor E. Valenti et al. Celso Ferreira Adriano Meneghini Marcelo Ferreira … Neif Murad Celso Ferreira Filho João Antônio Correa Luiz Carlos de Abreu Eduardo Colombari

BACKGROUND: The literature describes contradictory data regarding the onset of the baroreflex reduction in spontaneously hypertensive rats. OBJECTIVE:This investigation was undertaken to evaluate the baroreflex function in 13-week-old spontaneously hypertensive rats. METHODS:Male Wistar Kyoto (n=15) and spontaneously hypertensive rats (n=15) aged 13 weeks were studied. Cannulas were inserted in the abdominal aortic artery through the right femoral artery to measure mean arterial pressure and heart rate. Baroreflex function was calculated as the derivative of the variation of HR in function of the MAP variation (Δheart rate/Δmean arterial pressure) tested with a depressor dose of sodium nitroprusside (50µg/kg) and with a pressor dose of phenylephrine (8µg/kg) in the right femoral venous approach through an inserted cannula in awake spontaneously hypertensive rats and Wistar-Kyoto. Differences with p values < 0.05 were considered statistically significant. RESULTS:Spontaneously hypertensive rats: Δmean arterial pressure=43.5mmHg±5.2, Δheart rate=-59.7ppm±17.9 and Δheart rate/Δmean arterial pressure=1.3ppm/mmHg±0.1 tested with phenylephrine; Wistar Kyoto: Δmean arterial pressure=&56mmHg±3, Δheart rate=*-114.9ppm±11.3 and Δheart rate/Δmean arterial pressure=#1.9ppm/mmHg±0.3 tested with phenylephrine; spontaneously hypertensive rats: Δmean arterial pressure=-45.6mmHg±8.1, Δheart rate=40.1ppm±11.6 and Δheart rate/Δmean arterial pressure=0.9ppm/mmHg±0.5 tested with sodium nitroprusside; Wistar Kyoto: Δmean arterial pressure=-39.8mmHg±6.2, Δheart rate=51.9ppm±21.8 and Δheart rate/Δmean arterial pressure=1.4ppm/mmHg±0.7 tested with sodium nitroprusside (*p<0.05; #p<0.01; &p<0.001). CONCLUSION: Our results showed that 13-week-old spontaneously hypertensive rats presented reduced baroreflex function when tested with phenylephrine.

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Review Article

Case 3/2009 – six-month-old infant with large interventricular communication and enlarged thymus, which simulated the characteristic image of total anomalous drainage of the pulmonary veins at the chest x-ray

CLINICORADIOLOGICAL SESSION

Case 3/2009 – six-month-old infant with large interventricular communication and enlarged thymus, which simulated the characteristic image of total anomalous drainage of the pulmonary veins at the chest x-ray

[…]

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Artigo Original

The myocardium in tetralogy of Fallot: a histological and morphometric study

Maria Cecília Knoll Farah et al. Cláudia Regina Pinheiro de Castro Valéria Mello Moreira Arlindo de Almeida Riso … Antonio Augusto Barbosa Lopes Vera Demarchi Aiello

BACKGROUND: Patients with Tetralogy of Fallot frequently develop ventricular dysfunction in the postoperative period. The histological basis of this functional alteration has been scarcely studied. OBJECTIVE: To evaluate myocardial remodeling in anatomical specimens, comparing the subepicardial and subendocardial regions, especially because the subendocardial region is easily approached by means of endomyocardial biopsy. METHODS: Transmural sections of myocardium from the right ventricular (RV) inflow tract, anterior wall and infundibulum, and from the left ventricular (LV) free wall were evaluated regarding the degree of cardiomyocyte hypertrophy, vascularization and interstitial fibrosis were analyzed. RESULTS: The mean diameter of subendocardial cardiomyocytes is similar to that of subepicardial cardiomyocytes in all regions, except for the RV infundibulum, in which subendocardial cardiomyocytes are significantly larger in relation to those of the subepicardium (p=0.007). The amount of interstitial collagen is in the upper limits of normal and was similar in the subendocardial layers in comparison with the subpericardial layer of each region; however, it was greater in the inflow tract and RV anterior wall than in the LV lateral wall. The numerical density of subendocardial capillaries was similar to that of the subepicardium and was lower than the mean minus two standard deviations of normal in all regions and layers, except for the infundibulum, in which the subepicardium showed normal values and the subendocardium showed values lower than the mean minus two standard deviations. CONCLUSION: The postnatal myocardial changes in Tetralogy of Fallot are homogeneously distributed in the subepicardial and subendocardial halves of the ventricular walls, except for the infundibulum, which has peculiar remodeling characteristics and, therefore, is not representative of the other ventricular regions and layers for morphometric studies.

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Artigo Original

Cholesterol and fats in Brazilian foods: implications for prevention of atherosclerosis

Carlos Scherr et al. Jorge Pinto Ribeiro

BACKGROUND: In order to perform food surveys and prescribe diets, food composition tables have to be consulted. However, these tables are limited to the description of fatty acids and cholesterol contents and do not provide information on the different preparation methods. OBJECTIVE: Based on data derived from an extensive analysis of the chemical composition of Brazilian foods, we assessed the impact of certain types of foods on diets recommended for the prevention of coronary disease. METHODS: The fatty acid and cholesterol composition of some types of foods and different preparation methods were analyzed. These results were used according to the recommendations of the American Heart Association for an 1,800 calorie diet. RESULTS: Cholesterol found in 100g of eggs (400mg) or fried beef liver (453mg) exceeds the amount recommended for secondary prevention, and there is no difference in cholesterol content between factory-farmed eggs and free-range eggs. The eggs had an average of 400mg of cholesterol per 100g, thus exceeding the recommended amount of up to 300mg. Each egg has 50g on average; one egg can be consumed provided that not more than 100mg of cholesterol are consumed per day. As regards saturated fat, butter (55.2g), margarine (19.4g), tilsit cheese (20.4g), Brazilian Dutch Edam cheese (19.9g), yellow (16.8g) and fresh white cheese (15.5g) exceed the 14g recommended if 100g or more are consumed. The same is true for soy oil (17.5g) and corn oil (16.1g). CONCLUSION: Better knowledge on fat and cholesterol contents in foods allows the prescription of amounts not exceeding the recommended values for prevention, and this may result in better compliance to diets.

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