2011;96(2) – ABC CARDIOL

Case Report

Coronary artery bypass graft (CABG) in the presence of coronary aneurysms

Jarbas J. Dinkhuysen et al. Andrea de Souza Nogueira Jose Viera Zarate Domingos Spina Neto Teresa Lola Pena Soria

This is the case of a patient with coronary aneurysms, who underwent CABG for surgical exclusion of these aneurysms, followed by implant of the bypass grafts to the arteries affected, with satisfactory short-term and long-term results.

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Special Article

Using the impact factor and H index to assess researchers and publications

Petronio Generoso Thomaz et al. Renato Samy Assad Luiz Felipe P. Moreira

SPECIAL ARTICLE

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Case Report

Endovascular stent-graft treatment of penetrating aortic ulcer

Rogério Tadeu Tumelero et al. Norberto Toazza Duda Alexandre Pereira Tognon Luciano Panata … Júlio Cesar Canfield Teixeira João Batista Machado Giongo

Penet rat ing aor t ic atherosclerot ic ulcer i s an underdiagnosed condition that presents high rates of morbidity and mortality. We report two cases of patients with severe chest pain, with no ischemic features, who underwent chest angiotomography and showed an ulceration of the aortic wall, with contrast penetration into the middle layer. Due to the failure of the medical treatment, the patients underwent percutaneous aortic stent implantation with complete resolution of symptoms.

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Atualização

Pharmacogenetic implications of the eNOS polymorphisms for cardiovascular action drugs

Pâmela Souza Silva et al. Riccardo Lacchini Valéria de Aguiar Gomes José Eduardo Tanus-Santos

The pharmacogenetics is one of the most promising fields of medicine. The conclusion of the Genome Project allowed this field to start discovering complex factors modulating the response to drugs, and new technologies are close a great expansion of the area. The cardiovascular diseases are currently among the major causes of hospitalizations and death, and have been the target of a large part of genetic studies of complex diseases. Parallel to the susceptibility to disease markers identification, it is necessary to investigate how different genetic profiles can change the responses to the currently used drugs. The biological system that controls the endothelial production of the nitric oxide has been one of the greatest targets in the pharmacological responses to the drugs used in the cardiovascular diseases therapy. This review aims at approaching the current knowledge on interaction among the genetic variations of eNOS and the pharmacological responses to the drugs used in the cardiovascular system.

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Review Article

ERRATUM

December 2010 issue, vol. 95 (6), pp. 705-712

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Clinicoradiological Session

Case 2/2011: forty-three months old child, male, with multiple ventricular septal defect, unfavorable clinical course, long term after anatomical correction

Edmar Atik

CLINICORADIOLOGICAL SESSION

Case 2/2011 – forty-three months old child, male, with multiple ventricular septal defect, unfavorable clinical course, long term after anatomical correction

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Artigo Original

Acute effects of smoking on autonomic modulation: analysis by poincare plot

Beatriz Martins Manzano et al. Luiz Carlos Marques Vanderlei Ercy Mara Ramos Dionei Ramos

BACKGROUND: Smoking affects the autonomic function. OBJECTIVE:To investigate the acute effects of smoking on the autonomic modulation and the post-smoking recovery of the heart rate variability (HRV) index through Poincare plot and linear indices. METHODS: A total of 25 young smokers underwent beat-to-beat analysis of heart rate in the sitting position after 8 hours of tobacco abstinence, for 30 minutes at rest, 20 minutes while smoking and 30 minutes after smoking. The analysis of variance for repeated measures, followed by Tukey’s test or Friedman’s test followed by Dunn’s test, were applied depending on the normality of data, with p < 0.05. RESULTS: While smoking, there was a decrease in the indices: SD1 (23.4 ± 9.2 vs 13.8 ± 4.8), SD1/SD2 ratio (0.31 ± 0.08 vs 0.2 ± 0.04), RMSSD (32,7 ± 13 vs 19.1 ± 6.8), SDNN (47.6 ± 14.8 vs 35.5 ± 8.4), HFnu (32,5 ± 11.6 vs 19 ± 8.1) and the RR interval (816.8 ± 89 vs 696.5 ± 76.3) in relation to the rest period, whereas increases in the LFnu index (67.5 ± 11.6 vs 81 ± 8.1) and the LF/HF ratio (2.6 ± 1.7 vs 5.4 ± 3.1) were observed. The visual analysis of the plot showed a lower dispersion of RR intervals while smoking. Except for the SD1/SD2 ratio, the other indices presented recovery of values 30 minutes after smoking. CONCLUSION: Smoking resulted in acute modifications of the autonomic control, characterized by sympathetic activation and vagal withdrawal, presenting recovery 30 minutes after smoking.

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Artigo Original

Risk factors for mortality in octogenarians undergoing myocardial revascularization surgery

Isaac Newton Guimarães et al. Fernando Moraes João Paulo Segundo Igor Silva … Tamyris Guimarães Andrade Carlos R. Moraes

BACKGROUND: The complexity of reentrant circuits related to ventricular tachycardias decreases the success rate of radiofrequency ablation procedures. OBJECTIVE: To evaluate whether the epicardial mapping with multiple electrodes carried out simultaneously with the endocardial mapping helps in ablation procedures of sustained ventricular tachycardia (VT) in patients with nonischemic heart disease. METHODS: Twenty-six patients with recurrent sustained VT, of which 22 (84.6%) presenting chronic chagasic cardiomyopathy, 2 (7.7%) with idiopathic dilated cardiomyopathy and 2 with right ventricular arrhythmogenic dysplasia (RVAD), were submitted to epicardial mapping with two or three microcatheters, with 8 electrodes each, simultaneously to the conventional endocardial mapping. A catheter with a 4-mm tip was used for the ablation by radiofrequency (RF) carried out during the induced VT. RESULTS: Of the 33 induced VT, 25 were mapped and 20 had their origin defined. Eleven had epicardial and 9 had endocardial origin. The programmed ventricular stimulation did not induce sustained VT in 11 (42.0%) of the 26 patients after the ablation. Events such as VT recurrence and death occurred in 10.0% of the patients submitted to successful ablation and in 59.0% of the unsuccessful cases, during a mean ambulatory follow-up of 357 ± 208 days. CONCLUSION: Subepicardial circuits are frequent in patients with nonischemic heart disease. The epicardial mapping with multiple catheters carried out simultaneously with the endocardial mapping contributes to the identification of these circuits in a same procedure.

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Artigo Original

Epicardial mapping of sustained ventricular tachycardia in nonischemic heart disease

Geórgia Guedes da Silva et al. Henrique Horta Veloso Luiz Roberto Leite Roberto Lima Farias Angelo Amato Vincenzo de Paola

BACKGROUND: The complexity of reentrant circuits related to ventricular tachycardias decreases the success rate of radiofrequency ablation procedures. OBJECTIVE: To evaluate whether the epicardial mapping with multiple electrodes carried out simultaneously with the endocardial mapping helps in ablation procedures of sustained ventricular tachycardia (VT) in patients with nonischemic heart disease. METHODS: Twenty-six patients with recurrent sustained VT, of which 22 (84.6%) presenting chronic chagasic cardiomyopathy, 2 (7.7%) with idiopathic dilated cardiomyopathy and 2 with right ventricular arrhythmogenic dysplasia (RVAD), were submitted to epicardial mapping with two or three microcatheters, with 8 electrodes each, simultaneously to the conventional endocardial mapping. A catheter with a 4-mm tip was used for the ablation by radiofrequency (RF) carried out during the induced VT. RESULTS: Of the 33 induced VT, 25 were mapped and 20 had their origin defined. Eleven had epicardial and 9 had endocardial origin. The programmed ventricular stimulation did not induce sustained VT in 11 (42.0%) of the 26 patients after the ablation. Events such as VT recurrence and death occurred in 10.0% of the patients submitted to successful ablation and in 59.0% of the unsuccessful cases, during a mean ambulatory follow-up of 357 ± 208 days. CONCLUSION: Subepicardial circuits are frequent in patients with nonischemic heart disease. The epicardial mapping with multiple catheters carried out simultaneously with the endocardial mapping contributes to the identification of these circuits in a same procedure.

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Artigo Original

Correlation between diastolic function and maximal exercise capacity on exercise test

Maria Estefânia Bosco Otto et al. Márcio Mendes Pereira Adenalva Lima de Souza Beck Maurício Milani

BACKGROUND: Increased pulmonary capillary pressure (PCP) is one of the mechanisms of exercise intolerance. Assessment of the diastolic function by echocardiography (ECHO) enables estimation of PCP. OBJECTIVE: To identify variables that determine the exercise capacity in patients undergoing routine exercise test (ET), conventional ECHO, and tissue Doppler imaging (TD). METHODS: A total of 640 patients undergoing ET, ECHO, and TD were retrospectively studied. Patients with ejection fraction 10 was considered an estimate of increased PCP. Maximal exercise capacity was analyzed by the number of metabolic equivalents (MET). The patients were divided into two groups for analysis: MET7 (n=572). Morise score showed a population at low risk (60%) for coronary artery disease (CAD). RESULTS: The number of patients with E/e’ > 10 was significantly higher in the MET 7 group (41.7% vs 9.4%, p=0.001), and so was the presence of any degree of diastolic dysfunction (76.6% vs 34.1% p=0.001). Using logistic regression analysis, age, female gender and A velocity (late diastole) were the independent variables related to a low exercise capacity (MET < 7). CONCLUSION: Diastolic dysfunction as determined by ECHO, female gender, and age are associated with a lower exercise capacity in a population at low risk for CAD.

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Artigo Original

Prediction of metabolic syndrome in children through anthropometric indicators

Aparecido Pimentel Ferreira et al. Cristiane Batisti Ferreira Ciro José Brito Francisco José Gondim Pitanga … Clayton Franco Moraes Luciana Ansaneli Naves Otávio de Toledo Nóbrega Nancí Maria de França

BACKGROUND: Because of the need to measure anthropometric, biochemical and hemodynamic variables for the diagnosis of metabolic syndrome, we realize how difficult it is to analyze large populations, especially children, due to the poor accessibility and the invasive character. There is an urgent need to develop easy-to-use, accurate and low-cost diagnostic tools in order to predict metabolic syndrome at early ages. OBJECTIVE: To verify the prevalence of metabolic syndrome in children and to test predictive anthropometric indicators. METHODS: Cross-sectional study conducted among 109 children aged 7 to 11 years. The age-adjusted National Cholesterol Education Program definition was used for the diagnosis of metabolic syndrome. The following parameters were tested as possible predictors: body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), conicity index (C index), and body fat percentage. RESULTS: The prevalence of metabolic syndrome was 13.3% and 36% for boys and girls, respectively. The main anthropometric indicators were: BMI = 0.81 (0.69 – 0.94), WC = 0.79 (0.64 – 0.94), body fat = 0.79 (0.66 – 0.92) and WHR = 0.37 (0.21 – 0.54). CONCLUSION: WC higher than 78 cm, body fat higher than 41%, and BMI higher than 24.5 kg/m² were considered predictors of metabolic syndrome. The C index and WHR were not considered predictors.

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Artigo Original

Evaluation of cardiopulmonary fitness in individuals with hemiparesis after cerebrovascular accident

Angélica Cristiane Ovando et al. Stella Maris Michaelsen Tales de Carvalho Vanessa Herber

BACKGROUND: Due to the hemiparesis, the assessment of cardiorespiratory fitness on individuals after cerebrovascular accident (CVA), using exercise tests with conventional protocols, has become a challenge. OBJECTIVE: Perform cardiopulmonary test (CPT) in hemiparetic patients to a pre-participation evaluation aimed at a careful prescription of aerobic exercise. METHODS: The study included eight individuals with chronic hemiparesis who underwent CPT performed with individualized ramp protocol, developed from information on the gait speed of individuals previously evaluated in the track test. We considered the proposal of inclination ranging from 0 to 10.0%, initial speed corresponding to 70.0% of comfortable walking speed rhythm and 40.0% higher than the maximum speed on the track test, expecting that the CPT with this gradual and steady increase in intensity, lasted from 6 to 8 minutes. RESULTS: In 100.0% of the sample, the reason for discontinuation was peripheral fatigue. The peak VO2 achieved was 20.6 ± 5.7 ml/kg.min. The threshold I was identified in all tests, standing at 82.64 ± 4.78% of peak HR and 73.31 ± 4.97% of peak VO2. The respiratory quotient (R) of the group was 0.96 ± 0.09, and three out of eight individuals (37.5%) reached R higher than 1.00, and the Threshold II was identified in these individuals. We found positive relationships between CPT variables and balance scores, performance in the 6-minute walking test and running speed on the ground. CONCLUSION: The test proved to be useful for prescribing physical activity in these individuals.

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Review Article

Behavior of central and peripheral chemoreflexes in heart failure

Guilherme Veiga Guimarães et al. Juliana Fernanda Canhadas Belli Fernando Bacal Edimar Alcides Bocchi

The heart failure (HF) syndrome can be defined as the final pathway of any type of heart disease. The sympatho-inhibitory cardiovascular reflexes, such as the arterial baroreceptor reflex, are significantly decreased in HF. Patients with HF present higher ventilation for a certain workload when compared with normal individuals. This fact generates low ventilatory efficiency and is related to higher ventilation associated with the carbon dioxide production, which is a predictor of bad prognosis, in addition to being a limiting factor for the practice of exercises. There is evidence that the autonomic imbalance contributes to the pathogenesis and the progression of heart failure. The chemoreflexes are the main mechanisms of control and regulation of the ventilatory responses to the changes in concentrations of arterial oxygen and carbon dioxide. The chemoreflex activation causes an increase in the sympathetic activity, heart rate, arterial pressure and minute volume. However, the increase in the minute volume and the arterial pressure, due to negative feedback, cause inhibition of the sympathetic response at the chemoreflex activation. In spite of the functional alterations of the reflexes, their behavior in normal and pathological conditions, especially their contribution to the sympathoexcitatory state observed in HF has not been broadly studied. Therefore, this review aims at integrating the knowledge on central and peripheral chemoreflexes in HF syndrome, as well as clarifying the influence of the heart failure drug therapy on the chemoreflexes.

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Artigo Original

Sidestream cigarette smoke exposure effects on baroreflex in adult rats

Vitor E. Valenti et al. Luiz Carlos de Abreu Celso Ferreira

BACKGROUND: It has been evidenced in the literature that exposure to cigarette smoke causes hypertension in rats; however, it has not been demonstrated if the baroreflex function is impaired before the animal becomes hypertensive. OBJECTIVE: We evaluated short-term effects of sidestream cigarette smoke (SSCS) exposure on baroreflex function in Wistar normotensive rats. METHODS: Rats were exposed to SSCS during three weeks, 180 minutes, five days per week, at a concentration of monoxide carbon between 100-300 ppm. Mean arterial pressure (MAP) and heart rate (HR) were evaluated through cannulation of the femoral vein and artery. RESULTS: There was no significant difference between control and SSCS groups regarding basal mean arterial pressure and heart rate, sympathetic and parasympathetic components of the baroreflex function. CONCLUSION: Our data suggest that three weeks of exposure to SSCS is not enough to significantly impair cardiovascular parameters and baroreflex sensitivity in normotensive Wistar rats.

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Artigo Original

Intramyocardial adrenergic activation in chagasic cardiomyopathy and coronary artery disease

Luciano Nastari et al. Felix Jose Alvarez Ramires Vera Maria Cury Salemi Barbara Maria Ianni … Fábio Fernandes Célia Maria Strunz Edmundo Arteaga Charles Mady

BACKGROUND: Myocardial norepinephrine is altered in left ventricular impairment. In patients with Chagas’ cardiomyopathy (CC), this issue has not been addressed. OBJECTIVE: To determine the level of myocardial norepinephrine in patients with CC and compare it in patients with coronary artery disease, and to relate myocardial norepinephrine to left ventricular ejection fraction (LVEF). METHODS: We studied 39 patients with CC, divided into group 1: 21 individuals with normal LVEF and group 2: 18 individuals with decreased LVEF. Seventeen patients with coronary artery disease were divided into group 3: 12 individuals with normal LVEF and group 4: 5 individuals with decreased LVEF. Two-dimensional echocardiography was used to measure LVEF. Myocardial norepinephrine was determined by high-performance liquid chromatography. RESULTS: Myocardial norepinephrine in CC with and without ventricular dysfunction was 1.3±1.3 and 6.1±4.2 pg/μg noncollagen protein, respectively (p<0.0001); in coronary artery disease with and without ventricular dysfunction, it was 3.3±3.0 and 9.8±4.2 pgμg noncollagen protein, respectively (p<0.0001). A positive correlation was found between LVEF and myocardial norepinephrine concentration in the patients with Chagas' cardiomyopathy (p<0.01, r = 0.57) and also in those with coronary artery disease (p<0.01, r=0.69). A significant difference was demonstrated between norepinephrine concentrations in patients with normal LVEF (groups 1 and 3; p = 0.0182), but no difference was found in patients with decreased LVEF (groups 2 and 4; p = 0.1467). CONCLUSION: In patients with Chagas' cardiomyopathy and normal global ejection fraction there is an early cardiac denervation, when compared to coronary artery disease patients.

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Artigo Original

Anthropometric indicators as predictors of high blood pressure in adolescents

Carmem Cristina Beck et al. Adair da Silva Lopes Francisco José Gondim Pitanga

BACKGROUND: Hypertension is related to increased body fat, which can be evaluated by anthropometric indicators. OBJECTIVE: To determine the predictive power of anthropometric indicators and establish their cutoff points as discriminators of high blood pressure. METHODS: Cross-sectional study with a sample of 660 adolescents aged 14 to 19 including 51.9% girls. We considered the following anthropometric indicators: body mass index (BMI), waist circumference, waist-to-height ratio and conicity index. High blood pressure was characterized by values above the 90th percentile for systolic and/or diastolic blood pressure. To identify predictors of high blood pressure, we adopted the analysis of receiver operating characteristic curves (ROC) with a confidence interval of 95%. Subsequently, we identified the cutoff points with their relevant sensitivities and specificities. RESULTS: The areas under the ROC curves with confidence intervals were: boys – waist circumference = 0.80 (0.72 to 0.89); BMI = 0.79 (0.68 to 0.89), waist-to-height ratio = 0.77 (0.66 to 0.88); conicity index = 0.69 (0.56 to 0.81) and for girls – waist circumference = 0.96 (0.92 to 1.00); BMI 0.95 (0.87 to 1.00), waist-to-height ratio = 0.93 (0.85 to 1.00); conicity index = 0.74 (0.50 to 0.98). The different cutoff points of anthropometric indicators with better predictive power and their relevant sensitivities and specificities were identified. CONCLUSION: Although the waist-to-height ratio and BMI have shown good areas under the ROC curve, we suggest the use of waist circumference to predict high blood pressure.

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Artigo Original

Inflammatory markers and antichlamydial antibodies in patients with metabolic syndrome

Rosecler Riethmuller Franco et al. Luiz Carlos Bodanese Giuseppe Repetto Jacqueline da Costa Escobar Piccoli … Mario Wiehe Cassiane Bonato Marta Maria Medeiros Frescura Duarte Thiago Duarte

BACKGROUND: The metabolic syndrome is associated with increased risk of cardiovascular events. Inflammatory markers and antichlamydial antibodies have been linked to the development and progression of atherosclerosis and cardiovascular events. OBJECTIVE: To evaluate the inflammatory markers interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), as well as anti-chlamydia pneumoniae antibodies, in patients with metabolic syndrome (MS), with and without cardiovascular events. METHODS: Cross sectional study consisting of 147 individuals. Out of these, 100 (68%) with MS and without cardiovascular events; and 47 (32%) with MS and with cardiovascular events. Among the individuals who had had cardiovascular events, 13 (6.11%) had acute myocardial infarction (AMI) and ten (4.7%) had cerebrovascular accident (CVA). The diagnosis of MS was determined by the criteria of NCEP-ATPIII. RESULTS: The mean age of subjects with cardiovascular events was 61.26 ± 8.5 and 59.32 ± 9.9 in subjects without such events (p = 0.279), with a predominance of females. The weight, height, BMI and waist circumference of the group with MS and without event was greater. Among individuals with cardiovascular events (p = 0.001), the inflammatory markers IL-6 and TNF-α and the peripheral vascular disease were significantly greater. There were high levels of IgG antibodies to C. pneumoniae in the SM group, without events, and of IgA antibodies in the group with events, when the two groups were compared. With respect to AMI and stroke, the anti-chlamydia pneumoniae antibodies showed no statistical significance, compared to the group without cardiovascular events. An association was observed with the use of statins, nonsteroidal anti-inflammatory drugs and injectable, oral hypoglycemic agents, in the group with these events. CONCLUSION: The inflammatory markers were significantly elevated in patients with MS, with acute myocardial infarction and stroke. There was no significant difference in anti-chlamydial antibodies in patients with MS, with and without events.

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