2011;96(6) – ABC CARDIOL

This is the case report of a young infant with early respiratory distress and pulmonary hypertension, diagnosed as a variant of horseshoe lung and we have reviewed the literature to seek information about this rare pulmonary malformation and its cardiac and hemodynamic repercussions.

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Image

Penetrating atherosclerotic ulcer involving the ascending aorta

Delicia I Gentille-Lorente et al. Daniel Ortiz-Berbel

IMAGE

Penetrating atherosclerotic ulcer involving the ascending aorta

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Point of view

The density of disciplinary knowledge motivated by the natural history of valvular heart diseases

Max Grinberg et al. Tarso Augusto Duenhas Accorsi

POINT OF VIEW

The density of disciplinary knowledge motivated by the natural history of valvular heart diseases

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Review Article

Heart failure with preserved ejection fraction: fighting misconceptions for a new approach

Ricardo Fontes-Carvalho et al. Adelino Leite-Moreira

Over the last decades, heart failure with preserved ejection fraction (HFpEF) has received less attention by the medical and scientific communities, which led to the emergence of a number of misconceptions concerning its characteristics, diagnostic and therapeutic approach. In recent years, new studies have changed the concepts traditionally associated with HFpEF, contributing to a new view towards this disease. This review is intended to discuss the latest evidence on HFpEF and to fight the main misconceptions associated with it in order to improve its diagnostic and therapeutic approach. Today we have several data showing that HFpEF is a condition that requires a different clinical approach from that used in systolic heart failure (SHF). HFpEF is no longer seen as a “benign” disease because it is associated with a poor prognosis and high prevalence. Its pathophysiology is complex and not fully clarified. In addition to diastolic dysfunction, we now know that other cardiac and extracardiac factors are also involved in its onset and progression. Using recent consensus guidelines we have objective criteria for its diagnosis, especially by using the new echocardiographic parameters for assessing diastolic function, including the E/e’ ratio obtained by tissue Doppler. Finally, treatment of HFpEF remains unknown, because no therapeutic strategy has been shown to improve HFpEF prognosis. Thus, in this review we will also discuss the potentially new therapeutic targets for HFpEF.

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Letter to the Editor

Statin in prevention of atrial fibrillation after cardiac surgery

Bárbara Zen et al. Luiza Rossi Eduardo Maffini da Rosa

LETTER TO THE EDITOR

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Letter to the Editor

Acetylsalicylic acid and clopidogrel in the prevention of stent thrombosis

Mariana Menegotto et al. Eduardo Maffini da Rosa Marina Bertoni Guerra

LETTER TO THE EDITOR

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Editorial

For patients with acute coronary syndrome, is initial measurement of troponin alone the best we have to offer?

José Carlos Nicolau et al. Remo Holanda M Furtado

EDITORIAL

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Case Report

"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy

Viviane Tiemi Hotta et al. Marcelo Luiz Campos Vieira Daniela do Carmo Rassi Silvana Angelina D'orio Nishioka … Martino Martinelli Filho Wilson Mathias Jr

Cardiac resynchronization therapy consists of a promising treatment for patients with severe heart failure, but about 30% of patients do not exhibit clinical improvement with this procedure. However, approximately 10% of patients undergoing this therapy may have hyperresponsiveness, and three-dimensional echocardiography can provide an interesting option for the selection and evaluation of such patients.

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Artigo Original

Heart rate variability in preterm and term neonates

Fabio Augusto Selig et al. Emanuele Renata Tonolli Érico Vinicius Campos Moreira da Silva Moacir Fernandes de Godoy

BACKGROUND: Several studies have demonstrated the importance of the autonomic nervous system through sympathetic and parasympathetic components in the management of the interaction between different parts of the body. These studies have applied linear and nonlinear techniques (Chaos Theory) for assessment in different situations, illnesses and age groups, using the heart rate variability (HRV). OBJECTIVE: To apply knowledge of linear and nonlinear dynamics in the assessment of preterm neonates (PTN), analyzing their HRV and comparing with healthy term neonates (NT). METHODS: Forty-eight premature neonates with different gestational ages had their heart rates assessed with the aid of a Polar Advanced S810i and HRV obtained by recording RR intervals. HRV was analyzed according to time (SDNN, RMSSD, SD1/SD2), frequency (VLF, LF, HF and LF/HF) and chaos (TAU and its standardization [TAU(n)], Lyapunov Exponent and Enthropy). PTN were compared with a group of 78 healthy NT with no perinatal events using Kruskal-Wallis nonparametric test. RESULTS: We detected a statistically significant difference between groups for all variables, both in time, frequency and chaos. CONCLUSION: Preterm Neonates have a less complex heart rate variability behavior than term neonates, which was evident in time, frequency and chaos. The study of heart rate variability in this group can be considered another tool in the evaluation of autonomic maturation and hence the progression to normality.

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Artigo Original

Vitamin C restores blood pressure and vasodilator response during mental stress in obese children

Pricilla Regina Oliveira Fernandes Fernandes et al. Fabio Alexandre dos Santos Lira Vanessa Vieira Lopes Borba Maria José Carvalho Costa … Ivani Credidio Trombeta Maria do Socorro Brasileiro Santos Amilton da Cruz Santos

BACKGROUND: Peripheral vasodilation response plays an important role in the pathophysiology of obesity and heart disease. OBJECTIVE: To evaluate the chronic effect of vitamin C (VitC) supplementation on blood pressure and on vasodilation response to mental stress. METHODS: In a double-blind, randomized and prospective study we evaluated obese children with 8 to 12 years in 2 similar groups: 1) supplemented with 500 mg VitC (n = 11) and 2) placebo (n = 10) for 45 days. Eight age-matched lean control children were also studied. We evaluated: mean blood pressure (MBP), heart rate (HR) and forearm blood flow by venous occlusion plethismography. Forearm vascular conductance (FVC) was calculated by: (forearm blood flow/PAM) X100. RESULTS: On pre-intervention evaluations obese children showed higher MBP and lower FVC compared to lean control children. After intervention VitC diminished MBP at rest (81 ± 2 vs 75 ± 1 mmHg, p = 0.01), whereas placebo did not promote changes in MBP (p = 0.58). In addition, VitC promoted FVC increase at rest (3.40 ± 0.5 vs 5.09 ± 0.6 un, p = 0.04) and during the mental stress (3.92 ± 0.5 vs 6.68 ± 0.9 un, p = 0.03). Moreover, after VitC supplementation FVC levels were similar to the lean control children at rest (5.09 ± 0.6 vs 5.82 ± 0.4 un, p > 0.05) and during mental stress (6.68 ± 0.9 vs 7.35 ± 0.5 un, p > 0.05). CONCLUSION: VitC supplementation reduced the MBP and restored peripheral vasodilatation response during mental stress in obese children.

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Artigo Original

High blood pressure detection in adolescents by clustering overall and abdominal adiposity markers

Diego G. D Christofaro et al. Raphael M Ritti-Dias Rômulo A Fernandes Marcos D Polito … Selma M. de Andrade Jefferson R Cardoso Arli Ramos de Oliveira

BACKGROUND: Obesity is linked to high blood pressure (HBP) in childhood. However, the role of fat as a predictor of HBP in adolescents remains unknown. OBJECTIVE: To investigate the association between general and abdominal obesity with HBP and to identify the sensitivity and specificity of these indicators to detect HBP in adolescents. METHODS: The sample was composed of 1,021 adolescents aged 10-17 years. Subjects were classified as normal, overweight/obese, according to BMI measurements, and as non-obese and with abdominal obesity, according to waist circumference (WC) measurements. Systolic (SBP) and diastolic (DBP) blood pressure were assessed using an oscillometric device. Logistic regression and ROC curves were used in the statistical analysis. RESULTS: The overall prevalence of HBP was 11.8% (13.4% in boys and 10.2% in girls). The prevalence of HBP among general overweight/obese boys and girls was 10% and 11.1%, respectively. The prevalence of HBP among boys with abdominal obesity was 28.6%. For both genders, the odds ratio (OR) for HBP was higher in abdominal obesity than in general overweight/obesity (4.09 [OR95%CI = 2.57-6.51]) versus 1.83 [OR95%CI = 1.83-4.30]). The OR for HBP was higher when general overweight/obesity and abdominal obesity were clustered (OR = 4.35 [OR95%CI = 2.68-7.05]), than when identified by either general overweight/obesity or abdominal obesity alone (OR = 1.32 [OR95%CI = 0.65-2.68]). However, both types of obesity had low predictive power in HBP detection. CONCLUSION: General and abdominal obesity were associated to HBP, however, the sensitivity and specificity of these variables to detect HBP are low in Brazilian adolescents.

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Artigo Original

Method of heart rate variability threshold applied in obese and non-obese pre-adolescents

Mário Augusto Paschoal et al. Caio Cesar Fontana

BACKGROUND: The detection of anaerobic threshold (AT) by heart rate variability analysis (HRVt) may mean a new way to assess the cardiorespiratory capacity (CRC) in pre-adolescents. OBJECTIVE: To test the method of HRVt to detect AT in non-obese (NO), obese (O) and morbidly obese (MO) pre-adolescents in order to determine differences in their CRC. METHODS: Were studied 30 pre-adolescents, aged between 9 and 11 years, divided into three groups of ten pre-adolescents each: a) NO group – body mass index (BMI) between 5 and 85 percentiles of the chart of National Center for Chronic Disease Prevention and Health Promotion.; b) O group – BMI between 95 and 97 of the same chart; c) MO group – BMI with percentile over 97. All were submitted to an incremental protocol conducted on a treadmill, and the heart rate was recorded for the detection of the HRVt when the beat-to-beat variability (SD1), extracted from the RR intervals, reached the value of 3 ms. RESULTS: The mean values obtained at HRVt were higher for the NO group, which included: a) VO2 (ml/kg/min) NO = 27.4 ± 9.2; O = 13.1 ± 7.6, and MO = 11.0 ± 1.7 b) HR (bpm): NO = 156.3 ± 18.0, O = 141.7 ± 11.4 and 137.7 ± 10.4 MO; c) distance (m): NO = 1,194.9 ± 427.7, O = 503.2 ± 437.5 and MO = 399.9 ± 185.1. CONCLUSION: HRVt was effective for evaluation of CRC and could be applied as an alternative method to ergoespirometry in certain situations.

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Artigo Original

Use of bipolar radiofrequency for the treatment of atrial fibrillation during cardiac surgery

Leonardo Secchin Canale et al. Alexandre Siciliano Colafranceschi Andrey José Monteiro Marialda Coimbra … Clara Weksler Ernesto Koehler Bruno Miranda Marques Marco Antonio Mattos Fernando Eugênio dos Santos Cruz Filho Roberto Luiz Menssing da Silva Sá

BACKGROUND: Atrial fibrillation with tissue ablation device through bipolar radiofrequency in conjunction with cardiac surgery has proven to be an effective method to treat this arrhythmia. OBJECTIVE: Describe the initial experience of the Instituto Nacional de Cardiologia in the surgical treatment of atrial fibrillation using bipolar radiofrequency device in patients undergoing cardiac surgery, reporting the results of postoperative follow-up of one year. METHODS: Between January 2008 and March 2009, 47 consecutive patients (36 women), with mean age of 53.7 ± 10.6 years, with atrial fibrillation for a mean period of 34.6 months (3-192 months) underwent surgical ablation of this arrhythmia, through bipolar radiofrequency during the procedure which led to the indication of surgery. Eight of them showed intermittent atrial fibrillation and 39, continued. Eighty-one percent underwent valve surgery as the main procedure. This is a one-year postoperative retrospective, observational evaluation of clinical variables and 24-h Holter. RESULTS: Out of the 47 patients, 40 survived one year. Out of these, 33 underwent 24 h Holter, at an average interval of 401 days after the surgery. The following rhythm distribution was found: 24 (73.0%) sinus, five (15.0%) atrial fibrillation, three (9.0%) atrial Flutter and one (3.0%) junctional rhythm. Two cerebrovascular accidents were observed, one of which was associated with supraventricular arrhythmia. CONCLUSION: Surgical ablation of atrial fibrillation with bipolar radiofrequency device concomitant with cardiac surgery is an effective method for treating this arrhythmia.

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Artigo Original

Analysis of mortality and hospitalization for cardiovascular diseases in Niterói, between 1998 and 2007

Maria Luiza Garcia Rosa et al. Camila Giro Thiago de Oliveira e Alves Eduardo Cardoso de Moura … Letícia da Silva Lacerda Lívia Pessoa de SantAnna Raquel de Araújo Macedo Stefan Belizário Leal Karina Seixas Garcia Evandro Tinoco Mesquita

BACKGROUND: The reduction in mortality from cardiovascular disease has been observed in Brazil for years, attributed to a fall in risk factors, improved treatment and reduced hospital mortality. OBJECTIVE: To compare the mortality, the rate of hospitalization and hospital mortality in hospitals belonging to the Brazilian Public Health System, for ischemic heart disease (IHD), cerebrovascular diseases (CVD) and heart failure (HF), in Niterói, between 1998 and 2007. METHODS: We used the number of deaths and hospitalizations and mortality of residents in Niterói for Chapter IX of ICD10 and specific causes available in Datasus, in population aged 30 and older. The difference between the magnitude of the indicators was calculated for men and women taking the average of the first three year period less the average of the second three year period. RESULTS: There was drop in population mortality rates in men and women for all age groups, in three groups of causes and for Chapter IX. The falling trend of rates decreased with age. For IHD there was a decrease in hospital mortality. For CVD and HF, there was an increase. The rates of hospitalization from IHD decreased, with exception of some ranges. CONCLUSION: This study has clarified some aspects of cardiovascular morbidity and mortality in Niterói. The reduction in population and hospital mortality from IHD indicates that there is a better approach in this condition. Increased mortality rate from cerebrovascular diseases and HF points to the need to give greater attention to the quality of hospital care for these groups of diseases.

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Artigo Original

Microvascular complications and cardiac autonomic dysfunction in patients with diabetes mellitus type 1

Fernando K Almeida et al. Jorge L Gross Ticiana C Rodrigues

BACKGROUND: The presence of cardiac autonomic neuropathy (CAN) in patients with diabetes mellitus (DM) is associated with increased mortality and chronic microvascular complications of diabetes. OBJECTIVE: To investigate a possible association between specific findings of CAN during exercise testing (ET) and nephropathy and retinopathy in patients with type 1 DM. METHODS: We conducted a cross-sectional study of 84 patients with type 1 DM. All patients underwent clinical laboratory evaluation and performed ET, and those who presented findings suggesting myocardial ischemia were excluded from data analysis (n = 3). The assessment of microvascular complications (retinopathy and nephropathy) was performed in the sample. RESULTS: Patients with nephropathy and those with retinopathy achieved a lower heart rate (HR) at peak exercise (HR max) and smaller increase in HR in relation to rest (Peak ΔHR) compared with those without these complications. These patients also had a smaller reduction in HR in the second and 4th minutes after the end of the test (ΔHR recovery 2 and 4 minutes). After performing a multivariate analysis with control for possible confounding factors, the ΔHR recovery in two and four minutes, maximum HR and Peak ΔHR remained significantly associated with retinopathy; and ΔHR recovery in the second and 4th minutes remained associated with the presence of nephropathy. CONCLUSION: The ET can be considered an additional tool for early detection of CAN and to identify patients at increased risk for microvascular complications of diabetes.

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Artigo Original

Influence of nutritional status and VO2max on adiponectin levels in men older than 35 years

Eduardo Camillo Martinez et al. Macos de Sá Rego Fortes Luiz Antônio dos Anjos

BACKGROUND: Adiponectin is considered an important factor in the pathogenesis of cardiovascular and metabolic diseases, due to its anti- atherogenic and anti-inflammatory properties. Few studies, however, have suggested the existence of a direct association between adiponectin levels and cardiorespiratory fitness and physical activity levels. OBJECTIVE: To verify the influence of the nutritional status and cardiorespiratory fitness on plasma adiponectin levels in adult men. METHODS: A total of 250 subjects, all in active duty in the Brazilian Army (BA), with a mean age of 42,6 ± 4,8 years volunteered to participate in the study. Plasma levels of adiponectin were measured, as well as body mass, height, waist circumference (WC), fat percentage by hydrostatic weighing and VO2max by ergospirometry. A questionnaire was used to obtain the characteristics of the physical training performed by the individuals. RESULTS: The sample showed that 121 (48%) individuals were overweight and 36 (14%) were obese. Moreover, 66 individuals (27%) had a body fat percentage > 25% and 26,7% had a WC > 94 cm. Overweight and obese individuals had significantly lower adiponectin levels than those with an adequate nutritional status. Individuals at the highest tertile of VO2max had higher adiponectin levels than the others. The adiponectin levels were positively correlated with the total weekly physical training time and VO2max and inversely correlated with body mass, BMI and WC. The correlation between adiponectin levels and VO2max did not remain significant after being adjusted for BMI and WC. CONCLUSION: Individuals with better cardiorespiratory fitness and normal nutritional status seem to present healthier levels of adiponectin.

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Artigo Original

Acute effect of resistance exercise intensity in cardiac autonomic modulation after exercise

Aluísio Henrique Rodrigues de Andrade Lima et al. Cláudia Lúcia de Moraes Forjaz Gleyson Queiroz de Moraes Silva Annelise Lins Menêses … Anderson José Melo Rodrigues Silva Raphael Mendes Ritti-Dias

BACKGROUND: Cardiac sympathovagal balance is altered after resistance exercise. However, the impact of the characteristics of resistance training in this response remains unclear. OBJECTIVE: Analyze the acute effect of resistance exercise intensity for trunk and upper limbs in cardiac autonomic modulation after exercise. METHODS: Fifteen young men performed three experimental sessions in random order: control (C), resistance exercise with 50% of 1-RM (E50%) and resistance exercise with 70% of 1-RM (E70%). The sessions included 05 exercises for the trunk and upper limbs performed in three sets of 12, 9 and 6 repetitions, respectively. Before and at 20 and 50 minutes after the interventions, the heart rate was measured for spectral analysis of variability. RESULTS: In comparison to the values before the intervention, the RR interval and the band of high frequency (HF) increased (major changes: + 112 ± 83 ms; +10 ± 11 un, respectively, p < 0.01), while the low frequency band (LF) and LF/HF ratio decreased (major changes: -10 ± 11 pc; -2 ± 2, respectively, p 0.05). Compared to pre-exercise values, the RR interval and the HF band decreased (major changes: -69 ± 105 ms; -13 ± 14 un, respectively, p <0.01), while the LF band and the LF/HF ratio increased (major changes: -13 ± 14 un, 13 ± 3 14 ± 3 and un, respectively, p <0.01) after E70%. CONCLUSION: The higher intensity of resistance exercise for trunk and upper limbs promoted, in an acute manner, greater increase in cardiac sympathovagal balance after exercise.

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Atualização

Reference equations for the 6-minute walk test in healthy individuals

Victor Zuniga Dourado

El test de caminata de 6 minutos (TC6) ha sido ampliamente utilizado en el ambiente clínico. Algunas ecuaciones de referencia para la previsión de la distancia recorrida en el test (DTC6) están disponibles en la literatura. Esta revisión tuvo como objetivo discutir críticamente los hallazgos de la literatura, publicados en portugués y en inglés (LILACS, SCIELO, MEDLINE y PUBMED), que evaluaron los valores normales y elaboraron ecuaciones de referencia para la previsión de la DTC6 en individuos sanos, comparándolos a los resultados recientemente obtenidos en individuos brasileños. Edad, género, peso, estatura e índice de masa corporal fueron los atributos demográficos y antropométricos más frecuentemente correlacionados con la DTC6. Las ecuaciones resultantes de esos atributos fueron capaces de explicar entre 25 y 66% de la variabilidad total de la DTC6. Lamentablemente, las ecuaciones extranjeras no son adecuadas para la población brasileña. Aun cuando el test es realizado bajo estandarización rigurosa, la diferencia de performance en el TC6 entre extranjeros y brasileños permanece, indicando la necesidad de los valores de referencias específicos para cada población y/o etnia. En ese sentido, las ecuaciones desarrolladas recientemente en el Brasil son, probablemente, las más apropiadas para interpretar la performance de caminata de nuestros compatriotas con enfermedades crónicas que afectan su capacidad para realizar ejercicios. Estudios futuros con muestras substancialmente mayores (p.e. multicéntricos) y con técnica de muestreo randomizada son necesarios para que los valores de referencia de la DTC6 sean más representativos.

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