2011;97(5) – ABC CARDIOL

Letter to the Editor

Heart failure: walk test versus peak oxygen consumption

Guilherme Veiga Guimarães et al. Jean Marcelo Roque Edimar Alcides Bocchi

LETTER TO THE EDITOR

Heart failure: walk test versus peak oxygen consumption

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Clinical Update

Biofilm on artificial pacemaker: fiction or reality?

Ana Paula Azevedo Santos et al. Evandro Watanabe Denise de Andrade

Cardiac pacing through cardiac pacemaker is one of the most promising alternatives in the treatment of arrhythmias, but it can cause reactions natural or complex reactions, either early or late. This study aimed to describe the scientific evidence on the risk of infection and biofilm formation associated with cardiac pacemaker. This is a study of integrative literature review. It included 14 publications classified into three thematic categories: diagnosis (microbiological and/or clinical), complications and therapy of infections. Staphylococcus epidermidis and Staphylococcus aureus were the microorganisms most frequently isolated. It was not possible to determine the incidence of infection associated with pacemakers, since the studies were generally of prevalence. In terms of therapy, the complete removal of pacemakers stood out, especially in cases of suspected biofilm. Still controversial is the use of systemic antibiotic prophylaxis in reducing the incidence of infection associated with implantation of a pacemaker

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Point of view

Carcinoid heart valve disease: still a puzzle and a challenge

Paulo Roberto Barbosa Evora et al. Solange Bassetto Viviane S Augusto Walter V. A Vicente

POINT OF VIEW

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Case Report

Lactococcus garvieae endocarditis: first case report in Latin America

Tatiana Franco Hirakawa et al. Fernando Augusto Alves da Costa Marcos Cairo Vilela Micheli Rigon … Henry Abensur Maria Rita Elmor de Araújo

Lactococcus garvieae, an emerging zoonotic pathogen, is responsible for mastitis in rodents and sepsis in fish. Although deemed opportunistic and hardly ever causing infections in humans, its incidence is probably underestimated due to the difficulty in diagnosis. There are very few reports of osteomyelitis, liver abscess, and peritonitis, and only nine cases of endocarditis described in worldwide literature. We describe the first case of Lactococcus garvieae endocarditis in Latin America, in a female patient with metallic prosthetic heart valve who presented with daily fever, chills, Osler nodes and six positive blood cultures for Lactococcus garvieae, which met Duke’s criteria for the diagnosis of “definitive infective endocarditis”

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Editorial

Ebstein's Anomaly

Edmar Atik

EDITORIAL

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Case Report

Mycotic coronary aneurysm: report of two cases

Franco Javier Vallejo Garcia et al. Carlos Eusse Carlos Tenorio Carlos Uribe

The number of percutaneous interventions with stent implantation has increased dramatically in recent years, although the frequent use of this device in reports of infections is extremely rare. In this article we report two cases of mycotic aneurysm after implantation of stents with different clinical presentations and outcomes

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Review Article

Emerging role of the GH/IGF-I on cardiometabolic control

Carla R.P Oliveira et al. Rafael A Meneguz-Moreno Manuel H Aguiar-Oliveira José A. S Barreto-Filho

Growth hormone (GH), the main regulator for post-natal growth, has important metabolic actions on different tissues, similar or opposite to insulin like growth factor I (IGF-I), mainly produced by the liver after the binding of GH to its receptor. Experiments with animal models indicate an important role of GH on insulin resistance although the IGF-I role is not yet completely established. In humans, GH promotes an increase on lypolisis and lipid oxidation, while IGF-I leads to an increase on lipid oxidation only in a chronic way. While growth actions are time-limited, metabolic and cardiovascular actions of the GH/IGF-I axis are throughout life. GH anabolic effects have been used on chronic and hypercatabolic conditions, although investigations on the clinical outcomes are still scarce. In this paper, we intend to review GH metabolic actions experienced by animal models, studies with normal humans and GH deficient individuals, individuals with diabetes mellitus type 1 and metabolic syndrome individuals, hypercatabolic states and the relationship between GH and adipokines, endothelial disfunction and atherogenesis

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Correlação Clínico-Radiográfica

Case 6/2011 – 27-year-old woman with anomalous origin of left coronary artery from the pulmonary trunk

Edmar Atik

CLINICORADIOLOGICAL SESSION

Case 6/2011 – 27-year-old woman with anomalous origin of left coronary artery from the pulmonary trunk

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Artigo Original

Hemodynamic responses to an isometric handgrip training protocol

Claudio Gil Soares de Araújo et al. Carlos Vieira Duarte Fábio de Albuquerque Gonçalves Hugo Baptista de Oliveira Medeiros … Flávio Areal Lemos André Luiz Gouvêa

BACKGROUND: In the past, isometric exercises were proscribed for heart disease. However, recent evidence suggests that an isometric handgrip training (IHT) protocol – four sets of two minutes at 30% of maximum strength – produces favorable effects on the autonomic modulation and reduces resting systolic (SBP) and diastolic (DBP) blood pressure. OBJECTIVE: Aiming at obtaining support for broad clinical applicability, we quantified the main hemodynamic responses during an IHT session in patients from a supervised physical exercise program. METHODS: Forty-one patients (36 men) underwent the IHT with measurements of heart rate (HR) and BP before, during each of the two series performed with the left arm and one minute after completion. Measurements were obtained by an electrocardiogram signal in a digital Tango + oscillometric tensiometer, previously validated for physical exercise conditions. RESULTS: The IHT was appropriately carried out, with no clinical adverse reactions. There was a small increase in SBP and DBP levels, respectively, of 16 and 7 mmHg (p <0.05) and an even smaller increase in HR – 3 bpm – (p <0.05) when we compared the data obtained at 80 seconds of the last series with the pre-exercise CONCLUSION: IHT was well tolerated by patients undergoing exercise programs, resulting in a transient and modest hemodynamic effect, without inducing rapid cardiac vagal inactivation, characteristic of dynamic and short exercises.

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Artigo Original

Asymptomatic coronary artery disease in chagasic patients

Gustavo Carvalho et al. Salvador Rassi José Maria Dias de Azeredo Bastos Sílvio Sérgio Pontes Câmara

BACKGROUND: Concomitant asymptomatic coronary artery disease in patients with Chagas cardiomyopathy in heart failure is controversial in the medical literature, as both diseases are prevalent in some regions of Brazil. OBJECTIVE: To determine the prevalence of coronary artery disease (lesions > 50%) in a specific population of patients with Chagas cardiomyopathy in HF functional class III and IV, who had no previous coronary events. METHODS: Coronary angiography was performed in 61 consecutive patients with Chagasic cardiomyopathy, in heart failure functional class III and IV, to exclude coronary artery disease. These patients were part of the Cell Therapy Study in Heart Diseases protocol, which required the coronary angiography to be carried out before stem cells were injected. Risk factors for atherosclerosis also analyzed in this population were: age, arterial hypertension, diabetes, dyslipidemia, smoking and overweight. RESULTS: mean age was 51.6 + 9.6 years and 65.5% (n = 40) of them were males. The prevalence of coronary disease in this population was 1.6% (1). The prevalence of risk factors were: arterial hypertension 18% (11), smoking 59% (36), diabetes 1.6% (1) and dyslipidemia, 6.5% (4). CONCLUSION: The prevalence of asymptomatic coronary artery disease in patients with severe heart failure due to Chagas disease is low and among the risk factors for coronary heart disease, smoking was the most prevalent.

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Artigo Original

Intracoronary stem-cell injection after myocardial infarction: microcirculation sub-study

Rodrigo de Carvalho Moreira et al. Andréa Ferreira Haddad Suzana Alves Silva André Luiz Silveira Souza … Fábio Antônio Abrantes Tuche Mônica Amorim de Oliveira Cláudio Tinoco Mesquita Carlos Eduardo Rochitte Radovan Borojevic Hans Fernando Rocha Dohmann

BACKGROUND: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route. OBJECTIVE: To compare the cell distribution and retention pattern in the anterograde and retrograde routes. To investigate the role of microvascular obstruction by magnetic resonance imaging in cell retention by cardiac tissue after the injection of bone marrow mononuclear cells (BMMC) in AMI. METHODS: This was a prospective, open label, randomized study. Patients with AMI who presented: (1) successful chemical or mechanical reperfusion within 24 hours of symptom onset and (2) infarction involving more than 10% of the left ventricle (LV) at the myocardial scintigraphy were included in the study. One hundred million BMMC were injected into the infarction-related artery through IAC route, or vein through the IVC route. One percent of the injected cells were labeled with 99mTc-hexamethyl-propylene-amine-oxime (99mTc-HMPAO). Cell distribution was evaluated at 4 and 24 hours after the myocardial scintigraphy injection. Cardiac magnetic resonance imaging was performed before cell injection. RESULTS: Thirty patients were randomized into three groups. There were no serious adverse events related to the procedure. The early and late retention of labeled cells was higher in the IAC group than in IVC group, regardless of the presence of microcirculation obstruction. CONCLUSION: The injection using the retrograde approach was feasible and safe. Cell retention by cardiac tissue was higher using the anterograde approach. More studies are needed to confirm these findings.

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Artigo Original

Hospitalization and mortality rates for heart failure in public hospitals in São Paulo

Henrique L. Godoy et al. José A. Silveira Eduardo Segalla Dirceu R. Almeida

BACKGROUND: Advances in the treatment of heart failure (HF) have resulted in reduced mortality and hospitalization rates. On the other hand, when hospitalized, patients are at high risk of death. OBJECTIVE: As there are few studies in this group of patients in Brazil, we analyzed the numbers of hospitalization and deaths due to HF in the Brazilian Public Health System (SUS) in the city of São Paulo. METHODS: Historical prospective study carried out between 1992 and 2010. The data were obtained from DATASUS. We used Chi-square and t tests for comparison between the periods 1992-1993 and 2008-2009 and logistic regression models when appropriate. The level of significance was set at 5%. RESULTS: There was a 32% decrease in the number of hospitalizations for HF between 1992-1993 and 2008-2009 (p = 0.002). The in-hospital mortality rate for HF was 15%, with a 15% increase in the period (p = 0.004). Between 1992 and 1993, the mean time of hospitalization for HF was 8.8 days. Between 2008 and 2009, it was 11.3 days (p = 0.001). August was the month with the highest incidence of hospitalizations for HF, 20% higher than in February, the month with the lowest incidence (p = 0.041). CONCLUSION: This study showed changes in trends of hospitalization for HF and mortality over the last two decades. We emphasize important implications: 1: 32% decrease in the number of hospitalizations for HF in SUS hospitals in São Paulo; 2: 25% increase in hospitalization time, and 3: seasonal pattern of hospitalization for HF, with a peak in the third quarter.

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Artigo Original

Perioperative blood glucose level and postoperative complications in pediatric cardiac surgery

Rodrigo Leal Alves et al. Macius Pontes Cerqueira Nadja Cecília de Castro Kraychete Guilherme Oliveira Campos … Marcelo de Jesus Martins Norma Sueli Pinheiro Módolo

BACKGROUND: Anesthesia for pediatric cardiac surgery is systematically performed in severely ill patients under abnormal physiological conditions. In the intraoperative period, there are significant variations in blood volume, body temperature, plasma composition, and tissue blood flow, in addition to activation of inflammation, with important consequences. Serial measurements of blood glucose levels can indicate states of exacerbation of the neuroendocrine-metabolic response to trauma, serving as prognostic markers of morbidity in that population. OBJECTIVE: To correlate perioperative blood glucose levels of children undergoing cardiac surgery with the occurrence of postoperative complications, and to compare intraoperative blood glucose levels according to perioperative conditions. METHODS: Information regarding the surgical/anesthetic procedure and perioperative conditions of patients was collected from the medical records. The mean perioperative blood glucose levels in the groups of patients with and without postoperative complications and the frequencies of perioperative conditions were compared by use of odds ratio and non-parametric univariate analyses. RESULTS: Higher intraoperative blood glucose levels were observed in individuals who had postoperative complications. Prematurity, age group, type of anesthesia, and character of the procedure did not influence the mean intraoperative blood glucose level. The use of extracorporeal circulation (ECC) was associated with higher blood glucose levels during surgery. In procedures with ECC, higher blood glucose levels were observed in individuals who had infectious and cardiovascular complications. In surgeries without ECC, that association was observed with infectious and hematological complications. CONCLUSION: Higher intraoperative blood glucose levels are associated with higher morbidity in the postoperative period of pediatric cardiac surgery.

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Artigo Original

Calcium score in the evaluation of atherosclerosis in patients with HIV/Aids

Verônica Soares Monteiro et al. Heloisa Ramos Lacerda Marly Uellendahl Tien Man Chang … Valéria Maria de Albuquerque Josefina Cláudia Zirpoli Ricardo Araes Ximenes Maria de Fátima Militão de Albuquerque Demócrito de Barros Miranda Filho Dário Sobral Filho

BACKGROUND: Antiretroviral therapy has dramatically increased life expectancy in patients with HIV/AIDS although atherosclerosis has been associated with long-standing therapy. OBJECTIVE: To investigate the prevalence of atherosclerosis in patients with AIDS undergoing antiretroviral therapy and the influence of different schemes and duration of treatment. METHODS: HIV/AIDS patients were approached during routine consultations. Those who had been on antiretroviral therapy for at least two years had their blood collected for analysis of lipid profile and fasting glycemia and underwent cardiac CT for quantification of calcium score within six days at the most. Atherosclerosis was defined as calcium score greater than zero (CAC > 0). Traditional risk factors, metabolic syndrome and Framingham score were analyzed. RESULTS: Fifty-three patients performed cardiac CT. Twenty-seven (50.94%) were male, mean age 43.4 years; 20.00% had hypertension, 3.77% diabetes, 67.92% hypercholesterolemia, 37.74% hypertriglyceridemia and 47.17% low HDL. Thirteen (24.53%) met criteria for metabolic syndrome and 96.23% were classified in Framingham score as “low risk.” Ten patients (18.87%) were smokers. Mean duration of antiretroviral treatment was 58.98 months. Coronary atherosclerosis occurred in 11 (20.75%) patients. Duration of antiretroviral therapy was not related to atherosclerosis (p = 0.41) and there were no significant differences between different antiretroviral regimens (p = 0.71). Among traditional risk factors, smoking (OR = 27.20; p = 0.023) and age (OR = 20.59; p = 0.033) were significant in the presence of atherosclerosis. There was a trend towards a positive association of atherosclerosis with hypercholesterolemia (OR = 8.30; p = 0.0668). CONCLUSION: Factors associated with atherosclerosis were age, smoking and hypercholesterolemia. Duration and type of antiretroviral therapy had no influence on the prevalence of atherosclerosis.

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Artigo Original

Insulin resistance and its association with metabolic syndrome components

Carla Campos Muniz Medeiros et al. Alessandra Teixeira Ramos Maria Aparecida Alves Cardoso Inácia Sátiro Xavier França … Anajás da Silva Cardoso Nathalia Costa Gonzaga

BACKGROUND: Individuals with insulin resistance are more prone to the development of metabolic syndrome (MS), Type 2 Diabetes Mellitus and Cardiovascular Disease (CVD) OBJECTIVE: To evaluate the association between insulin resistance (IR) and metabolic syndrome components. METHODS: Cross-sectional study of 196 individuals between 2 and 18 years, treated at the Brazilian Public Healthcare system. The association of IR with the MS components was evaluated by Chi-square test, adopting the Homeostasis model assessment-insulin resistance (HOMA-IR) value > 2.5, and by analysis of variance (ANOVA) and Tukey’s test, by comparing the means of the components in the HOMA-IR quartiles. Statistical analysis was performed using SPSS 17.0 software and significance level was set at 5%. RESULTS: IR was observed in 41.3% of the studied population and was associated with age between 10-18 years (p = 0.002 PR = 3.2), to MS in both sexes [Male (p = 0.022 PR = 3.7) and female (p = 0.007 PR = 2.7)] and altered triglycerides (p = 0.005 PR = 2.9) in females. The mean values of the MS components differed significantly between HOMA-IR quartiles (p <0.01), except for HDL-cholesterol. CONCLUSION: Insulin resistance can be considered a marker of cardiovascular risk.

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Artigo Original

Preoperative C-reactive protein predicts respiratory infection after coronary artery bypass graft surgery

Agda Mezzomo et al. Odemir L. Bodin Jr. Vera Lucia

BACKGROUND: Increased levels of high-sensitive C-reactive protein (hsCRP) in the preoperative evaluation for coronary artery bypass graft surgery (CABG) have been associated to poor outcomes in the postoperative period. OBJECTIVE: To evaluate the association of high levels of hsCRP with short-term outcomes after cardiac surgery. METHODS: Prospective cohort with 331 patients who underwent CABG surgery with cardiopulmonary bypass (CPB) at our Institution. Patients were assigned to two groups according to hsCRP levels, measured before surgery: normal (N group) with 3 mg/l hsCRP. This cutoff of 3 mg/l had a sensitivity and specificity of 60% for predicting respiratory infection, with a power of 90%. The patients were followed-up during the in-hospital period. RESULTS: The mean age was 60 years, and 71.6% of the patients were male. HsCRP was increased (group A) in 144 patients (43.5%). In-hospital mortality was 4.8% and the most frequent complications in both groups were: overall infections (18%), respiratory infections (16%), atrial fibrillation (15%) and acute myocardial infarction (7.6%). The incidence of postoperative overall infections was 14.4% in the N group and 23.6% in the A group (P=0.046). Respiratory infections were also more frequent in the A group (21.5% vs. 11.8%; p = 0.024). Multivariate analyses showed that hsCRP level represented an independent predictor of postoperative respiratory infection (OR=2.08, 95% IC = 1.14-3.79). CONCLUSION: High preoperative hsCRP level is an independent predictor of respiratory infections in the mid-term postoperative period of elective coronary artery bypass graft surgery.

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Artigo Original

Effects of angiotensin-I and ischemia on functional recovery in isolated hearts

Ubirajara Oliveira de Oliveira et al. Álvaro Reischak de Oliveira Luiz Carlos Kucharski Ubiratan Fabres Machado … Maria Claudia Irigoyen Beatriz D'Agord Schaan

BACKGROUND: Cardiac arrest resuscitation can present myocardial dysfunction determined by ischemic time, and inhibition of the angiotensin-converting enzyme (ACE) can reduce cardiac dysfunction during reperfusion. OBJECTIVE: To investigate the effects of angiotensin-I and different periods of ischemia on functional recovery in isolated rat hearts. METHODS: Isolated hearts from Wistar rats (n=45; 250-300 g) were submitted to different periods of global ischemia (20, 25 or 30 min) and reperfused (30 min) with Krebs-Henseleit buffer alone or with the addition of 400 nmol/L angiotensin-I, or 400 nmol/L angiotensin-I + 100 mmol/L captopril along the reperfusion period. RESULTS: The maximal positive derivative of pressure (+dP/dt max) and rate-pressure product were reduced in hearts exposed to 25 min ischemia (~73%) and 30 min ischemia (~80%) vs. 20 min ischemia. Left ventricular end-diastolic pressure (LVEDP) and perfusion pressure (PP) were increased in hearts exposed to 25 min ischemia (5.5 and 1.08 fold, respectively) and 30 min ischemia (6 and 1.10 fold, respectively) vs. 20 min ischemia. Angiotensin-I caused a decrease in +dP/dt max and rate-pressure product (~85-94%) in all ischemic periods and an increase in LVEDP and PP (6.9 and 1.25 fold, respectively) only at 20 min ischemia. Captopril was able to partially or completely reverse the effects of angiotensin-I on functional recovery in 20 min and 25 min ischemia. CONCLUSION: These data suggest that angiotensin-II directly or indirectly participates in the post-ischemic damage, and the ability of an ACE inhibitor to attenuate this damage depends on ischemic time.

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Artigo Original

Association of different anthropometric measures and indices with coronary atherosclerotic burden

Patricia Chagas et al. Paulo Caramori Christiano Barcellos Tatiana Pizzato Galdino … Irênio Gomes Carla Helena Augustin Schwanke

BACKGROUND: The association between anthropometric parameters and atherosclerotic burden is not well established and few studies have addressed this issue. OBJECTIVE: To evaluate the association of different anthropometric parameters with the coronary atherosclerotic burden. METHODS: Adult patients undergoing coronary angiography were enrolled in the study. Sociodemographic characteristics and cardiovascular risk factors were collected through a standardized questionnaire. Weight, height, waist circumference (WC), abdominal circumference (AbC), hip circumference (HC) and neck circumference (NC) were measured and body mass index (BMI), waist-hip ratio (WHR), abdominal circumference-hip ratio (AbCHR) and waist-height ratio (WHtR) were calculated. The atherosclerotic burden at the coronary angiography was measured through Friesinger score (FS). Significant atherosclerosis was considered when FS > 5. RESULTS: The sample consisted of 337 patients, of whom 213 were men (63.2%). The mean age was 60.1 ± 10 years. Only WHR (r = 0.159 and p = 0.003) showed a significant linear correlation with the coronary atherosclerotic burden as measured by FS. When the sample was stratified by gender, we found a significant correlation between women’s AbCHR (r = 0.238 and p = 0.008) and WHR (r = 0.198 and p = 0.028) with FS. Men showed no correlation between anthropometric parameters and FS. After adjusting for gender, age, hypertension, smoking and DM, no anthropometric parameter was associated with coronary atherosclerotic burden as measured by FS in the total sample or when separated by gender. CONCLUSION: No anthropometric parameter was an independent risk factor for coronary atherosclerotic burden.

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