2012;98(2) – ABC CARDIOL

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Case Report

Cardiovascular magnetic resonance in unsuspected interrupted inferior vena cava

Andre Mauricio Fernandes et al. Vikas Rathi June Yamrozik Ronald Willians Robert W. Biederman

Interrupted inferior vena cava (IVC) is a rare anomaly. Anomalies of IVC are clinically important for cardiologists and radiologists who plan to intervene in the right heart. We describe three cases of IVC interruption diagnosed by cardiac magnetic resonance imaging study.

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Case Report

Association between immunological diseases and their similar clinical manifestations

Alexandre de Matos Soeiro et al. Maria Carolina Feres de Almeida Tarso Augusto Duenhas Accorsi Guilherme Sobreira Spina … Carlos Vicente Serrano Jr Flávio Tarasoutchi

We report on a 30-year-old female patient, with biological mitral valve prosthesis due to symptomatic mitral stenosis and a history of acute myocardial infarction and generalized tonic-clonic seizure episodes, visual hallucinations, cerebral thromboembolic events and, at present, chorea and acute carditis. The patient was diagnosed with active rheumatic fever (RF), systemic lupus erythematosus (SLE) and Antiphospholipid syndrome (APS). The combination of three unusual diagnoses in the same patient makes this a unique case, modifying patient treatment and prognosis.

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Special Article

1st Guidelines of the Brazilian Society of Cardiology on processes and skills for education in cardiology in Brazil: executive summary

Marcos Roberto de Sousa et al. Ricardo Mourilhe-Rocha Angelo Amato Vincenzo de Paola Ilmar Köhler … Gilson Soares Feitosa Jamil Cherem Schneider Gilson Soares Feitosa-Filho José Carlos Nicolau João Fernando Monteiro Ferreira Nelson Siqueira de Morais

This article summarizes the “1st Guidelines of the Brazilian Society of Cardiology on Processes and Skills for Education in Cardiology in Brazil,” which can be found in full at: . The guideline establishes the education time required in Internal Medicine and Cardiology with Specialization through theoretical and practical training. These requirements must be available at the center forming Specialists in Cardiology and the Cardiology contents.

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Clinicoradiological Session

Case 2/2012: eleven-day-old infant with marked coarctation of the aorta in cardiogenic shock

CLINICORADIOLOGICAL SESSION

Case 2/2012 – eleven-day-old infant with marked coarctation of the aorta in cardiogenic shock

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Letter to the Editor

How to broaden the debate and utility of scientific communications: the open access journals

Guilherme Ribeiro Camara

LETTER TO THE EDITOR

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Atualização

Advances in mechanical circulatory support in the treatment of heart failure

Claudio Leo Gelape et al. Si M. Pham

CLINICAL UPDATE

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Point of view

Peer review: a constantly-evolving scientific process

Claudio Gil Soares de Araújo

POINT OF VIEW

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Revisão

Mobilization of endothelial progenitor cells with exercise in healthy individuals: a systematic review

Jemima Fuentes Ribeiro da Silva et al. Natália Galito Rocha Antonio Claudio Lucas da Nóbrega

Physical exercise mobilizes endothelial progenitor cells (EPCs) to peripheral blood. However, this effect seems to depend on exercise characteristics, such as duration and intensity. The aim of this systematic review was to verify the impact of a single bout of aerobic exercise on the mobilization of EPCs in healthy individuals, and the potential mechanisms involved. The bibliographic search was conducted on the following electronic databases in May 2011: SciELO, LILACS, Cochrane, ClinicalTrials.gov, SPORTDiscus and Medline. Of the 178 articles initially identified, 12 met the inclusion criteria and were classified regarding quality according to the PEDro scale. The magnitude and duration of the EPC mobilization response were higher after long/ultralong duration exercises, and they are correlated with vascular endothelial growth factor (VEGF) plasma levels. The EPC mobilization peak in response to a maximal or submaximal single bout of exercise lasting up to one hour occurs immediately after the exercise or within the first hour after it. One possible mechanism is nitric oxide (NO) bioavailability. The individuals’ age and exercise intensity seem to interfere with the EPC mobilization response. Long/ultralong duration exercises promote more pronounced EPC mobilization as compared with maximal or submaximal exercises. The mechanisms involve VEGF release in long/ultralong duration exercises and NO bioavailability in maximal or submaximal exercises lasting less than one hour.

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Artigo Original

Percutaneous occlusion of left atrial appendage with the Amplatzer Cardiac PlugTM in atrial fibrillation

Márcio José Montenegro et al. Edgard Freitas Quintella Aníbal Damonte Hugo de Castro Sabino … Ricardo Zajdenverg Gustavo Pinaud Laufer Bernardo Amorim André Pereira Duque Estrada Cristian Paul Yugcha Armas Aline Sterque

Background: Atrial fibrillation is associated with embolic strokes that often result in death or disability. Effective in reducing these events, anticoagulation has several limitations and has been widely underutilized. Over 90% of thrombi identified in patients with atrial fibrillation without valvular disease originate in the left atrial appendage, whose occlusion is investigated as an alternative to anticoagulation. Objective: To determine the feasibility of percutaneous occlusion of the left atrial appendage in patients at high risk of embolic events and limitations to the use of anticoagulation. Methods: We report our initial experience with Amplatzer Cardiac PlugTM (St. Jude Medical Inc., Saint Paul, Estados Unidos) in patients with nonvalvular atrial fibrillation. We selected patients at high risk of thromboembolism, major bleeding, contraindications to the use or major instability in response to the anticoagulant. The procedures were performed percutaneously under general anesthesia and transesophageal echocardiography. The primary outcome was the presence of periprocedural complications and follow-up program included clinical and echocardiographic review within 30 days and by telephone contact after nine months. Results: In five selected patients it was possible to occlude the left atrial appendage without periprocedural complications. There were no clinical events in follow-up. Conclusion: Controlled clinical trials are needed before percutaneous closure of the left atrial appendage should be considered an alternative to anticoagulation in nonvalvular atrial fibrillation. But the device has shown to be promissory in patients at high risk of embolism and restrictions on the use of anticoagulants.

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Artigo Original

Evaluation of accuracy of rastreometer: a new equipment for hypertension tracking

Fernando Bitencourt et al. Carlos Antonio Mascia Gottschall

Background: Hypertension is one of the major cardiovascular risk factors affecting more than one billion people. The low awareness of the disease is one of the greatest difficulties related to hypertension. The population screening for hypertension is widely recognized as an effective strategy to detect new cases, but until now, there is no instrument that has become feasible for mass screening of the population. Objective: Evaluate the accuracy and reproducibility of the Rastreometer, a new instrument for the screening of hypertension for community health agents. Methods: Cross-sectional study with a sample of 436 individuals served by the Family Health Strategy. The evaluation was conducted comparing the results of blood pressure obtained by the oscillometric method and reading of the Rastreometer performed by community health agents. Results: The Rastreometer presented a sensitivity of 81.3% and a specificity of 85.6% when assessed in relation to the values of systolic pressure. The operators’ performance influenced the results of the Rastreometer independently (p = 0.0001). The Rastreometer showed substantial reproducibility (Kendall’s W 0.71). Conclusion: The Rastreometer, when operated by community health agents, showed good sensitivity, specificity and reproducibility, especially when evaluated with the values of systolic pressure, tending to confirm this new instrument as a method of screening for hypertension in primary health care.

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Artigo Original

Left atrium measurement in patients suspected of having heart failure with preserved ejection fraction

Antônio José Lagoeiro Jorge et al. Mario Luiz Ribeiro Maria Luiza Garcia Rosa Fernanda Volponi Licio … Luiz Cláudio Maluhy Fernandes Pedro Gemal Lanzieri Bruno Afonso Lagoeiro Jorge Flavia Oliveira Xavier Brito Evandro Tinoco Mesquita

BACKGROUND: The pathophysiological model of heart failure (HF) with preserved ejection fraction (HFPEF) focuses on the presence of diastolic dysfunction, which causes left atrial (LA) structural and functional changes. The LA size, an indicator of the chronic elevation of the left ventricular (LV) filling pressure, can be used as a marker of the presence of HFPEF, and it is easily obtained. OBJECTIVE: To estimate the accuracy of measuring the LA size by using indexed LA volume and diameter (ILAV and ILAD, respectively) for diagnosing HFPEF in ambulatory patients. METHODS: This study assessed 142 patients (mean age, 67.3 ± 11.4 years; 75% of the female sex) suspected of having HF, divided into two groups: with HFPEF (n = 35) and without HFPEF (n = 107). RESULTS: The diastolic function, assessed by use of Doppler echocardiography, showed a significant difference between the groups regarding the parameters assessing ventricular relaxation (E’: 6.9 ± 2.0 cm/s vs. 9.3 ± 2.5 cm/s; p < 0.0001) and LV filling pressure (E/E' ratio: 15.2 ± 6.4 vs. 7.6 ± 2.2; p < 0.0001). The ILAV cutoff point of 35 mL/m2 best correlated with the diagnosis of HFPEF, showing sensitivity, specificity, and accuracy of 83%. The ILAD cutoff point of 2.4 cm/m2 showed sensitivity of 71%, specificity of 66%, and accuracy of 67%. CONCLUSION: For diagnosing HFPEF in ambulatory patients, the ILAV proved to be a more accurate parameter than ILAD. On echocardiographic assessment, ILAV, rather than ILAD, should be routinely measured. (Arq Bras Cardiol. 2011; [online].ahead print, PP.0-0)

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Artigo Original

Self measurement of blood pressure for control of blood pressure levels and adherence to treatment

Weimar Kunz Sebba Barroso Souza et al. Paulo César Brandão Veiga Jardim Ludmila Porto Brito Fabrício Alves Araújo Ana Luíza Lima Sousa

BACKGROUND: The measurement of blood pressure (BP) by the patient himself without strict protocols, adequate training, and validated equipment at their own household is defined as self measured blood pressure (SMBP). OBJECTIVE: To evaluate the interference of the SMBP in treatment adherence and blood pressure control. METHODS: The study included 57 patients, 38 in the study group (SG) and 19 in the control group (CG). These patients were followed for 12 months and assessed at randomization (V1) as well as in the sixth (V2) and the twelfth month (V3). Compare the mean blood pressure by casual measurement, by SMBP and by ambulatory monitoring of blood pressure (AMBP), laboratory tests and the answers to the questionnaire on lifestyle. The instruments used were: OMRON HEM 714, for SMBP; OMRON 705 CP, for the casual measurement, and Monitor SPACELABS 9002 for the AMBP. RESULTS: The average age was 62.05 ± 10.78 in the SG and 55.42 ± 11.87 in the CG (p = 0.03). The values of systolic blood pressure (SBP) by casual measurement in the SG and CG were: 140.01 ± 16.73 mmHg and 141.79 ± 23.21 mmHg in V1 (p = 0.72), 135.49 ± 12.73 mmHg and 145.69 ± 19.31 mmHg in V2 (p = 0.02), 131.64 ± 19.28 mmHg and 134.88 ± 23.21 mmHg at V3 (p = 0.59). The values of diastolic blood pressure (DBP) were: 84.13 ± 10.71 mmHg and 86.29 ± 10.35 mmHg in V1 (p = 0.47), 81.69 ± 10.88 mmHg and 89.61 V2 ± 11.58 mmHg (p = 0.02), 80.31 ± 11.83 mmHg and 86 ± 13.38 mmHg in V3 (p = 0.12). CONCLUSION: Patients in the SG had adherence to non-pharmacological treatment similar to the CG, but they had greater adherence to drug treatment and used fewer antihypertensive drugs. There was no difference between groups when comparing the metabolic profile and renal function. (Arq Bras Cardiol. 2011; [online].ahead print, PP.0-0)

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Artigo Original

Prevalence and predictors of pulmonary embolism in patients with acutely decompensated heart failure

Luís C. L. Correia et al. Creuza Góes Hysla Ribeiro Manuela Cunha … Rogério de Paula J. Péricles Esteves

BACKGROUND: The prevalence of pulmonary embolism (PE) has not been reported in patients hospitalized due to classical findings of decompensated heart failure (HF). OBJECTIVE: To describe the prevalence of PE and to assess the diagnostic accuracy of the Wells and Geneva scores in patients hospitalized due to HF. METHODS: Patients hospitalized primarily due to HF underwent systematic ventilation-perfusion lung scan, and PE was defined by a result of high probability. Aiming at interpreting, low clinical probability of PE was defined as prevalence < 5%, according to the literature. When calculating the sample size, 49 patients were required to provide a 95% confidence interval with ±10% accuracy, estimating an a priori prevalence of 15%. RESULTS: Of 51 patients studied, six had a high probability of PE on lung scan, resulting in 12% prevalence (95% CI = 5% – 23%). The Wells and Geneva scores had an area under the ROC curve of 0.53 (95% CI = 0.27 – 0.80; p = 0.80) and 0.43 (95% CI = 0.13 – 0.73; p = 0.56), respectively, indicating lack of accuracy for the diagnosis of PE. Alternatively, variables related to HF showed a tendency towards association with PE, and an exploratory model formed by that type of variable showed diagnostic accuracy for PE (ROC = 0.81; 95% CI = 0.66 – 0.96; p = 0.01). CONCLUSION: (1) Despite the lack of primary suspicion, patients admitted with HF have intermediate clinical probability of concomitant PE; (2) the scores usually used to estimate the clinical probability of PE do not apply to the population with HF, and future predictive models should consider variables related to that syndrome.

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Artigo Original

Resveratrol causes antiatherogenic effects in an animal model of atherosclerosis

Rossane Serafim Matos et al. Lis Andréa Villela Baroncini Leonardo Brandão Précoma Guilherme Winter … Pedro Henrique Lambach Caron Flávia Kaiber Dalton Bertolim Précoma

BACKGROUND: Resveratrol protects the cardiovascular system by a number of mechanisms, including antioxidant and anti-platelet activities. OBJECTIVE: To assess the potential anti-inflammatory and antiatherogenic effects of resveratrol using rabbits fed a hypercholesterolemic diet (1% cholesterol). METHODS: Twenty white male rabbits were selected and divided into two groups: control group (CG), 10 rabbits; and resveratrol group (RG), 10 rabbits. The animals were fed a hypercholesterolemic diet for 56 days. For the RG diet, resveratrol (2mg/kg weight/day) was added from days 33 – 56. RESULTS: There was no significant difference in the total serum cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides between the groups. Of the CG, 70% had advanced aortic atherosclerotic lesions (types III, IV, V, or VI). All animals from the RG had mild aortic atherosclerotic lesions (types I or II, or no lesions). The intima area and the intima/media layer area ratio was significantly lower in the RG as compared to the CG (p<0.001). Positive areas for VCAM-1 molecules were lower in the RG (p=0.007). The MCP-1 and IL-6 concentrations were lower in the RG than the CG (p=0.039 and p=0.015, respectively). CONCLUSION: Resveratrol had significant anti-atherogenic and anti-inflammatory effects in an animal model with rabbits fed a hypercholesterolemic diet (1% cholesterol).

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Artigo Original

Anthropometric measures as predictors of cardiovascular disease risk factors in the urban population of Iran

Reza Gharakhanlou et al. Babak Farzad Hamid Agha-Alinejad Lyn M. Steffen Mahdi Bayati

BACKGROUND: Overweight and obesity are an important public health problem in society, due to their association with various chronic diseases. OBJECTIVE: The purpose of this study is to determine the prevalence and distribution of overweight and obesity, using different anthropometric measurements and to identify the best anthropometric indicator which is most closely related to cardiovascular disease (CVD) risk factors in an Iranian urban population. METHODS: This cross-sectional study was conducted with 991 men and 1188 women aged 15 to 64 years. Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and percentage of body fat were measured. A fasting blood specimen was obtained. CVD risk factors, including fasting blood glucose, triglycerides, total cholesterol (Tchol), low-density (LDL-C) and high-density-lipoprotein cholesterol (HDL-C) were assessed. RESULTS: Based on BMI, more than 49% of men and 53% of women were either overweight or obese with 10.2% of men and 18.6% of women being obese. In both men and women, the prevalence of overweight was greater among 40-49 year olds and the prevalence of obesity was greater among those 50+ years. Using the multiple regression analysis, BMI, WHtR and WHR explained the highest percentage of variation of triglycerides, Tchol/HDL-C ratio and LDL-C in men, respectively, whereas WHR explained the highest percentage of variation of triglycerides and WC explained the highest percentage of variation of Tchol/HDL-C ratio and LDL-C in women. CONCLUSION: Our data indicated that WHR and WHtR were the anthropometric indicators that best predicted CVD risk factors in men and WHR and WC in women.

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Artigo Original

Emergency service admission time and in-hospital mortality in acute coronary syndrome

Julio Yoshio Takada et al. Larissa Cardoso Roza Rogério Bicudo Ramos Solange Desiree Avakian … José Antonio Franchini Ramires Antonio de Pádua Mansur

BACKGROUND: The relationship between admission time to an emergency service and in-hospital outcomes in acute coronary syndrome (ACS) is controversial. Admission during off-hours would be associated with worse prognosis. OBJECTIVE: To assess the influence of admission time on prolonged hospitalization and mortality for ACS patients, regarding regular hours (7AM-7PM) and off-hours (7PM-7AM). METHODS: The study assessed prospectively 1,104 consecutive ACS patients. In-hospital mortality and length of hospital stay > 5 days were the outcomes analyzed. RESULTS: Admission during regular hours was greater as compared with that during off-hours (63% vs. 37%; p < 0.001). Unstable angina was more prevalent during regular hours (43% vs. 32%; p 5 days were as follows: age [OR 1.042 (95%CI: 1.025 – 1.058), p < 0.001]; ejection fraction (EF) [OR 0.977 (95%CI: 0.966 – 0.988), p < 0.001]; NSTEMI [OR 1.699 (95%CI: 1.221 – 2.366), p = 0.001]; and smoking [OR 1.723 (95%CI: 1.113 – 2.668), p = 0.014]. Predictive factors for in-hospital mortality were as follows: age [OR 1.090 (95%CI: 1.047 – 1.134), p < 0.001]; EF [OR 0.936 (95%CI: 0.909 – 0.964), p < 0.001]; and surgical treatment [OR 3.781 (95%CI: 1.374 – 10.409), p = 0.01]. CONCLUSION: Prolonged length of hospital stay and in-hospital mortality in ACS patients do not depend on admission time.

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Artigo Original

Cardiac autonomic and ventricular mechanical functions in asymptomatic chronic chagasic cardiomyopathy

Daniel França Vasconcelos et al. Luiz Fernando Junqueira Junior

BACKGROUND: The association of variably altered cardiac autonomic and ventricular systolic and diastolic functions is still controversial and little explored in chronic Chagas’ disease. OBJECTIVE: To evaluate the extent to which cardiac autonomic and mechanical ventricular functions are altered and whether they are associated in asymptomatic chagasic cardiomyopathy. METHODS: A total of 13 patients with asymptomatic chagasic cardiomyopathy and 15 normal subjects (control group) were evaluated and the autonomic modulation of heart rate variability for five minutes, in the temporal and spectral domains, in the supine and orthostatic positions, as well as ventricular function based on morphological-functional variables obtained by Doppler echocardiography were correlated. Statistical analysis used the Mann-Whitney test and Spearman’s correlation. RESULTS: In both positions, the temporal index (p = 0.0004 to 0.01) and total (p = 0.0007-0.005) and absolute spectral areas, of low and high frequencies (p = 0.0001 to 0.002), were lower in the chagasic group. The vagal-sympathetic balance was similar in both positions (p = 0.43 to 0.89). The echocardiographic variables did not differ between groups (p = 0.13 to 0.82), except the left ventricular end-systolic diameter, which was larger (p = 0.04) and correlated directly with reduced rates of global (p = 0.01 to 0.04) and parasympathetic (p = 0.002 to 0.01) autonomic modulation in patients with Chagas disease in the orthostatic position. CONCLUSION: The sympathetic and parasympathetic depressions with preserved balance were associated with only one ventricular dysfunction indicator. This suggests that cardiac autonomic dysfunction may precede and be independently more severe than ventricular dysfunction, with no causal association between both disorders in chronic chagasic cardiomyopathy.

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Artigo Original

Functional limitation and intermittent claudication: impact of blood pressure measurements

Rita de Cássia Gengo e Silva et al. Cassiana Rosa Galvão Giribela Nelson Wolosker Fernanda Marciano Consolim-Colombo

BACKGROUND: Arterial hypertension is an important risk factor for Lower-Limb Occlusive Arterial Disease (LLOAD). However, the correlation between blood pressure and pulse pressure (PP) with LLOAD severity and functional impairment resulting from this disease is not well established in the Brazilian population. OBJECTIVE: To verify whether there is a correlation between blood pressure, PP, LLOAD severity and functional capacity in patients with symptomatic LLOAD. METHODS: A total of 65 patients (62.2 + 8.1 years, 56.9% males) were evaluated. They were divided into two groups: normal (A) and high (B) blood pressure. LLOAD severity was assessed using the ankle-brachial index (ABI) and functional capacity by the total and pain-free walking distance at the 6-minute walking test (6MWT). RESULTS: Group A consisted of 17 (26.1%) patients. The systolic (SBP), diastolic blood pressure (DBP), and PP were, respectively, 125.4 ±11.7, 74.5 ± 9.1 and 50.9 ± 10.0 mmHg in group A and 160.7 ± 19.6, 90.0 ± 12.2 and 70.7 ± 20.2 mmHg in group B. The ABI was significantly lower in group B (0.66 ± 0.12 vs. 0.57 ± 0.13, p 40 mmHg walked shorter distances. CONCLUSION: SBP and PP significantly correlated with the distances walked in the 6MWT, suggesting they are clinical markers of functional capacity impairment in patients with symptomatic LLOAD.

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