2012;99(1) – ABC CARDIOL

Special Article

First Brazilian position on resistant hypertension

SPECIAL ARTICLE

[…]

Read Full Article

Editorial

Message from the Editor

Luiz Felipe P. Moreira

MESSAGE FROM THE EDITOR

Luiz Felipe P. Moreira

[…]

Read Full Article

Case Report

Latent obstructive hypertrophic cardiomyopathy: is echocardiography enough?

João Abecasis et al. Regina Ribeiras Antonio Ferreira Raquel Gouveia Miguel Mendes

CASE REPORT

Latent obstructive hypertrophic cardiomyopathy: is echocardiography enough?

[…]

Read Full Article

Review Article

The diagnosis of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Beatriz Piva e Mattos et al. Marco Antonio Rodrigues Torres Taiane Francieli Rebelatto Melina Silva de Loreto Fernando Luís Scolari

Hypertrophic cardiomyopathy is a prevalent genetic disease characterized by left ventricular hypertrophy, presenting dynamic obstruction of outflow tract with subaortic gradient happening at rest in 30% of the cases. It is attributed to the intricate interaction between the anterior mitral leaflet, the interventricular septum and altered flow vectors generated in left ventricle along with changes in outflow tract geometry. Mitral regurgitation in varying degrees is found with or without association with structural deformities of the valve apparatus. The exercise echocardiogram evidences latent obstruction easily induced by exercise in 60 to 75% of non-obstructive forms. The determination of the gradient under this condition must be considered in routine investigation of patients with mild or no obstruction at rest. The evaluation of hypertrophic cardiomyopathy incorporates methods based on the ultrasound image, which, along with MRI, allow recognizing ventricular obstruction generating mechanisms, thus facilitating the diagnosis and management of obstructive and latent obstructive forms.

Read Full Article

Case Report

Occlusion of post-myocardial infarction ventricular defect with prosthesis CERA

Henrique Barbosa Ribeiro et al. Luciano Moreira Baracioli Luiz Junya Kajita Martina Battistini Pinheiro … Expedito E. Ribeiro José Carlos Nicolau

CASE REPORT

Occlusion of ventricular defect post-myocardial infarction with prothesis CERA

[…]

Read Full Article

Letter to the Editor

Comments on the article by Araújo: are the criteria for peer review and publication clear?

Paulo Roberto Benchimol-Barbosa

LETTER TO THE EDITOR

[…]

Read Full Article

Clinicoradiological Session

Case 5/2012: six-year-old child with anomalous origin of left coronary artery and mitral regurgitation

Edmar Atik

CLINICORADIOLOGICAL SESSION

Case 5/2012 – six-year-old child with anomalous origin of left coronary artery and mitral regurgitation

[…]

Read Full Article

Artigo Original

Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting

Luiz Augusto Ferreira Lisboa et al. Omar Asdrúbal Mejia Luís Alberto Dallan Luiz Felipe Moreira … Luiz Boro Puig Fabio Biscegli Jatene Noedir Antonio Stolf

BACKGROUND: Percutaneous coronary intervention (PCI) has increased as the initial revascularization strategy in chronic coronary artery disease. Consequently, more patients undergoing coronary artery bypass grafting (CABG) have history of coronary stent. OBJECTIVE: Evaluate the impact of previous PCI on in-hospital mortality after CABG in patients with multivessel coronary artery disease. METHODS: Between May/2007 and June/2009, 1099 consecutive patients underwent CABG on cardiopulmonary bypass. Patients with no PCI (n=938, 85.3%) were compared with patients with previous PCI (n=161, 14.6%). Logistic regression models and propensity score matching analysis were used to assess the risk-adjusted impact of previous PCI on in-hospital mortality. RESULTS: Both groups were similar, except for the fact that patients with previous PCI were more likely to have unstable angina (16.1% x 9.9%, P=0.019). In-hospital mortality after CABG was higher in patients with previous PCI (9.3% x 5.1%, P=0.034) and it was comparable with EuroSCORE and 2000 Bernstein-Parsonnet risk score. Using multivariate logistic regression analysis, previous PCI emerged as an independent predictor of postoperative in-hospital mortality (odds ratio 1.94, 95% CI 1.02-3.68, P=0.044) as strong as diabetes (odds ratio 1.86, 95% CI 1.07-3.24, P=0.028). After computed propensity score matching based on preoperative risk factors, in-hospital mortality remained higher among patients with previous PCI (odds ratio 3.46, 95% CI 1.10-10.93, P=0.034). CONCLUSIONS: Previous PCI in patients with multivessel coronary artery disease is an independent risk factor for in-hospital mortality after CABG.This fact must be considered when PCI is indicated as initial alternative in patients with more severe coronary artery disease. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Read Full Article

Artigo Original

Effects of levosimendan on TNF-alpha, BNP and MMP-1 in patients with heart failure with anemia

Mutlu Büyüklü et al. Akif Turhan Kürüm Ersan Tatlý Turan Set

BACKGROUND: Levosimendan is known with its two-sided effects of strengthening myofibril contraction without increasing myocardial oxygen demand. Anemia is a deteriorating situation that causes increase of drug dosing in patients with heart failure. OBJECTIVES: In this study, we compared the effectiveness of levosimendan treatment in decompensated heart failure patients with or without anemia. METHODS: Twenty-three anemic patients having class 3 or 4 heart failure according to New York Heart Association (NYHA) and an ejection fraction of below 35% were included to the study. Another 23 patients with the same cardiac diagnosis but without anemia served as control group. Twenty-four hours levosimendan treatment was added to the traditional heart failure treatment of these patients. Samples were taken to measure serum tumor necrotizing factor alpha (TNF-alpha), aminoterminal pro-brain natriuretic peptide (NT-proBNP) and matrix metalloproteinase-1 (MMP-1) levels before and after the administration. RESULTS: There was no significant difference between serum TNF-alpha and MMP-1 levels before and after the treatment (p>0.05). Although NT-proBNP level decreased in both groups after the treatment this was not statistically significant (p=0.531 and p=0.913 for anemia and control groups respectively). Significant restoration of functional capacity was seen in both groups assessed according to NYHA (p<0.001 and p=0.001 for anemia and control groups respectively). CONCLUSION: Levosimendan treatment shows similar effects in heart failure patients with anemia to that of patients without anemia. However, the early effect of this treatment on TNF-alpha, NT-proBNP and MMP-1 levels is not evident. It provides significant improvement in functional capacity without influence from anemia.

Read Full Article

Artigo Original

Influence of creatine supplementation on the functional capacity of patients with Heart Failure

Ana Paula Perillo Ferreira Carvalho et al. Salvador Rassi Keila Elizabeth Fontana Krislainy de Sousa Correa Roberta Helena Fernandes Feitosa

BACKGROUND: Heart failure (HF) is a complex syndrome characterized by intolerance to exertion and reduced functional capacity. OBJECTIVE: To assess the functional capacity of patients with HF and supplemented with creatine. METHODS: Prospective, randomized, double-blind study. Thirty-three male patients over the age of 18 years with functional class II to IV HF were randomized into two groups as follows: the experimental group (CRE, n = 17), supplemented with 5 g/day of creatine for six months; and the placebo group (PLA, n = 16), receiving 5 g/day of maltodextrin for that same period. Both groups underwent functional capacity assessment by use of cardiopulmonary exercise test and 6-minute walk test (6MWT) before and after the intervention. The Ancova statistical model and Pearson correlation were used to assess the groups and the treatment. RESULTS: Of the variables assessed on the cardiopulmonary exercise test, peak oxygen consumption (peak VO2), anaerobic threshold (AT), and oxygen pulse (O2 pulse) showed no significant differences between the groups (P>0.05). On the 6MWT, no significant difference was observed in the covered distance. CONCLUSION: Creatine supplementation in patients with HF did not significantly improve functional capacity.

Read Full Article

Artigo Original

Cost-effectiveness of fondaparinux in patients with acute coronary syndrome without ST-segment Elevation

Camila Pepe et al. Márcio Machado Alexandre Olimpio Rui Ramos

BACKGROUND: The combined use of antithrombotic agents, antiplatelet agents and invasive strategies in acute coronary syndrome without ST-segment elevation (ACSWSTE) reduces cardiovascular events. Fondaparinux has demonstrated equivalence to enoxaparin in reducing cardiovascular events, but with a lower rate of bleeding in patients using fondaparinux. OBJECTIVE: Evaluate the cost-effectiveness of fondaparinux versus enoxaparin in patients with ACSWSTE in Brazil from the economic perspective of the Brazilian Unified Health System (SUS). METHODS: A decision analytic model was constructed to calculate the costs and consequences of the compared treatments. The model parameters were obtained from the OASIS-5 study (N = 20,078 patients with ACSWSTE randomized to fondaparinux or enoxaparin). The target outcome consisted of cardiovascular events (i.e., death, myocardial infarction, refractory ischemia and major bleeding) on days 9, 30 and 180 after ACSWSTE. We evaluated all direct costs of treatment and ACSWSTE-related events. The year of the analysis was 2010 and the costs were described in reais (R$). RESULTS: On day 9, the cost of treatment per patient was R$ 2,768 for fondaparinux and R$ 2,852 for enoxaparin. Approximately 80% of total costs were associated with invasive treatments. The drug costs accounted for 10% of the total cost. The combined rates of cardiovascular events and major bleeding were 7.3% and 9.0% for fondaparinux and enoxaparin, respectively. Sensitivity analyses confirmed the initial results of the model. CONCLUSION: The use of fondaparinux for the treatment of patients with ACSWSTE is superior to that of enoxaparin in terms of prevention of further cardiovascular events at lower cost. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Read Full Article

Artigo Original

Treatment adherence and blood pressure control in older individuals with hypertension

Rachel G. Bastos-Barbosa et al. Eduardo Ferriolli Julio C. Moriguti Charlys B. Nogueira … Fernando Nobre Julieta Ueta Nereida K. C. Lima

BACKGROUND: Non-adherence to treatment has been identified as the main cause of uncontrolled blood pressure (BP), and may represent a greater risk in older individuals. OBJECTIVE: The aim of this study was to evaluate and compare the rate of adherence to hypertension treatment using different methods, to estimate the BP control rate, and to observe if there is an association between BP control and adherence. METHODS: Treatment adherence was evaluated in older patients with hypertension, followed by the public primary health care, through four methods, including the Morisky-Green test (reference), the Attitude regarding the Medication Intake questionnaire (AMI), an evaluation of adherence by the nurse in the office (Nurse Adherence Evaluation – NAE), and at home (Home Adherence Evaluation – HAE). Salt intake was estimated by 24-hour sodium urinary excretion. BP control was assessed by the awake ambulatory blood pressure monitoring. RESULTS: Concordance between the Morisky-Green test and AMI (Kappa=0.27) or NAE (Kappa=0.05) was poor. There was a moderate concordance between the Morisky-Green test and HAE. Eighty percent had controlled BP, including 42% with white-coat effect. The group with lower salt excretion informed to avoid salt intake more times (p<0.001) and had better medication adherence (p<0.001) than the higher salt excretion group. CONCLUSION: The evaluated tests did not show a good concordance to the Morisky-Green test. Adherence to hypertension treatment was low; however, there was a high rate of BP control when subjects with the white-coat effect were included in the analysis.

Read Full Article

Artigo Original

Association between the 8-item Morisky Medication Adherence Scale (MMAS-8) and blood pressure control

Alfredo Dias Oliveira-Filho et al. José Augusto Barreto-Filho Sabrina Joany Felizardo Neves Divaldo Pereira de Lyra Junior

BACKGROUND: Non-adherence to treatment is an important and often unrecognized risk factor that contributes to reduced control of blood pressure (BP). OBJECTIVE: To determine the association between treatment adherence measured by a validated version in Portuguese of the 8-item Morisky Medication Adherence Scale (MMAS-8) and BP control in hypertensive outpatients. METHODS: A cross-sectional study was carried out with hypertensive patients older than 18 years, treated at six of the Family Health Strategy Units in Maceió (AL), through interviews and home blood pressure measurements, between January and April 2011. Adherence was determined by MMAS-8 version translated for this study. The patients were considered adherent when they had a score equal to 8 at the MMAS-8. RESULTS: The prevalence of adherence among the 223 patients studied was 19.7%, while 34% had controlled BP (> 140/90 mmHg). The average adherence value according to the MMAS-8 was 5.8 (± 1.8). Adherent patients showed to be more prone (OR = 6.1, CI [95%] = 3.0 to 12.0) to have blood pressure control than those who reached mean (6 to <8) or low values (<6) at the adherence score. The Portuguese version of MMAS-8 was showed a significant association with BP control (p = 0.000). CONCLUSION: The diagnosis of non-adherent behavior through the application of MMAS-8 in patients using of antihypertensive medications was predictive of elevated systolic and diastolic BP.

Read Full Article

Artigo Original

Minimally-invasive video-assisted coronary-artery bypass grafting

Rodrigo Mussi Milani et al. Paulo Brofman Maximiliano Guimarães Márcia Olandoski … Hugo Meister Filho Thales Baggio Maria Fernanda Domingues Rodrigo Jardim Aline Sanches Francisco Maia

BACKGROUND: In general, surgeries currently tend to be less invasive and cardiac surgery has started to follow this trend. OBJECTIVE:To evaluate the evolution of one hundred patients undergoing minimally-invasive coronary artery bypass grafting. METHODS: Access to the heart was attained through a small; 6-cm thoracotomy, located in the 4th left intercostal space, starting at the nipple. Through the same intercostal space, 3 cm after the primary incision, a 6.5-mm optical device was inserted at 30º. Where the saphenous vein was used, the pericardium was opened above the aorta and the latter was partially clamped with a systolic pressure of 80 mmHg, with the proximal anastomosis being carried out in the conventional manner. The distal anastomoses were carried out in the conventional manner. The procedure was performed off-pump using single lung ventilation. RESULTS: The mean age was 63.9 ± 10.66 years. Sixty-eight (68%) patients were males. Fifty-three (53%) were in functional class III or IV. Left ventricular function was normal in fifty-three (53%) patients. Forty-two (42%) had undergone previous angioplasty. A total of 153 anastomoses were performed, ranging from 1 to 3. The average ventilation time was 4.06 ± 4.08 hours. Seventeen (17%) patients had atrial fibrillation and eight (8%) had pneumonia. There were two deaths in this series. CONCLUSION: Revascularization was safe with low mortality and morbidity. With the advent of new devices, this surgery may have a greater applicability.

Read Full Article

Artigo Original

Prognostic value of B-type natriuretic peptide in the mortality of patients with Acute Coronary Syndrome

Alexandre Vaz Scotti et al. Bernardo Rangel Tura Ronilson Gonçalves Rocha Denilson Campos de Albuquerque

BACKGROUND: The prognostic value of BNP in acute coronary syndrome (ACS) has been repeatedly assessed, but not completely well established. Literature data for establishing the best time for assessing BNP, be it on hospital admission or after coronary intervention, are controversial. OBJECTIVE: To analyze BNP in non-ST segment elevation ACS (NSTE-ACS) in the long term, and to assess the association between BNP (pg/ml), death, coronary anatomy, and TIMI Risk Score. METHODS: Forty patients with NSTE-ACS and troponin>0.50 ng/ml had their BNP levels measured on admission and 96 hours after, and were followed up for four years. The difference between the two measures was assessed by use of Wilcoxon test (p 300 pg/ml (95% CI 1.90 a 29.30 p<0.01). An association between 96-hour BNP and TIMI Risk Score was observed (p<0.01). An association was observed between the increase in 96-hour BNP and multivessel disease (p=0.02). CONCLUSION: In NSTE-ACS with positive troponin, 96-hour BNP can be a tool for risk stratification. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Read Full Article

Artigo Original

Prevalence of resistant hypertension in non-elderly adults: prospective study in a clinical setting

Daniela Massierer et al. Ana Claudia Tonelly Oliveira Ana Maria Steinhorst Miguel Gus … Aline Maria Ascoli Sandro Cadaval Gonçalves Leila Beltrami Moreira Vicente Correa Jr. Gerson Nunes Sandra Costa Fuchs Flávio Danni Fuchs

BACKGROUND: In face of variable definitions and sampling criteria, the real prevalence of resistant hypertension in a clinical setting is unknown. OBJECTIVE: We investigated the prevalence of true resistant hypertension in an outpatient hypertension clinic. METHODS: True resistant hypertension was diagnosed when white coat phenomenon, lack of compliance and secondary hypertension were excluded in patients with blood pressure ≥ 140/90 mmHg in two consecutive visits, despite to be using three blood pressure-lowering agents, including a diuretic. RESULTS: In the total, 606 patients, with 35 to 65 years of age, mostly women, with BP of 156.8 ± 23.8 mmHg by 91.9 ± 15.6 mmHg and a BMI of 29.7 ± 5.9 Kg/m² were sequentially evaluated. One hundred and six patients using three BP drugs had uncontrolled blood pressure (17.5% of the whole sample) in the first visit. Eighty-six patients (81% of the patients with uncontrolled BP in the first evaluation) returned for the confirmatory evaluation. Twenty-five had controlled BP, 21 had evidence of low adherence to treatment, 13 had white coat phenomenon and 9 had secondary hypertension, leaving only 18 patients (20.9% of those uncontrolled in the confirmatory visit and 3% of the whole sample) with true resistant hypertension. Considering patients with secondary hypertension as cases of resistant hypertension, the prevalence of resistant hypertension increased to 4.5%. CONCLUSION: The frequency of patients with true resistant hypertension in non-elderly patients is low in a clinical setting, and is not substantially increased with the inclusion of patients with secondary hypertension. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Read Full Article

Artigo Original

Leptin and aldosterone in sympathetic activity in resistant hypertension with or without type 2 diabetes

Leandro Boer-Martins et al. Valéria Nasser Figueiredo Caroline Demacq Luiz Cláudio Martins … Ana Paula Cabral de Faria Carolina de Haro Moraes Heitor Moreno Jr.

BACKGROUND: The finding of adipocyte-derived hormone leptin as an overstimulator of sympathetic activity brought a new perspective to the pathophysiological mechanisms of obesity-hypertension. OBJECTIVES: As aldosterone also increases sympathetic activity, we aimed to assess the relationship between sympathetic overactivity and plasma leptin and aldosterone levels in resistant hypertension (RHTN), comparing the groups with and without T2D. METHODS: Twenty-five RHTN patients underwent ambulatory electrocardiography to analyze heart rate variability (HRV) in time and frequency domains, which were stratified into two periods: 24 hours and daytime (DT), comprising the records between 2:00 p.m to 6:00 p.m (time domain) and one hour at 3:00 p.m (frequency domain). RESULTS: T2D group (n=10) had higher serum aldosterone and plasma leptin levels than the non-T2D (n=15) (26.0±11.5 vs. 16.9±7.0 ng/dL – p=0.021; 81.368.7±47.086.1 vs 41.228.1±24.523.1 pg/mL – p=0.048, respectively). Both groups had aldosterone correlated with HRV in frequency domain. Non-T2D had aldosterone correlated with DT low frequency in normalized units (LF nu) (r=0.6 [0.12-0.85] p=0.018) and DT high frequency in normalized units (HF nu) (r=-0.6 [-0.85- -0.12] p=0.018). Type-2-diabetes group had aldosterone correlated with DT LF nu (r=0.72 [0.16-0.93] p=0.019) and DT HF nu (r=-0.72 [-0.93- -0.16] p=0.019). However, despite of the importance of leptin in sympathetic overactivity in hypertension, leptin did not correlate with HRV. CONCLUSION: Aldosterone seems to overdrive sympathetic activity in RHTN with and without T2D. This information combined with the clinical efficacy of mineralocorticoid receptor blocker in RHTN may reinforce that aldosterone is a major player to be a therapeutic target in RHTN. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Read Full Article