2012;99(2) – ABC CARDIOL

Case Report

Use of therapeutic hypothermia in a patient with acute coronary heart disease

Rafael Alves Franco et al. Natali Schiavo Giannetti Carlos Vicente Serrano Jr José Carlos Nicolau

CASE REPORT

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Case Report

Giant aneurysm of saphenous vein bypass for right coronary after angioplasty

Mauro Guimarães Albuquerque et al. Jorge Alcântara Farran Carlos Alberto Pires Pereira Edson Renato Romano … Isabela Neto Macri Brotto Marcelo Luz Pereira Romano

CASE REPORT

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Letter to the Editor

Intracoronary ultrasound-guided stenting: is it really beneficial?

Lucas Lodi-Junqueira et al. Marcos Roberto Sousa Antônio Luiz Pinho Ribeiro

LETTER TO THE EDITOR

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Anatomopathological Session

Case 03/12: a 41-year-old female patient with hypertrophic cardiomyopathy and congestive heart failure

Fernando Luiz de Melo Bernardi et al. Luiz Alberto Benvenuti

ANATOMOPATHOLOGICAL SESSION

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Letter to the Editor

Calculation of the Ankle Brachial Index

Hasan Kutsi Kabul et al. Aydogan Aydogdu Ilker Tasci

LETTER TO THE EDITOR

Calculation of the Ankle Brachial Index

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Review Article

Inspiratory muscle training in patients with heart failure: meta-analysis of randomized trials

Rodrigo Della Méa Plentz et al. Graciele Sbruzzi Rodrigo Antonini Ribeiro Janaína Barcellos Ferreira Pedro Dal Lago

Patients with chronic heart failure (CHF) may have lower inspiratory muscle strength and endurance, which may contribute to exercise intolerance. Inspiratory muscle training (IMT) can have beneficial effects on these patients. Thus, the aim of this study was to systematically review the effects of IMT compared to control groups (placebo-IMT or another intervention) in patients with CHF. A search of databases (MEDLINE, Cochrane CENTRAL and PEDro) and references of published studies, from 1960 to 2011, was conducted. Randomized trials comparing IMT to control groups in the treatment of patients with CHF were included. The GRADE approach was used to determine the quality of evidence for each outcome. Of 119 articles identified, 7 studies were included. IMT increased the distance walked in the six-minute walk test [69 m (95% CI: 7.21 to 130.79)] (very low evidence) and maximal static inspiratory pressure [23.36 cmH20 (95% CI: 11.71 to 35.02)] (low evidence) compared to control groups. However, IMT provides a significant improvement in peak oxygen consumption only in the studies that performed IMT for 12 weeks against no inspiratory load in patients with inspiratory muscle weakness [3.02 ml/kg/min-1 (95% CI: 0.43 to 5.61)]. IMT improves functional capacity and inspiratory muscle strength thereby deserving consideration as an additional intervention in patients with CHF. Larger and better-designed studies, however, are needed to clarify the potential benefit of IMT in this patient population.

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Artigo Original

Trimetazidine and inflammatory response in coronary artery bypass grafting

Gerez Fernandes Martins et al. Aristarco Gonçalves de Siqueira Filho João Bosco de Figueiredo Santos Claudio Roberto Cavalcanti Assunção … Francisca Bottino Vieira Alberto Valência Káttia Gerúncio de Carvalho Barbara Jessen

BACKGROUND: Organic inflammatory response is a pathophysiological mechanism present at every coronary artery bypass grafting with extracorporeal circulation (CABG-ECC), the release of inflammatory mediators being one of its defense mechanisms. OBJECTIVE: To assess, in a prospective double-blind randomized and placebo-controlled study, the effects of trimetazidine (Tmz) on the inflammatory response, by using the variation in interleukins 6 and 8, TNF-α, complements C3 and C5, and highly sensitive C-reactive protein (HS-CRP) levels in the pre- and post-operative periods. METHODS: This study assessed 30 patients undergoing CABG-ECC with intermittent hypothermic cardioplegia, and having, at most, mild ventricular dysfunction. The patients were divided into two groups (placebo and Tmz), stratified by echocardiography, and received drug/placebo at the dose of 60 mg/day. Measurements were taken as follows: in the pre-operative period with no drug; on the day of surgery, corresponding to 12 to 15 days on drug/placebo; five minutes after aortic unclamping; 12 and 24 hours after surgery, for interleukins and complements; and 48 hours after surgery, for HS-CRP. RESULTS: No significant difference between the levels of interleukin 8, TNF-α, C3 and C5, and HS-CRP was observed. However, the interleukin 6 levels were significantly lower in the group treated as compared with those in the control group at all time points assessed. CONCLUSION: Trimetazidine proved to be effective only for reducing interleukin 6 in patients undergoing CABG.

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Artigo Original

Autonomic dysfunction and anti-M2 and anti-β1 receptor antibodies in Chagas disease patients

Clarissa Antunes Thiers et al. João Luis Barbosa Basílio de Bragança Pereira Emília Matos do Nascimento … José Hamilton do Nascimento Emiliano Horácio Medei Roberto Coury Pedrosa

BACKGROUND: Sudden death is the leading cause of death in Chagas’ disease, affecting patients even in the early stages of the disease. The impairment of the autonomic nervous system in this disease has been recognized, as well as its potential as a trigger for malignant arrhythmias when associated with structural or metabolic changes. OBJECTIVE: We sought to identify, in Chagas patients with preserved systolic function, the impairment of the autonomic nervous system and its association with functionally active anti-m2 and anti-β1 receptor antibodies. METHODS: Using spectral analysis of RR variability during passive tilt test, chronic chagasic patients were compared with healthy controls matched for age. Subsequently, the association of autonomic dysfunction with functionally active antibodies with anti-m2 and anti-β1 action was investigated by the Langendorf method. RESULTS: We observed that patients with Chagas disease without ventricular dysfunction express parasympathetic activity against a vagal stimulus, however with less intensity compared to controls. Chagasic patients with anti-m2 or anti-β1 antibodies showed a further significant reduction of the vagal response during respiratory sinus arrhythmia, regardless of the presence of structural lesion. However, the association of both factors promoted response to vagal stimulation similar to that seen in Chagas disease without their presence. CONCLUSION: The lower vagal reserve in Chagas patients with preserved function was associated with functionally active anti-m2 or anti-β1 antibodies, and not with the presence of structural heart lesion.

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Artigo Original

Effect of dry coffee residues fermented with Monascus ruber on the metabolism of Apo E mice

Larissa Froede Brito et al. Lívia Dias de Queirós Maria do Carmo Gouveia Peluzio Sônia Machado Rocha Ribeiro … Sérgio Luis Pinto da Matta José Humberto de Queiroz

BACKGROUND: Atherosclerosis is a chronic inflammatory disease of multifactorial origin, which occurs in response to endothelial injury. The fungus Monascus ruber has hypocholesterolemic activity, and the polyphenols present in coffee residue have an antioxidant activity and can help prevent cardiovascular diseases. Coffee residue has a significant amount of fermentable sugars, being an adequate substrate for growing fungi. OBJECTIVE: The objective of this study was to assess the effect of dry coffee residue fermented with Monascus ruber on the lipid metabolism of ApoE knockout mice. METHODS: The biological assay was performed with 30 ApoE knockout mice, divided into five groups and undergoing different treatments. The phytochemical prospection and quantification of phenolic compounds of the fermented and non-fermented coffee residues were performed. The sera of the animals were analyzed by using enzyme kits, and the aortic tissue was embedded in paraffin and stained with hematoxylin and eosin to undergo histopathological analysis. RESULTS: Comparing with the control group, the group receiving 2% non-fermented coffee residue showed a reduction of 42% in the serum levels of triacylglycerols and of approximately 41% in VLDL-c. The groups receiving 10% non-fermented coffee residue and 2% fermented coffee residue showed reductions in the lesion areas of 10.5% and 15.4%, respectively, as compared with the control group. The fermented coffee residue showed a higher content of phenolic compounds as compared with the non-fermented coffee residue. CONCLUSION: The present study showed that coffee residue fermentation has a potentially beneficial effect on cardiovascular diseases, especially atherosclerosis.

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Artigo Original

Mitral valve and atrial septal defect surgery: minimally invasive or sternotomy approach

Josué V. Castro Neto et al. Emanuel Melo Juliana Fernandes Regina Gomes … Caroline Freitas João Machado Francisco Martins Aloísio Barbosa Bernardo Oliveira Cesar Gondim

BACKGROUND: To decrease the surgical trauma in heart procedures, minimally invasive (MI) techniques were alternatively introduced. OBJECTIVE: To compare MI surgical access with median sternotomy (MS) for the treatment of mitral valve (MV) disease and atrial septal defect (ASD). METHODS: Forty patients underwent surgery for correction of MV disease or ASD. Patients were divided into group A (GA) (n=20), access by right minithoracotomy and video-assistance; and group B (GB) (n=20), access by full MS. Aortic cross-clamp and cardiopulmonary bypass time, intensive care unit (ICU) time, hospital stay and morbidity were compared in this prospective study . RESULTS: Fifteen patients were submitted to MV procedures and five to ASD corrections in each group. There were 9 mitral replacements (7 bioprostetic and 2 mechanical) and 6 repairs in GA, and 10 (all bioprostetic) and five in GB. The mean aortic cross-clamp and cardiopulmonary bypass time, in minutes, were 65.1 ± 29.3 in GA and 50.2 ± 21.4 in GB (p=0.074); and 91.8±35 in GA and 63.7±27.3 in GB ( p=0.008). The mean ICU time, in hours, were 51.7 ± 16.3 in GA and 55.8±17.5 in GB (p=0.45). The in hospital stay, in days, were 5.2 ± 1 in GA and 6.4±1.5 in GB (p=0.009). CONCLUSION: MI access for correction of the MV disease and ASD implicated in a longer cardiopulmonary bypass time for finalization of the main procedure, nevertheless it didn´t affect patient’s recuperation. MI treated patients were discharged earlier than sternotomy treated patients.

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Artigo Original

Transcatheter bioprosthesis implantation for the treatment of aortic stenosis: three-year experience

Fabio Sandoli de Brito Junior et al. Alexandre Abizaid Breno O. Almeida Adriano Caixeta … Flávio Tarasoutchi Eberhard Grube Marco Perin

BACKGROUND: Transcatheter aortic bioprosthesis implantation is a new treatment modality for patients with aortic stenosis who are inoperable or at high surgical risk. OBJECTIVE: To report the three-year experience with transcatheter CoreValve® bioprosthesis implantation. METHODS: From January 2008 to January 2011, 35 patients with aortic stenosis (33) or aortic valve bioprosthesis dysfunction (two) at high surgical risk underwent transcatheter CoreValve® bioprosthesis implantation. RESULTS: The patients’ mean age was 81.5 ± 9 years, and 80% had heart failure functional class III or IV. The EuroScore was 18.4 ± 14.3% and the STS risk score was 14.5 ± 11.6%. Successful device implantation was achieved in 34 (97.1%) patients. After the intervention, a reduction in the transvalvular pressure gradient from 84.9 ± 22 to 22.5 ± 9.5 mm Hg was observed, and 87.1% of the patients progressed to functional class I or II. Thirty-day mortality and mortality in the follow-up of 400 ± 298 days were 11.4% and 31.4%, respectively. The occurrence of life-threatening hemorrhagic complications was the only independent predictor of cardiovascular mortality. Stroke occurred in 5.7% of the patients. Permanent pacemaker was required in 32.1% of the patients within the first month after the procedure. CONCLUSION: Transcatheter aortic bioprosthesis implantation is a safe and effective procedure to be used in patients with aortic stenosis at high surgical risk. The CoreValve® prosthesis proved to have mid-term efficacy in a three-year follow-up.

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Artigo Original

Echocardiographic parameters as cardiovascular event predictors in hemodialysis patients

Thayse Mayara Aragão Siqueira et al. Pedro Antônio Muniz Ferreira Francisco das Chagas Monteiro Júnior Natalino Salgado Filho … Adalgisa de Souza Paiva Ferreira Eugênio dos Santos Neto Francival Leite de Souza Paulo de Tarso Cardoso

BACKGROUND: Patients with chronic kidney disease (CKD) on hemodialysis have high rates of cardiovascular morbidity and mortality. Although structural and functional echocardiographic alterations in patients undergoing hemodialysis have been the subject of several survival analysis studies, the prognostic value of these alterations is not well established in literature. OBJECTIVE: To determine the prognostic value of echocardiographic parameters in patients with CKD on hemodialysis. METHODS: Sixty consecutive patients with CKD on hemodialysis were clinically evaluated and underwent Doppler echocardiography, being followed for 19 ± 6 months. The outcome measures were fatal and nonfatal cardiovascular events and overall mortality. The predictive value of echocardiographic variables was evaluated by Cox regression model and survival curves were constructed using the Kaplan-Meier method and log rank test to compare them. RESULTS: Rates of survival free of cardiovascular events, of cardiovascular and overall mortality in two years were 79.4%, 88.5% and 83% respectively. Diabetes, previous diagnosis of cardiovascular disease (CVD), ejection fraction, fractional shortening, left ventricular systolic diameter and E/e’ ratio were predictors of cardiovascular outcome at univariate analysis. In the multivariate analysis, previous history of CVD (HR = 6.17, 95%CI: 1.7 – 22.2, p = 0.005) and moderate to severe diastolic dysfunction (HR = 3.76, 95%CI: 1.05 – 13.4, p = 0.042) were independent risk factors for cardiovascular events. CONCLUSION: Moderate to severe diastolic dysfunction is an independent predictor of cardiovascular events in hemodialysis patients.

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Artigo Original

Felypressin increases blood pressure during dental procedures in hypertensive patients

Ana Lúcia Aparecida Bronzo et al. Crivaldo Gomes Cardoso Jr. Kátia Coelho Ortega Décio Mion Jr

BACKGROUND: Felypressin has been added to local anesthetic to increase the length of the anesthetic effect and reduce toxicity during dental procedures. However, the effect on blood pressure remains uncertain, and this may be highly relevant in the dental treatment of hypertensive patients. OBJECTIVE: To investigate the effect of felypressin on blood pressure in hypertensive patients with controlled BP. METHODS: 71 subjects with these characteristics and in need of periodontal treatment were studied. After 10 minutes of rest, local anesthesia (prilocaine) was infiltrated with and without addition of felypressin. Then, a deep subgingival scaling was performed. Blood pressure was measured by an automated oscillometric device (DIXTAL DX2010). Ten minutes after the administration of the anesthetic, peak anesthetic action was recorded. The State-Trait Anxiety Inventory (STAI) was used to assess the patients’ trait anxiety. RESULTS: Systolic blood pressure increased after anesthesia, regardless of association with felypressin, throughout the dental procedure (p<0.05) and this response can be explained, at least in part, by the trait anxiety levels of the subjects. However, a further increase in diastolic blood pressure was observed when prilocaine was associated with felypressin (p<0.05), but this response did not change with trait anxiety levels. CONCLUSION: Felypressin increased the diastolic blood pressure of hypertensive patients with controlled blood pressure. Patients with high trait anxiety presented increases in systolic blood pressure upon some procedures, suggesting that an increase in blood pressure might also be related to fear or anxiety.

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Artigo Original

Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update

Antonio de Padua Mansur et al. Desidério Favarato

BACKGROUND: Cardiovascular diseases (CVD) are the leading causes of death in our population. There was a progressive decrease in mortality due to CVD up to 2005. OBJECTIVE: To update the trends in mortality from cardiovascular diseases in Brazil and in the metropolitan region of São Paulo (MRSP) from 1990 to 2009. METHODS: Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk of death was adjusted by the direct method, having as reference the world population in 2000. RESULTS: There was a progressive decrease in the risk of death from ischemic heart disease (IHD) and stroke in Brazil and in the MRSP. From 1990 to 2009, there was a decrease in mortality from IHD and stroke in men and women in Brazil and in the MRSP. There was a greater reduction in mortality from IHD in men in the MRSP than in Brazil (36.24% vs. 23.35%, p <0.001) and in women in the MRSP (44.55% vs. 29.5%; p <0.001). The highest reduction in stroke mortality was observed in men in the MRSP, when compared to Brazil (42.43% vs. 34.9%, p = 0.036) and an equal reduction in women in the MRSP and in Brazil (42.98% vs. 36.15%, p = 0.082). The decrease in mortality was significant for all age groups. CONCLUSION: We observed a progressive decrease in mortality from CVD, IHD and stroke in Brazil and in the MRSP. In spite of this decrease, we still have high rates of mortality from these diseases.

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Artigo Original

Diltiazem as an alternative to beta-blocker in coronary artery computed tomography angiography

Carlos Eduardo Rochitte et al. Guilherme Santana Antunes Azevedo Afonso Akio Shiozaki Clerio Francisco Azevedo Roberto Kalil Filho

BACKGROUND: Reducing heart rate (HR) in CT angiography of the coronary arteries (CTACor) is critical to image quality. The effectiveness of calcium channel blockers as alternatives for patients with contraindications to beta-blockers has not been established. OBJECTIVES: To compare the efficacy in the reduction of HR and RR variability of metoprolol and diltiazem in CTACor. METHODS: Prospective, randomized, open study that included patients with clinical indication of CTACor in sinus rhythm with HR > 70 bpm and no use of agents that could interfere with HR. Fifty patients were randomized to the groups: metoprolol IV 5-15 mg or up to HR ≤ 60 bpm (M), and diltiazem IV 0.25 to 0.60 mg/kg or up to HR ≤ 60 bpm (D). Blood pressure (BP) and HR were measured at baseline, 1 minute, 3 minutes and 5 minutes after the agents, at the acquisition and after CTACor. RESULTS: HR reduction in absolute values was higher in group M than in group D (1, 3, 5 min, acquisition and post-test). The percentage reduction of HR was significantly higher in group M only 1 min and 3 min after the start of the agents. There was no difference in 5 min at acquisition and after examination. The percentage RR variability in group D was lower than that in group M during acquisition (RR variability/mean HR of acquisition). A single case of AVB, 2:1 Mobitz I occurred, which was spontaneously reverted (group D). CONCLUSION: We conclude that diltiazem is an effective and safe alternative to beta-blockers in the reduction of HR when performing computed tomography angiography of coronary arteries. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

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Artigo Original

Clinical outcomes after investigation for pulmonary embolism using CT angiography and venography

Eduardo S. Darze et al. João F.M. Braghiroli Ricardo V. Almeida Ênio P. Araújo … Sergio M. Toscano César Augusto Araújo-Neto

BACKGROUND: The diagnosis of pulmonary embolism (PE) still requires long work-up periods and multiple tests. OBJECTIVE: We aim to assess clinical outcomes after a negative investigation using a combined protocol of CT pulmonary angiography and CT venography (CTA/CTV) as a sole diagnostic test in unselected patients with suspected PE. METHODS: This retrospective cohort study enrolled consecutive patients with suspected PE who were investigated with a combined CTA/CTV protocol. Patients who had an initially negative investigation and were not anticoagulated were followed for 6 months for the occurrence of recurrent venous thromboembolic events. RESULTS: Out of 425 patients with suspected PE, 62 (14.6%) had venous thromboembolism diagnosed on the initial CTA/CTV. The mean age was 56 ± 19 years and 61% of the population fell into the low clinical probability category. Isolated deep vein thrombosis represented 21% of all venous thromboembolic events, and when considering the whole population, CTV was associated with an increment in diagnostic yield of 3.1%. Our cohort was composed of 320 patients with initially negative CTA/CTVs and who were not anticoagulated. After 6 months of follow up, only three patients presented with recurrent thromboembolic events (0.9%; 95% CI -0.1% – 2.0%) and none was fatal. There were no PE-related deaths. CONCLUSION: Our study suggests that a diagnostic strategy that utilizes CTA/CTV as a sole diagnostic test can safely rule out PE in a low to moderate risk population and is associated with favorable outcomes with a negative predictive value of 99.1%. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

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