2012;99(3) – ABC CARDIOL

BACKGROUND: The high and increasing prevalence of Dilated Cardiomyopathy (DCM) represents a serious public health problem. New technologies are being used aiming at more accurate diagnoses in order to improve therapeutic approach. In this scenario, speckle tracking echocardiography (STE) uses natural myocardial markers to analyze the systolic deformation of the left ventricle (LV). OBJECTIVE: To measure the longitudinal transmural global strain (GS) of the LV through STE in patients with severe DCM, comparing the results with normal individuals and with echocardiographic parameters established for the analysis of LV systolic function, validating the method in this population. METHODS: We studied 71 patients with severe DCM (53 ± 12 years, 72% men) and 20 controls (30 ± 8 years, 45% men). We obtained LV volumes and ejection fraction by two and three-dimensional echocardiography, Doppler parameters, tissue Doppler and GS was obtained by STE. RESULTS: Compared to controls, LV volumes were higher in the DCM group; however, LVEF and peak velocity of E wave were lower in the latter. The myocardial performance index was higher among patients. Myocardial velocities at the tissue Doppler (S’, e’, a’) were significantly lower and E/e’ ratio was higher in the DCM group. The GS was decreased in the DCM group (-5.5% ± 2.3%) when compared to controls (-14.0% ± 1.8%). CONCLUSION: In this study, GS was significantly lower in patients with severe DCM, bringing new perspectives for therapeutic approaches in this specific population.

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Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome

Carolina Esteves Barbosa et al. Mateus Viana Mariana Brito Michael Sabino … Guilherme Garcia Mayara Maraux Alexandre Costa Souza Márcia Noya-Rabelo J. Péricles Esteves Luis Cláudio Lemos Correia

BACKGROUND: The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. OBJECTIVE: To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. METHODS: Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). RESULTS: Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 – 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 – 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 – 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 – 0.76). CONCLUSION: (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

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Prognostic value of endothelial function in patients with atherosclerosis: systematic review

Maristela Magnavita Oliveira Garcia et al. Paulo Roberto Passos Lima Luis Claudio Lemos Correia

Analysis of flow-mediated vasodilation (FMV) of the brachial artery by use of ultrasound allows assessing endothelial function, and provides pathophysiological, diagnostic and prognostic information. This systematic review was aimed at assessing the literature level of evidence of the predictive capacity of endothelial function, measured through brachial artery FMV by use of ultrasound, regarding cardiovascular events in individuals with atherosclerosis. The MEDLINE, SCIELO and LILACS databases were searched, and prospective cohort studies on human beings about the prognostic value of endothelial function, measured by use of brachial artery FMV in individuals with peripheral or coronary atherosclerosis, were selected. Studies with clear methodological biases were excluded. The final selection consisted of 15 studies. Of the 13 studies that on univariate analysis showed statistical significance of the FMV method to predict cardiovascular events, 12 showed independent predictive capacity on multivariate analysis. None of the studies reviewed described the incremental predictive value of FMV to the traditional predictive models, such as the Framingham score. Results of three studies have suggested that the method adds prognostic value to isolated markers such as ankle-brachial index (ABI), diabetes, and high-sensitivity C-reactive protein (hsCRP). In conclusion, brachial artery FMV predicts cardiovascular risk, but its incremental predictive value to clinical prognostic models has not been established. In addition, solid evidence supporting its use in routine clinical practice to predict cardiovascular risk still lacks.

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Sildenafil vs. sodium nitroprusside for the pulmonary hypertension reversibility test before cardiac transplantation

Aguinaldo Figueiredo Freitas Jr et al. Fernando Bacal José de Lima Oliveira Júnior Alfredo Inácio Fiorelli … Ronaldo Honorato Santos Luiz Felipe Pinho Moreira Christiano Pereira Silva Sandrigo Mangini Jeane Mike Tsutsui Edimar Alcides Bocchi

BACKGROUND: Pulmonary hypertension is associated with a worse prognosis after cardiac transplantation. The pulmonary hypertension reversibility test with sodium nitroprusside (SNP) is associated with a high rate of systemic arterial hypotension, ventricular dysfunction of the transplanted graft and high rates of disqualification from transplantation. OBJECTIVE: This study was aimed at comparing the effects of sildenafil (SIL) and SNP on hemodynamic, neurohormonal and echocardiographic variables during the pulmonary reversibility test. METHODS: The patients underwent simultaneously right cardiac catheterization, echocardiography, BNP measurement, and venous blood gas analysis before and after receiving either SNP (1 – 2 µg/kg/min) or SIL (100 mg, single dose). RESULTS: Both drugs reduced pulmonary hypertension, but SNP caused a significant systemic hypotension (mean blood pressure – MBP: 85.2 vs. 69.8 mm Hg; p < 0.001). Both drugs reduced cardiac dimensions and improved left cardiac function (SNP: 23.5 vs. 24.8%, p = 0.02; SIL: 23.8 vs. 26%, p < 0.001) and right cardiac function (SIL: 6.57 ± 2.08 vs. 8.11 ± 1.81 cm/s, p = 0.002; SNP: 6.64 ± 1.51 vs. 7.72 ± 1.44 cm/s, p = 0.003), measured through left ventricular ejection fraction and tissue Doppler, respectively. Sildenafil, contrary to SNP, improved venous oxygen saturation, measured on venous blood gas analysis. CONCLUSION: Sildenafil and SNP are vasodilators that significantly reduce pulmonary hypertension and cardiac geometry, in addition to improving biventricular function. Sodium nitroprusside, contrary to SIL, was associated with systemic arterial hypotension and worsening of venous oxygen saturation.

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Immunohistochemical expression of cell differentiation and growth in neonate cardiomyocytes

Tarcísio Fulgêncio Alves da Silva et al. Greyce Kelly de Souza Mona Adalgisa Simões Francisco Cesar Pabis Lucia de Noronha

BACKGROUND: The cardiac alterations during the fetal heart transition to extrauterine life have been explored by several animal studies and the cell mechanisms responsible for these modifications are not well documented in humans. OBJECTIVE: To evaluate the mechanism of cell differentiation into cardiomyocytes that occur in the first days of life, through immunohistochemical analysis of proteins involved in proliferation and muscle contraction processes, in samples of human neonate myocardium. METHODS: Cross-sectional study of paraffin-sample sections of myocardium from an autopsy database of human neonates, divided into two sample groups: full-term neonates who died after a maximum of two days of life (NEO1) with 10 cases, and full-term infants who died between 3 and 10 days of life (NEO2) with 14 cases, in order to follow a temporal line that would contemplate the transition from fetal circulation to extrauterine life. The samples were studied in tissue microarray and the antibodies used were Ki67, PCNA, PTEN, Bcl2 (proliferation), HHF35 and sarcomeric actin (contractile proteins). RESULTS: Difference was observed regarding Ki67, p = 0.02; HHF35, p <0.01 and sarcomeric actin, p = 0.02, with Ki67 expression being higher in NEO1 group, whereas HHF35 and sarcomeric actin expression was higher in the NEO2 group. CONCLUSION: The results suggest that cardiomyocytes have a proliferation characteristic (Ki67) in NEO1 which, following a temporal line, will be replaced by a differentiation characteristic (HHF35 and sarcomeric actin) in NEO2.

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Cardiorespiratory fitness of a Brazilian regional sample distributed in different tables

Karlyse Claudino Belli et al. Carine Calegaro Cleusa Maria Richter Jonatas Zeni Klafke … Ricardo Stein Paulo Ricardo Nazario Viecili

BACKGROUND: Most classification tables of cardiorespiratory fitness (CRF) used in clinical practice are international and have not been validated for the Brazilian population. That can result in important discrepancies when that classification is extrapolated to our population. OBJECTIVE: To assess the use of major CRF tables available in a Brazilian population sample of the Central High Plan of the state of Rio Grande do Sul (RS). METHODS: This study assessed the retrospective data of 2,930 individuals, living in 36 cities of the Central High Plan of the state of RS, and considered the following: presence of risk factors for cardiovascular disease and estimated maximum oxygen consumption (VO2peak) values obtained through exercise test with Bruce protocol. To classify CRF, the individuals were distributed according to sex, inserted in their respective age groups in the Cooper, American Heart Association (AHA) and Universidade Federal de São Paulo (Unifesp) tables, and classified according to their VO2peak. RESULTS: Women had lower VO2peak values as compared with those of men (23.5 ± 8.5 vs. 31.7 ± 10.8 mL.kg-1.min-1, p < 0.001). Considering both sexes, VO2peak showed an inverse and moderate correlation with age (R = -0.48, p < 0.001). An important discrepancy in the CRF classification levels was observed between the tables, ranging from 49% (Cooper x AHA) to 75% (Unifesp x AHA). CONCLUSION: Our findings indicate important discrepancy in the CRF classification levels of the tables assessed. Future studies could assess whether international tables could be used for the Brazilian population and populations of different regions of Brazil.

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Accuracy of chest radiography plus electrocardiogram in diagnosis of hypertrophy in hypertension

Sergio Marrone Ribeiro et al. José Morceli Renato Souza Gonçalves Roberto Jorge da Silva Franco … Francisco Habermann Domingos Alves Meira Beatriz Bojikian Matsubara

BACKGROUND: Chest radiography and electrocardiogram have been criticized due to their low sensitivity for Left Ventricular Hypertrophy diagnosis compared to echocardiogram. This one, however, is not available in primary health care centers to all hypertensive population. OBJECTIVE: To evaluate whether the association chest radiography-electrocardiogram provides the accuracy to justify its use in left ventricular hypertrophy detection in hypertensive patients, as well as the usefulness of the cardiothoracic ratio and oblique radiographs in relation to frontal and lateral views in evaluating dimensions of left cardiac chambers. METHODS: This was a prospective study including 177 consecutive hypertensive patients through chest radiography, electrocardiogram and echocardiography. Accuracy test was used to compare these methods using echocardiography as gold standard. RESULTS: The cardiothoracic ratio showed 17% sensitivity for detection of left ventricular hypertrophy, only indicating cardiac alterations at an advanced stage. Frontal plus lateral views showed sensitivity of 52%, which rose to 54% when chest radiography was associated with electrocardiogram. The oblique views did not significantly improve chest radiography accuracy. Chest radiography presented high specificity and elevated sensitivity for detection of aortal enlargement. Interestingly, this alteration was present in half of the hypertensive patients with left ventricular hypertrophy. CONCLUSION: We conclude that the association chest radiography-electrocardiogram is useful for the screening of hypertensive patients for the diagnosis of left ventricular hypertrophy, especially if echocardiogram is unavailable. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

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eNOS correlates with mitochondrial biogenesis in hearts of congenital heart disease with cyanosis

Juan Xiao et al. Lin Chen Xuefeng Wang Mei Liu Yingbin Xiao

BACKGROUND: Mitochondrial biogenesis program in heart appears to exhibit adaptive remodeling following biomechanical and oxidative stress. The adaptive mechanisms that protect myocardium metabolism during hypoxia are coordinated in part by nitric oxide (NO). OBJECTIVE: To observe mitochondrial biogenesis and nitric oxide synthase (NOS) expression in hearts of congenital heart disease with cyanosis, discuss mitochondrial response to chronic hypoxia in myocardium. METHODS: 20 patients with cyanotic (n=10) or acyanotic cardiac defects (n=10) were investigated. Samples from the right ventricular outflow tract myocardium taken during operation were studied. Morphometric analysis of mitochondria was performed with transmission electron microscope. Relative mtDNA/nDNA ratio was determined with real-time PCR. Cytochrome c oxidase subunit I (COXI), peroxisome-proliferator-activated receptor Î³ coactivator-1α (PGC-1α), nuclear respiratory factor 1 (NRF1), and mitochondrial transcription factor A (Tfam) transcript levels were detected by real-time fluorescent RT-PCR. COXI and nNOS, iNOS and eNOS protein levels were measured with western blot. RESULTS: Mitochondrial volume density (Vv) and numerical density (Nv) were significantly elevated in patients with cyanotic compared to acyanotic congenital heart disease. Elevated mtDNA and up-regulated COXI, PGC-1α, NRF1 and Tfam mRNA levels were observed in cyanotic patients. Protein levels of COXI and eNOS were significantly higher in the myocardium of cyanotic than of acyanotic patients. PGC-1α transcript levels correlated with the levels of eNOS. Conclusion: Mitochondrial biogenesis is activated in right ventricular outflow tract myocardium in congenital heart disease with cyanosis, which could be the adaptive response to chronic hypoxia and possibly involves eNOS up-regulation. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

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Effects of age and aerobic fitness on heart rate recovery in adult men

Gabriela Alves Trevizani et al. Paulo Roberto Benchimol-Barbosa Jurandir Nadal

BACKGROUND: Physiological aging leads to cardiac autonomic dysfunction, which is associated with the onset and worsening of cardiovascular disease and an increased risk of death. Currently, physical exercise is considered a cardioprotective strategy and more research is needed on its benefit on cardiac autonomic function. OBJECTIVE: To evaluate the autonomic control of heart rate in healthy young and middle-aged volunteers with different levels of aerobic fitness. METHODS: The study included 68 volunteers, stratified for age and level of aerobic fitness. Based on aerobic fitness assessed by the submaximal exercise test, subjects were separated into two groups, good fitness and poor fitness. Assessment of cardiac autonomic control was performed based on measurements of heart rate variability at rest and heart rate recovery post-exercise. Analysis of variance with two factors was used to compare the variables investigated. RESULTS: The heart rate variability is significantly lower in middle-aged volunteers than in young individuals, regardless of the aerobic fitness level (p <0.01). Higher levels of aerobic fitness in middle-aged volunteers are associated with earlier post-effort vagal reentry – rate of HR decline after 1min30s: 39.6% good aerobic fitness vs. poor 28.4% (p < 0.01). CONCLUSION: Better levels of aerobic fitness act beneficially on the autonomic control of post-exercise heart rate, preserving the vagal reentry velocity in healthy middle-aged volunteers. However, it does not attenuate the decrease in heart rate variability due to the natural aging process.

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Continuous noninvasive hemodynamic monitoring in decompensated heart failure

Marcelo Villaça Lima et al. Marcelo Eidi Ochiai Kelly Novaes Vieira Juliano Novaes Cardoso … Euler Cristovan Brancalhão Raphael Puig Antônio Carlos Pereira Barretto

BACKGROUND: The clinical and hemodynamic assessment at the bedside and the use of pulmonary artery catheter for the estimation of hemodynamic data have been used in decompensated heart failure. However, there are no data on the use of continuous noninvasive hemodynamic monitoring. OBJECTIVE: To compare the data obtained through noninvasive hemodynamic monitoring with invasive ones in patients with decompensated heart failure and refractory to treatment. METHODS: The non-invasive hemodynamic measurements were obtained through continuous monitoring of systemic blood pressure by the pulse wave model (Modelflow) and compared with measurements obtained by the passage of a pulmonary artery catheter, simultaneously. RESULTS: A total of 56 measurements were performed in 14 patients studied on different days and time periods. The correlation index between systolic blood pressure measurements was r = 0.26 (95% CI = 0.00 to 0.49, p = 0.0492) and diastolic ones, r = 0.50 (95% CI = 0.27 to 0.67, p <0.0001). The correlation was r = 0.55 (95% CI = 0.34 to 0.71, p <0.0001) for cardiac index and r = 0.32 (95% CI = 0.06 to 0 53, p = 0.0178) for systemic vascular resistance. CONCLUSION: There was a correlation between the hemodynamic measurements when compared to noninvasive pulmonary artery catheter measurements. The continuous noninvasive hemodynamic monitoring may be useful for hospitalized patients with decompensated heart failure.

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Hemodynamic profile of severity at pulmonary vasoreactivity test in schistosomiasis patients

Flávio A. A. Japyassú et al. Adriano A. Mendes Ângela P. Bandeira Flávio R. A. Oliveira Dário Sobral Filho

BACKGROUND: The pulmonary vasoreactivity rate of Schistosomal Pulmonary Artery Hypertension (SPAH) is not known. Hemodynamic data obtained by cardiac catheterization are associated with the most commonly used clinical criteria of severity. OBJECTIVE: To estimate the percentage of positive vasoreactivity to nitric oxide in schistosomal pulmonary arterial hypertension and verify the association of hemodynamic parameters with WHO functional classification and the six-minute walk test in these patients. METHODS: A total of 84 patients with schistosomal pulmonary hypertension were selected from a database, who had been submitted to the right and left cardiac catheterization and pulmonary vasoreactivity test with nitric oxide. Data on WHO functional classification and six-minute walk test were collected for comparison with invasive data. RESULTS: Of the 84 patients with SPAH, 3 (3.5%) had positive criteria for pulmonary vasoreactivity. The increase in pulmonary vascular resistance was significantly associated with lower exercise capacity measured by the six-minute walk test (p = 0.045) and greater symptom severity by higher functional classifications (WHO class III/IV) (p = 0.013). The decrease in oxygen saturation in the pulmonary artery was significantly associated with higher functional classifications (p = 0.041). CONCLUSION: The pulmonary response rate to the vasodilation test of schistosomiasis patients is below the values found for idiopathic pulmonary hypertension. Pulmonary vascular resistance and oxygen saturation in the pulmonary artery are hemodynamic data that can be used as markers of severity in schistosomal pulmonary hypertension.

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