2013;100(1) – ABC CARDIOL

BACKGROUND: There are few registries documenting clinical practice in Brazilian patients with acute coronary syndrome. OBJECTIVES: Demography description, occurrence of major clinical adverse events and comparative analysis in patients submitted or not to an invasive strategy (coronary angiography and myocardial revascularization) in a Brazilian multicenter registry of acute coronary syndrome. METHODS: The ACCEPT/SBC registry prospectively collected data on acute coronary syndrome patients from 47 Brazilian hospitals. The current analysis reports the occurrence of major clinical outcomes and according to the performance or not of a procedure for myocardial revascularization at the end of 30 day follow-up. RESULTS: Between August 2010 and December 2011, 2.485 patients were enrolled in this registry. Of these, 31.6% had unstable angina, 34.9% and 33.4% had acute coronary syndrome without and with ST-segment elevation. At 30 days, the performance of a myocardial revascularization procedure was progressively higher according to the severity of clinical presentation (38.7% vs. 53.6% vs. 77.7%, p < 0.001). Cardiac mortality among those submitted or not to myocardial revascularization procedure was 1.0% vs. 2.3% (p = 0.268), 1.9% vs. 4.2% (p = 0.070) and 2.0% vs. 8.1% (p < 0.001), in those with unstable angina, acute coronary syndrome without and with ST-segment elevation, respectively. CONCLUSIONS: The prescription of a myocardial revascularization procedure was progressively more frequent according to the severity of clinical presentation; for those treated during acute coronary syndrome without and with ST-segment elevation, there was a trend and significant decrease in mortality rate at 30 day of follow-up, respectively.

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Brief Communication

Calcium score to evaluate chest pain in the emergency room

Henrique Lane Staniak et al. Márcio Sommer Bittencourt Rodolfo Sharovsky Isabela Benseñor … Rodrigo Diaz Olmos Paulo A. Lotufo

Some authors have suggested that a zero calcium score (CAC) can be used to rule out the diagnosis of acute coronary syndrome. Objective this study is to evaluate the diagnostic accuracy of a zero CAC when compared to the coronary computed tomography angiography (CCTA) at the emergency department. 135 symptomatic patients with no previous coronary heart disease (CHD) who presented to the emergency department were submitted to CAC and CCTA to rule out CHD. All patients had normal electrocardiogram and cardiac biomarkers and were TIMI risk score 0 to 2. The CCTA was considered positive if any obstructive lesion (> 50%) was identified. The mean age was 51.7 ± 13.6 years with 50.6% of men. Seventy-three (54.1%) patients had a calcium score of zero. Of them, 3 (4.1%) had an obstruction > 50 % and underwent invasive coronary angiography. Calcium score showed a sensitivity of 92.9%, specificity of 75.3%, positive and negative predictive values of, respectively, 62.9% and 95.9%. Positive and negative likelihood ratios were respectively of 3.7 and 0.09 to detect lesions greater than 50% in the CCTA. A negative likelihood ratio of 0.09 is very good to rule out most cases of significant coronary obstruction in epidemiologic studies. However, it is important to understand that in a clinical scenario, all evidence including history, clinical examination, data from eletrocardiogram and myocardial biomarkers have to be interpreted together. In our study, three cases with a zero CAC score had coronary obstruction higher than 50% at the CCTA.

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Original Article

Echocardiography in thalassemic patients on blood transfusions and chelation without heart failure

Alexandre Rodrigues et al. Fábio Villaça Guimarães-Filho João Carlos Ferreira Braga Cássia Spínola Custódio Rodrigues … Paulo Waib Antonio Fabron-Junior Doralice Marvulle Tan Ana Cristina C. V. França Marina Politi Okoshi Katashi Okoshi

BACKGROUND: Patients with thalassemia major present chronic hemolysis and require regular blood transfusions which may cause iron overload cardiomyopathy and chronic heart failure. Hemochromatosis is characterized by excessive iron accumulation in tissues, and heart involvement is the main cause of death in patients with thalassemia. OBJECTIVE: The aim of this study was to evaluate cardiac structure and function by conventional Doppler echocardiography and tissue Doppler imaging in patients with TM and no clinical evidence of heart failure. METHODS: This is a prospective observational study including 18 patients with thalassemia major (TM) receiving regular blood transfusion. To separately evaluate anemia and blood transfusion effects, two gender, age, weight, and height-matched control groups were included: one with healthy individuals (Healthy, n=18) and one with iron deficient anemia patients (Anemia, n=18). Statistical analysis was performed using ANOVA followed by Tukey’s test or Kruskal-Wallis’s and Dunn’s test. RESULTS: The following echocardiographic variables presented significantly higher values in TM than the Anemia and Healthy groups: left atrium volume index (Healthy: 16.4±6.08; Anemia: 17.9±7.02; TM: 24.1±8.30 cm³/m²); mitral septal E/Em ratio (Healthy: 6.55±1.60; Anemia: 6.74±0.74; TM: 8.10±1.31); and duration of reverse pulmonary vein flow [Healthy: 74.0 (59.0-74.0); Anemia: 70.5 (67.0-74.0); TM: 111 (87.0-120) ms]. The mitral E/A ratio was higher in TM than Anemia (Healthy: 1.80±0.40; Anemia: 1.80±0.24; TM: 2.03±0.34). No differences were found in left ventricular structures and systolic function indexes. CONCLUSION: Conventional Doppler echocardiography and tissue Doppler allow changes in left ventricular diastolic function to be identified in asymptomatic patients with thalassemia major.

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Original Article

Prevalence of high platelet reactivity in aspirin-treated patients referred for coronary angiography

André Manica et al. Rogério Sarmento-Leite Clara Manfroi La Hore Rodrigues Jr … Carlos Gottschall Julio F Marchini Kevin Croce

BACKGROUND: Aspirin (ASA) reduces adverse events in coronary artery disease (CAD) patients by inhibiting platelets. Some CAD patients have high platelet reactivity (HPR) despite ASA therapy and these individuals have increased risk of adverse events. OBJECTIVE: The purpose of this study was to determine the prevalence of HPR in ASA-treated patients referred for coronary angiography and to assess whether the HPR correlates with the severity of CAD. METHODS: This single center investigation enrolled 115 consecutive ASA-treated patients with stable CAD. ADP- and collagen-induced platelet reactivity were evaluated by light transmittance aggregometry (LTA). Patients with greater than 70% ADP- and collagen-induced aggregation were determined to have HPR and, in this group, ASA compliance was assessed by examining blood salicylate levels. Mean age was 60.9 years and average ASA dose was 164.2 mg. RESULTS: Smoking and DM were present in 28.7% and 31.5% respectively. HPR was found in 14 patients (13%) however 7 of the 14 patients (50%) with HPR had low serum salicylate levels (< 2.0 µg/mL) suggesting medication noncompliance. Of the entire cohort, 6.5% of patients had HPR and detectable serum salicylate levels suggesting reduced ASA efficacy. HPR correlated with number and severity of coronary stenosis (p = 0.04). CONCLUSION: In a general population of ASA-treated patients referred for coronary angiography, elevated platelet reactivity is prevalent (13%) with 50% related to noncompliance and 50% related to reduced aspirin efficacy.

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Original Article

Effects of atorvastatin and T-786C polymorphism of eNOS gene on plasma metabolic lipid parameters

Vanessa Helena de Souza Zago et al. José Eduardo Tanus dos Santos Mirian Regina Gardin Danelon Roger Marcelo Mesquita da Silva … Natália Baratella Panzoldo Eliane Soler Parra Fernanda Alexandre Vítor Wilson de Moura Virgínio Eder Carlos Rocha Quintão Eliana Cotta de Faria

BACKGROUND: Endothelial nitric oxide synthase (eNOS) activity may be modulated by high-density lipoprotein cholesterol (HDL-C), statins or polymorphisms, such as the T-786C of eNOS. OBJECTIVE: This study aimed at evaluating if the T-786C polymorphism is associated with changes of atorvastatin effects on the lipid profile, on the concentrations of metabolites of nitric oxide (NO) and of high sensitivity C-reactive protein (hsCRP). METHODS: Thirty male volunteers, asymptomatic, aged between 18 and 56 years were genotyped and classified according to absence (TT, n = 15) or presence (CC, n = 15) of the polymorphism. They were randomly selected for the use of placebo or atorvastatin (10 mg/day/14 days). After each treatment lipids, lipoproteins, HDL2 and HDL3 composition, cholesteryl ester transfer protein (CETP) activity, metabolites of NO and hsCRP were evaluated. RESULTS: The comparisons between genotypes after placebo showed an increase in CETP activity in a polymorphism-dependent way (TT, 12±7; CC, 22±12; p < 0.05). The interaction analyses between treatments indicated that atorvastatin has an effect on cholesterol, LDL, nitrite and lipid-protein ratios (HDL2 and HDL3) (p < 0.001) in both genotypes. Interestingly, we observed genotype/drug interactions on CETP (p < 0.07) and lipoprotein (a) (Lp(a)) (p < 0.056), leading to a borderline decrease in CETP, but with no effect on Lp(a). HsCRP showed no alteration. CONCLUSION: These results suggest that statin treatment may be relevant for primary prevention of atherosclerosis in patients with the T-786C polymorphism of eNOS, considering the effects on lipid metabolism.

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Original Article

Acute effects of prolonged physical exercise: evaluation after a twenty-four-hour ultramarathon

Daniela Guinther Passaglia et al. Luiz Gustavo Marin Emed Silvio Henrique Barberato Surya Toledo Guerios … Andre Isolani Moser Miguel Morita Fernandes Silva Elissa Ishie Luiz Cesar Guarita-Souza Costantino Roberto Frack Costantini José Rocha Faria-Neto

BACKGROUND: The consequences and risks of prolonged physical exercise are not well established. OBJECTIVE: To evaluate the effects of prolonged physical exercise on the participants of a 24-hour ultramarathon race. METHODS: Twenty male runners were selected for evaluation a day before and immediately after the race, where the athletes had to cover the most distance in 24 hours. Clinical, laboratory and echocardiographic data were obtained at both evaluations. RESULTS: Mean distance covered was 140.3 ± 18.7 km. Runners showed weight loss (p < 0.001) and decrease in systolic (p < 0.001) and diastolic (p = 0.004) blood pressure. Hematological changes were compatible with the physiological stress. Plasma levels of creatine phosphokinase strikingly increased post-race (163.4 ± 56.8 vs. 2978.4 ± 1921.9 U/L; p < 0.001) and was inversely correlated with distance covered: those who covered the longest distances showed the lowest CPK levels (Pearson r = 0.69, p = 0.02). After the race, 2 runners showed a slight increase in Troponin levels. One of them also had simultaneous decrease in left ventricular ejection fraction (coronary artery disease was subsequently ruled out). Basal echocardiography assessment had shown LV hypertrophy in one and increased left atrial volume in five runners. After the race, there was a decrease in E/A ratio (p < 0.01). CONCLUSION: Prolonged physical exercise is associated with metabolic and cardiovascular alterations. Cardiac abnormalities found in our study suggest that cardiac fatigue may occur in this specific race modality. The long-term effect of these alterations, while maintaining the routine practice of prolonged strenuous physical activity, is still unknown.

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Original Article

Validity of self-reported hypertension is inversely associated with the level of education in Brazilian individuals

Soraya Sant'Ana de Castro Selem et al. Michele Alessandra Castro Chester Luiz Galvão César Dirce Maria Lobo Marchioni Regina Mara Fisberg

BACKGROUND: Self-reported hypertension is an important piece of information for public health that is available in epidemiological studies. For proper use of this information, such studies should be validated. OBJECTIVE: To validate self-reported hypertension and associated factors in adults and elderly individuals in São Paulo, Brazil. METHODS: Participants were selected from the sample of a population-based cross-sectional health survey carried out in São Paulo (ISA Capital-2008). Their age was 20 years or older, they were from both genders, and had their blood pressure measured (n = 535). Hypertension was defined as blood pressure > 140/90 mmHg and/or use of medication for hypertension. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Kappa coefficient were calculated. Poisson regression was used to identify factors associated with sensitivity of self-reported hypertension. RESULTS: Sensitivity of self-reported hypertension was 71.1% (95%CI: 64.8 to 76.9), specificity 80.5% (95%CI: 75.6 to 84.8), PPV 73.7% (95%CI: 67.4 to 79.3), and NPV 78.5% (95%CI: 73.5 to 82.9). There was moderate agreement between self-reported hypertension and hypertension as diagnosed by blood pressure measurement (kappa = 0.52, 95%CI: 0.45 to 0.59). Body mass index and level of education were independently associated with sensitivity (body mass index > 25 kg/m²: PR = 1.42, 95% CI: 1.15 to 1.76; schooling > 9 years: PR = 0.71 95%CI: 0.54-0.94). CONCLUSION: Self-reported hypertension was shown to be valid in adults and the elderly in the city of São Paulo, and is thus an appropriate indicator for the surveillance of hypertension prevalence in the absence of blood pressure measurement. Overweight was positively associated with validity of self-reported hypertension. Further studies are needed to elucidate the inverse association between the validity of self-reported hypertension and level of education.

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Original Article

Cardiac implications after myocardial infarction in rats previously undergoing physical exercise

Eduardo Carvalho de Arruda Veiga et al. Leslie Andrews Portes Danilo Sales Bocalini Ednei Luiz Antonio … Alexandra Alberta dos Santos Marília Higuchi Santos Flavio André Silva Paulo José Ferreira Tucci

BACKGROUND: Few studies have analyzed the cardiac effects of exercise prior to coronary occlusion. OBJECTIVE: To evaluate the effects of myocardial infarction in rats undergoing physical exercise. METHODS: Female rats underwent swimming exercise or were kept sedentary for eight weeks and were randomized to coronary occlusion or sham surgery, in one of the following four groups: Sedentary (S), exercise (E), Sedentary myocardial infarction (SMI) and Exercise myocardial infarction (EMI). After six weeks, their biometrics, Doppler echocardiography, hemodynamics and myocardial mechanics were analyzed. RESULTS: No cardioprotection was observed in EMI animals and there was no difference in infarct size (%LV) between EMI (38.50 ± 4.60%) and SMI (36.58 ± 4.11%). Water content of the lung (%) of SMI (80 ± 0.59) and EMI (80 ± 0.57) was higher than that of S (78 ± 0.15) and E (78 ± 0.57) groups. Left ventricular systolic pressure (mmHg) (S: 130 ± 5, E: 118 ± 8; SMI: 91 ± 3; EMI: 98 ± 3) and the first positive time derivative (mmHg) positive pressure (S: 8216 ± 385; E: 8437 ± 572; SMI: 4674 ± 455; EMI: 5080 ± 412) of S and E were higher than those of SMI and EMI. The transverse fractional shortening (%) of SMI (27 ± 2) and EMI (25 ± 2) were similar and lower than that of E (65 ± 2) and S (69 ± 2). The E/A ratio was higher in SMI (5.14 ± 0.61) and EMI (4.73 ± 0.57) compared to S (2.96 ± 0.24) and E (2.83 ± 0 21). In studies of isolated papillary muscle, depression of the contractile capacity observed was similar to that of SMI and EMI, and there was no change in myocardial stiffness. CONCLUSION: Previous training by swimming did not attenuate cardiac implications due to myocardial infarction.

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Original Article

Differentiation of adipose tissue-derived mesenchymal stem cells into cardiomyocytes

Pablo Herthel Carvalho et al. Ana Paula Falci Daibert Betânia Souza Monteiro Bárbara Silva Okano … Juliana Lott Carvalho Daise Nunes Queiroz da Cunha Lukiya Silva Campos Favarato Vanessa Guedes Pereira Luis Eugênio Franklin Augusto Ricardo Junqueira Del Carlo

BACKGROUND: Cardiomyocytes have small potential for renovation and proliferation in vivo. Consequently, the heart muscle has limited capacity of self-renewal. Mesenchymal stem cells (MSC) therapy, as well as MSC differentiated into cardiomyocytes, has been used in the attempt to minimize the effects of ischemic-hypoxic lesions and those affecting the electrical conduction system of the heart. OBJECTIVE: The present study compared three distinct protocols for induced differentiation of MSC into cardiomyocytes aimed at finding a viable method for producing a large number of functional cells expressing cardiomyogenic phenotype. METHODS: Mesenchymal stem cells were obtained from the adipose tissue of young transgenic Lewis rats expressing green fluorescent protein (GFP), and submitted to three distinct differentiation-inducing media: 1) Planat-Bérnard, 2) 5-azacytidine, and 3) Planat-Bérnard + 5-azacytidine; further, these cells were identified based on the expression of cardiac cell markers. RESULTS: All three protocols detected the expression of sarcomeric-alpha-actinin protein in the exoskeleton of cells, expression of connexin-43 in the nuclear and cytoplasmic membrane, and formation of gap junctions, which are necessary for electrical impulse propagation in the myocardium. However, no spontaneous cell contraction was observed with any of the tested protocols. CONCLUSION: Induction with 5-azacytidine provided an effective cadiomyogenic cellular differentiation similar to that obtained with Planat-Bénard media. Therefore, 5-azacytidine was the method of choice for being the simplest, fastest and lowest-cost protocol for cell differentiation.

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Original Article

Pulse wave velocity, blood pressure and adipocytokines in young adults: the Rio de Janeiro study

Oswaldo Luiz Pizzi et al. Andréa Araujo Brandão Roberto Pozzan Maria Eliane Campos Magalhães … Erika Maria Gonçalves Campana Flavia Lopes Fonseca Elizabete Viana de Freitas Ayrton Pires Brandão

BACKGROUND: Data on noninvasive vascular assessment and their association with cardiovascular risk variables are scarce in young individuals. OBJECTIVE: To evaluate the association between pulse wave velocity and blood pressure, anthropometric and metabolic variables, including adipocytokines, in young adults. METHODS: A total of 96 individuals aged 26 to 35 years (mean 30.09 ± 1.92; 51 males) were assessed in the Rio de Janeiro study. Pulse wave velocity (Complior method), blood pressure, body mass index, glucose, lipid profile, leptin, insulin, adiponectin and insulin resistance index (HOMA-IR) were analyzed. Subjects were stratified into three groups according to the PWV tertile for each gender. RESULTS: The group with the highest pulse wave velocity (PWV) tertile showed higher mean systolic and diastolic blood pressure, mean blood pressure, body mass index, insulin, and HOMA-IR, as well as lower mean adiponectin; higher prevalence of diabetes mellitus/glucose intolerance and hyperinsulinemia. There was a significant positive correlation of PWV with systolic blood pressure, diastolic blood pressure, pulse pressure and mean blood pressure, body mass index, and LDL-cholesterol, and a negative correlation with HDL-cholesterol and adiponectin. In the multiple regression model, after adjustment of HDL-cholesterol, LDL-cholesterol and adiponectin for gender, age, body mass index and mean blood pressure, only the male gender and mean blood pressure remained significantly correlated with PWV. CONCLUSION: PWV in young adults showed a significant association with cardiovascular risk variables, especially in the male gender, and mean blood pressure as important determinant variables. The findings suggest that PWV measurement can be useful for the identification of vascular impairment in this age group.

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Original Article

P-wave dispersion and left atrial volume index as predictors in heart failure

Rose Mary Ferreira Lisboa da Silva et al. Nadya Mendes Kazzaz Rosália Morais Torres Maria da Consolação Vieira Moreira

BACKGROUND: Studies have shown that P-wave dispersion (PWD) and left atrial volume index (LAVi) are predictors of cardiovascular events (CE). OBJECTIVE: To verify the prognostic value of PWD and LAVi for the occurrence of CE in patients with heart failure (HF). METHODS: This was a longitudinal prospective study of 78 consecutive patients with a mean age of 47.2 years, of which 52 were males. Patients had stable HF and underwent clinical evaluation, electrocardiogram and echocardiogram assessments, with a follow-up of 26.5 months. RESULTS: The means of the variables were: 50 ms for PWD and 35.5 mL/m² for LAVi. Considering PWD > 40 ms and, as reference, LAVi > 28 mL/m², the positive predictive value of PWD was 87.5% and the negative predictive value was 76.9%. During follow-up, 21 patients had CE. There was an association between left atrial measurements, left ventricular volumes, ejection fraction and CE. There was no association between PWD and CE. At the multivariate analysis, the left atrium and LAVi were predictors of events (p = 0.00 and 0.02). Through the operating characteristic curve for the variable stable CE, areas of 0.80 and 0.69 were obtained for LAVi (p = 0.00) and LAVi > 28 mL/m² (p = 0.01). Survival curves (Kaplan-Meier) free of those events for LAVi > 28 mL/m² and for Chagas disease etiology showed an odds ratio of 14.4 (p = 0.00) and 3.2 (p = 0.03). There was no difference in outcome between patients with ischemic and nonischemic heart failure. CONCLUSION: PWD was not correlated to CE. LAVi was an independent predictor of CE, and chagasic patients showed worse outcomes.

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Original Article

Exercise tolerance in rats with aortic stenosis and ventricular diastolic and/or systolic dysfunction

Olga Castro Mendes et al. Mario Mateus Sugizaki Dijon Salomé Campos Ricardo Luiz Damatto … André Soares Leopoldo Ana Paula Lima-Leopoldo Vilmar Baldissera Carlos Roberto Padovani Katashi Okoshi Antonio Carlos Cicogna

BACKGROUND: Physical stress tolerance (ST) is a measurement of cardiorespiratory fitness. Aerobic capacity is reduced in heart failure (HF) although there is no data available on this parameter in animals with ventricular dysfunction and no signs of HF. OBJECTIVE: Evaluate ST in rats with ventricular diastolic dysfunction isolated or associated with systolic dysfunction induced by ascending aortic stenosis (AoS). METHODS: Young male Wistar rats (20-30 days old), divided in: control group (CG, n=11) and AoSG group, (n=12). Animals were assessed at 6 and 18 weeks after AoS surgery. Treadmill exercise test was until exhaustion and evaluated treadmill speed and lactate concentration [LAC] at lactate threshold, treadmill speed and [LAC] at exhaustion, and total testing time. RESULTS: Echocardiography data revealed remodeling of the left atrium and left ventricular concentric hypertrophy at 6 and 18 weeks. Endocardial fractional shortening was greater in AoSG than CG at 6 and 18 weeks. Midwall fractional shortening was greater in AoSG than in CG only 6 week. Cardiac index was similar in CG and AoSG at 6 and 18 weeks and decreased between from 6 to 18 weeks in both groups. The E wave to A wave ratio was greater in CG than in AoSG at both periods and did not change in both groups between week 6 and 18. Treadmill stress testing parameters were similar in both groups at 6 or 18 weeks. CONCLUSION: Although AoS promotes isolated diastolic dysfunction or associated with systolic dysfunction at 6 or 18 weeks, it is not sufficient to modify physical stress tolerance.

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