2013;100(2) – ABC CARDIOL

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Artigo Original

The influence of hypertension on quality of life

Maria Virgínia de Carvalho et al. Liza Batista Siqueira Ana Luiza Lima Sousa Paulo César Brandão Veiga Jardim

BACKGROUND: Systemic Hypertension (SH) is a major cardiovascular risk factor with a high prevalence in almost all countries. Studies show the negative effect of SH on health-related quality of life. OBJECTIVE: To evaluate the quality of life of hypertensive patients when compared with the general population. METHODS: A total of 333 individuals of both genders and older than 18 years were evaluated; they were divided into the Study Group, consisting of 246 hypertensive patients undergoing treatment in a multidisciplinary service and the Control group, comprised of 87 normotensive individuals from the community. A sociodemographic questionnaire and the SF-36 for quality of life assessment were administered to both groups. The Chi-square, Kolmogorov-Smirnov test, Mann Whitney U-test, Kruskal-Wallis test and multivariate analysis were used for the statistical analysis. Data were analyzed using SPSS and p values <0.05 were considered significant. RESULTS: The groups were homogeneous for age, gender, ethnicity, educational level and marital status. It was observed that normotensive individuals showed a better health-related quality of life when compared with hypertensive patients. CONCLUSIONS: Although considered to be almost always a clinically silent disease, systemic hypertension impairs the quality of life of patients who suffer from it.

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Artigo Original

Prognostic value of stress hyperglycemia for in-hospital outcome in acute coronary artery disease

Carlos Passos Pinheiro et al. Marcos Danillo Peixoto Oliveira Gustavo Baptista de Almeida Faro Esdras Correa Silva … Eduardo Augusto Andrade da Rocha José Augusto Soares Barreto-Filho Joselina Luzia Menezes Oliveira Antônio Carlos Sobral Sousa

BACKGROUND: In acute coronary syndrome (ACS), admission hyperglycemia is associated with adverse cardiovascular events in diabetic and nondiabetic patients. OBJECTIVE: To assess the prognostic value of stress hyperglycemia for the in-hospital outcome of patients admitted due to ACS. METHODS: This study included 152 patients admitted to the chest pain unit of a tertiary hospital diagnosed with ACS, who had admission blood glucose data, from September 2005 to February 2010. Group I comprised patients with stress hyperglycemia, defined as admission blood glucose concentration > 126 mg/dL for nondiabetic individuals and admission blood glucose concentration > 200 mg/dL for diabetic individuals. Group II was formed by patients with admission blood glucose concentration lower than those established. The association of hyperglycemia and in-hospital outcome was assessed. RESULTS: Stress hyperglycemia associated with in-hospital complications, age increase and female sex. On multivariate analysis, only female sex (OR = 2.04; 95% CI: 1.03 – 4.06; p = 0.007) and in-hospital complications (OR = 3.65; 95% CI: 1.62 – 8.19; p = 0.002) associated independently with admission hyperglycemia. CONCLUSIONS: Stress hyperglycemia is an independent predictive factor for in-hospital complications after ACS in diabetic and nondiabetic patients. The results highlight the need to assess admission blood glucose concentration in all patients admitted due to ACS, including nondiabetic ones, aiming at identifying those at higher risk for complications.

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Artigo Original

Myocardial perfusion imaging and cardiac involvement in the indeterminate phase of chagas disease

Amalia Peix et al. Raymid García Jesús Sánchez Lázaro O. Cabrera … Kenia Padrón Oscar Vedia Hugo V. Choque Jorge Fraga Juan Bandera Alberto Hernández-Cañero

BACKGROUND: Myocardial perfusion imaging (MPI) has been used in the assessment of chagasic heart disease. OBJECTIVE: To investigate the value of gated-single photon emission computed tomography (gated-SPECT) MPI to detect early cardiac involvement in chagasic patients in the indeterminate phase, who present segmental motion abnormalities detected by tissue Doppler imaging (TDI)-derived strain. METHODS: Forty individuals (mean age: 25±2 years, 50% males) from an endemic area of Chagas disease and with positive serologic diagnosis, were included. All underwent gated-SPECT two-day (stress-rest) MPI and echocardiography. RESULTS: Thirty individuals (75%) showed a normal scan. In three cases (8%) the MPI was slightly abnormal, and in seven it was equivocal. In all cases with reversible defects, the affected segments were coincident with those with motion abnormalities. A post-stress left ventricular ejection fraction (LVEF) reduction > 5% (ΔLVEF < -5%) was found in 11 out of 40 individuals (28%). Both the phase-derived standard deviation and the histogram bandwidth showed a significant difference between post-stress and rest. In both cases there was a slight dyssynchrony at rest which normalized at post-stress. CONCLUSIONS: A stress-rest gated-SPECT is a valid approach to detect early myocardial alterations, as well as intraventricular dyssynchrony in the indeterminate phase of Chagas disease in patients with segmental motion abnormalities previously detected by TDI-derived strain.

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Artigo Original

Heart neoplasms in children: retrospective analysis

Juliano Gomes Penha et al. Leina Zorzanelli Antônio Augusto Barbosa-Lopes Vera Demarchi Aiello … Vitor Oliveira Carvalho Luiz Fernando Caneo Arlindo de Almeida Riso Carla Tanamati Edimar Atik Marcelo Biscegli Jatene

BACKGROUND: The advancement of noninvasive imaging methods has resulted in the increase in diagnosis of heart neoplasms. However, the literature has few studies involving primary cardiac neoplasms in children. OBJECTIVE: To retrospectively review cases of primary heart neoplasms in children, considering the initial clinical manifestations, diagnostic tests used, surgical indication, histopathological types and immediate postoperative course. METHODS: The retrospective study was based on the assessment of medical records from 1983 to 2011. Only cases that were referred for surgical treatment during that period were included. Age at admission, prenatal diagnosis, family history, initial symptoms and the results of performed tests were assessed. Moreover, the date and indication of the surgery, intraoperative findings, the result of the histopathological analysis, as well as the immediate postoperative complications were recorded. RESULTS: Of the 18 patients studied, the most frequent clinical manifestations were dyspnea and heart murmur (7 and 6 patients, respectively); the most often used adjunct diagnostic method was echocardiography (18 patients); cavitary obstruction or ventricular inflow or outflow tract obstruction was the main indication for surgery (12 cases); the most common histological profile was rhabdomyoma (7 patients) and most patients showed good clinical outcome. CONCLUSIONS: In this study, imaging diagnosis was basically attained through echocardiography, with good correlation with intraoperative findings. Histopathological findings were consistent with the literature, with rhabdomyoma being the most common neoplasm in children. The evolution after surgical treatment was favorable in most cases.

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Point of view

Common goals to face crisis at coronary care units

Antônio Pazin-Filho et al. Otávio Rizzi Coelho André Schmidt

VIEWPOINT

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Artigo Original

Evaluation of the autonomic function in patients with hypertrophic cardiomyopathy with and without syncope

Milena Frota Macatrão-Costa et al. Edmundo Arteaga-Fernandez Fábio Sandoli de Brito Francisco Darrieux … Sissy Lara de Melo Mauricio Scanavacca Eduardo Sosa Denise Hachul

BACKGROUND: Several mechanisms may be involved in the trigger of syncope in patients with hypertrophic cardiomyopathy (HCM), including hemodynamic collapses that might be related to an autonomic imbalance. OBJECTIVE: To evaluate and compare the autonomic function of patients presenting HCM with unexplained syncope (US) to those without syncope. METHODS: Thirty-seven patients were included, 16 with US and 21 without syncope. Their autonomic function was assessed by spontaneous and phenylephrine induced baroreflex sensitivity (BRS), by heart rate variability (HRV) in time domain during 24-hour Holter and in frequency domain (spectral analysis), both in supine position and at 70º head-up tilt (HUT). RESULTS: The spontaneous BRS was similar in both groups (16,46 ± 12,99 vs. 18,31 ± 9,88 ms/mmHg, p = 0,464), as was phenylephrine-induced BRS (18,33 ± 9,31 vs. 15,83 ± 15,48 ms/mmHg, p = 0,521). No differences were observed in SDNN (137,69 ± 36,62 vs . 145,95 ± 38,07 ms, p=0,389). The group presenting syncope had a significantly lower RMSSD (24,88±10,03 vs. 35,58 ± 16,43 ms, p = 0,042) and a tendency to lower pNN50 (4,51 ± 3,78 vs . 8,83 ± 7,98%, p =0,085) and lower values of the high frequency component of HRV spectral analysis at rest (637,59±1.295,53 vs. 782,65±1.264,14ms2, p=0,075). No significant difference was observed in response to HUT (p = 0,053). HUT sensitivity, specificity and accuracy in identifying the etiology of US in HCM patients were 6%, 66% and 40%, respectively. CONCLUSIONS: A lower parasympathetic tone was observed in HCM patients with US, but the clinical relevance of this finding remains unclear. HUT is not a valuable tool for evaluating the origin of syncope in these patients, mainly because of its poor specificity.

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Letter to the Editor

Use of sildenafil in the evaluation of candidates for heart transplantation

Eduardo da Rosa Maffini et al. Luísa Stefânia Demore Roberta Casanova Wilhelms

LETTER TO THE EDITOR

Use of sildenafil in the evaluation of candidates for heart transplantation

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Artigo Original

Association between endothelial function and autonomic modulation in patients with chagas disease

Adriana Barni Truccolo et al. Thiago Dipp Bruna Eibel Rodrigo Antonini Ribeiro … Karina Rabello Casali Maria Claudia Irigoyen Iseu Gus Lucia Campos Pellanda Rodrigo Della Meã Plentz

BACKGROUND: Under homeostatic condition, the autonomic nervous system (ANS), through the release of vasoconstrictor neurotransmitters, and the endothelium, through the release of vasodilating substances, interact to maintain blood vessel tone. However, the association between those two systems in patients with Chagas disease in its indeterminate phase (IChD) has not been studied. OBJECTIVE: To assess the association between autonomic modulation parameters and endothelial function in patients with IChD. METHODS: Thirteen patients with IChD (59.2 ± 11.23 years) and no risk factors for cardiovascular disease were assessed for autonomic modulation by using the blood pressure oscillometric method (Finapress) and the heart rate variability technique (HRV) in the frequency domain. Endothelial function was assessed by use of the brachial artery flow-mediated dilation (FMD) method with high-resolution ultrasound images. RESULTS: In the dorsal decubitus position, correlation of FMD was observed with normalized high-frequency (r = 0.78; p = 0.007) and low-frequency spectral components (r = 0.68; p = 0.01), as well as with sympathovagal balance (r = -0.78; p = 0.004). CONCLUSIONS: Our study indicates the existence of a relationship between the changes in autonomic modulation and endothelial function in patients with IChD.

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Special Article

I guideline for cardiopulmonary resuscitation and emergency cardiovascular care – Brazilian Society of Cardiology: executive summary

Maria Margarita Gonzalez et al. Sergio Timerman Renan Gianotto de Oliveira Thatiane Facholi Polastri … Luis Augusto Palma Dallan Sebastião Araújo Silvia Gelás Lage André Schmidt Claudia San Martín de Bernoche Manoel Fernandes Canesin Frederico José Neves Mancuso Maria Helena Favarato

Despite advances related to the prevention and treatment in the past few years, many lives are lost to cardiac arrest and cardiovascular events in general in Brazil every year. Basic Life Support involves cardiovascular emergency treatment mainly in the pre-hospital environment, with emphasis on the early recognition and delivery of cardiopulmonary resuscitation maneuvers focused on high-quality thoracic compressions and rapid defibrillation by means of the implementation of public access-to-defibrillation programs. These aspects are of the utmost importance and may make the difference on the patient’s outcomes, such as on hospital survival with no permanent neurological damage. Early initiation of the Advanced Cardiology Life Support also plays an essential role by keeping the quality of thoracic compressions; adequate airway management; specific treatment for the different arrest rhythms; defibrillation; and assessment and treatment of the possible causes during all the assistance. More recently, emphasis has been given to post-resuscitation care, with the purpose of reducing mortality by means of early recognition and treatment of the post-cardiac arrest syndrome. Therapeutic hypothermia has provided significant improvement of neurological damage and should be performed in comatose individuals post-cardiac arrest. For physicians working in the emergency department or intensive care unit, it is extremely important to improve the treatment given to these patients by means of specific training, thus giving them the chance of higher success and of better survival rates.

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Brief Communication

Digital stethoscope as an innovative tool on the teaching of auscultatory skills

Claudio Tinoco Mesquita et al. Jader Costa dos Reis Luciana Silveira Simões Eduardo Cardoso de Moura … Gustavo Amarante Rodrigues Carolina Cunto de Athayde Hugo Lima Machado Pedro Gemal Lanzieri

Physical cardiovascular examination, particularly cardiac auscultation, is one of the most difficult clinical skills for students during their medical training. Studies suggest that the use of technologies such as digital stethoscope increase the accuracy of clinical examination, however, its impact on the teaching of cardiac auscultation for undergraduate students of medicine is not known. The objective is to demonstrate the usefulness of the digital stethoscope compared to traditional methods as a tool in the teaching of auscultatory skills. nterventional, longitudinal, controlled, unicenter and randomized study. Thirty-eight medicine students were enrolled for a cardiovascular semiology course lasting eight weeks. The course program included lectures and bedside practice in Cardiology wards. In the practical lessons, the students were randomized into two groups: 1) (n = 21) digital stethoscope (Littmann® Model 3200, 3M); and 2) (n = 17) conventional stethoscopes. A pre-training evaluation was conducted through a test using the software Heart Sounds®, which was repeated after the course. The average scores were compared by paired T test and unpaired T test. It is observed that, at the end of the course, there was a significantly greater improvement in the group that used the digital stethoscope (51.9%) compared to the group using the conventional stethoscope (29.5%). Short-term interventions for cardiac semiology teaching are able to contribute significantly to improving proficiency in the identification of heart sounds. The use of digital stethoscope proved to be a positive factor in teaching these skills.

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Artigo Original

Evolution of socioeconomic indicators and cardiovascular mortality in three brazilian states

Gabriel Porto Soares et al. Júlia Dias Brum Gláucia Maria Moraes de Oliveira Carlos Henrique Klein Nelson Albuquerque Souza e Silva

BACKGROUND: Cardiovascular diseases are the major cause of death in Brazil. OBJECTIVE: To correlate cardiovascular mortality rates in the states of Rio de Janeiro, São Paulo and Rio Grande do Sul, and in their capitals, between 1980 and 2008, with socioeconomic indicators collected from 1949 onwards. METHODS: Population and death data were obtained from the Brazilian Unified Health System databank (Datasus). Mortality rates due to the following were calculated and adjusted by use of the direct method and compensated for poorly defined causes: ischemic heart diseases; cerebrovascular diseases; cardiovascular diseases; poorly defined causes; and all causes. Child mortality data were obtained from state and municipal health secretariats and from the Brazilian Institute of Geography and Statistics (IBGE). Information on gross domestic product (GDP) and educational level was obtained from the Brazilian Institute of Applied Economic Research (Ipea). The mortality rates and socioeconomic indicators were correlated by using the estimation of Pearson linear coefficients to determine optimized year lag. The inclination coefficients of the regression between the dependent variable “disease” and the independent variable “socioeconomic indicator” were estimated. RESULTS: The three states showed a reduction in mortality, which was especially due to a decrease in cardiovascular mortality, mainly of cerebrovascular diseases. The decrease in cardiovascular mortality was preceded by a reduction in child mortality, an elevation in the per capita GDP, and an increase in the educational level, and a strong correlation between indicators and mortality rates was observed. CONCLUSIONS: The three indicators showed an almost maximum correlation with the reduction in cardiovascular mortality. Such relationship indicates the importance of improving quality of life to reduce cardiovascular mortality.

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Artigo Original

Association between inflammatory markers and left atrial enlargement in patients on hemodialysis

Silvio Henrique Barberato et al. Sérgio Gardano Elias Bucharles Admar Moraes de Souza Costantino Ortiz Costantini … Costantino Roberto Frack Costantini Roberto Pecoits-Filho

BACKGROUND: In individuals with concurrent chronic kidney disease (CKD) and cardiovascular disease (CVD), the association between left atrial volume (LAV) and serum levels of C-reactive protein (CRP) is shown. OBJECTIVE: Verify the presence of associations between systemic inflammation and LA dilation in patients on hemodialysis (HD) without clinically evident CVD. METHODS: This was an observational cross-sectional study of a population on HD (> 3 months), which excluded patients with acute or chronic inflammatory diseases (infections, malignancies, autoimmune diseases) hemodynamic instability, use of anti-inflammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior cardiovascular (CV) events. CRP and interleukin-6 (IL-6) measurements as well as Doppler echocardiography were obtained. Correlation coefficients were determined to evaluate the associations between variables. RESULTS: A total of 58 patients were included (28 men, aged 55 ± 15 years), on HD for 24 ± 16 months, 45% were hypertensive, 26% diabetic, with median CRP of 5.1 mg/dL and IL-6 of 6.1 pg/dL. CRP significantly correlated with LAV (p = 0.040), LAV index (LAVi, p = 0.02) and mitral inflow E wave (p = 0.014). IL-6, despite the strong association with CRP levels (r = 0.75, p < 0.001), did not correlate with echocardiographic indices. Individuals in the top quartile of CRP had significantly higher LAVi than the others (42 ± 17 versus 32 ± 11 mL/m², p = 0.015). CONCLUSIONS: In subjects on HD with no prior CV event, there was an association between elevated CRP levels and LA enlargement. The findings suggest an association between physiopathological processes related to left atrial dilation and systemic inflammatory state of patients on HD.

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Anatomopathological Session

Case 1/2013: 69-year-old male patient with sudden back and lower right limb pain and shock

Carlos Vinícius Abreu do Espirito Santo et al. Rafael Alves Franco Luiz Alberto Benvenuti

The patient, MSM, a 69-year-old man, sought medical care due to left dorsal and right lower limb pain. The chest x-ray showed mediastinal enlargement. He was undergoing examination when he lost consciousness and went into shock. Subcutaneous emphysema was observed in the left hemithorax, as well as abolition of breath sounds at auscultation. Tracheal intubation was performed with draining of blood-tinged fluid from the left hemithorax. Echocardiography showed left ventricle with 44/29 mm; septum, 12 mm; posterior wall, 13 mm; mild aortic root dilation, dissection of the lamina and periaortic hematoma. The valves and pericardium were normal. The patient was transferred to Instituto do Coraçao – InCor. Physical examination (21 Oct 2004: 10:45) showed that the patient was sedated with tracheal intubation, pale, heart rate at 90 bpm, blood pressure 130 x 80 mmHg, bloody drainage in the chest tube. Electrocardiogram – frequency 90 bpm, sinus rhythm, low voltage in the frontal plane and decreased voltage in left leads (Fig. 1). Computed tomography showed bilateral subcutaneous emphysema, thoracic aorta with inaccurate borders in its descending portion (from the subclavian artery to the middle portion), collapsed left lung and extensive collection of hematic characteristics in same hemithorax and middle and posterior mediastinum. Small right pneumothorax; small right pleural effusion with underlying parenchymal alterations. The analysis of the heart was impaired by the presence of hemothorax. While undergoing computed tomography, the patient showed no pulse, mydriasis, with asystole unresponsive to resuscitation and died (21 Oct 2011; 15:00 h).

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Artigo Original

The oxidative response of mouse hearts is modulated by genetic background

Marco Aurélio Santos-Silva et al. Akinori Cardozo Nagato Eduardo Tavares Lima Trajano Jackson Nogueira Alves … Ana Carla Balthar Bandeira Luís Cristóvão Porto Frank Silva Bezerra

BACKGROUND: Smoking plays an important role in cardiovascular diseases. However, the reasons why some individuals develop those diseases and others do not remain to be explained. OBJECTIVE: This study aimed at assessing the redox profile of the heart of different mouse strains after exposure to cigarette smoke. METHODS: Male mice of the Swiss (n = 10), C3H (n = 10), BALB/c (n = 10) and C57BL/6 (n = 10) strains were exposed to cigarette smoke (12 cigarettes/day), while their respective controls (n = 10) were exposed to ambient air for 60 days. After being euthanized, their heart was removed for biochemical analyses. RESULTS: Although the malondialdehyde content did not increase in any of the groups, catalase activity decreased in the Swiss (p < 0.05) and BALB/c (p < 0.05) strain mice as compared with their respective control groups, while myeloperoxidase decreased in the C3H (p < 0.05) and C57BL/6 (p < 0.001) strain mice as compared with their respective control groups. The reduced glutathione content decreased in the Swiss, C3H, C57BL/6 (p < 0.05) and BALB/c (p < 0,001) strain mice as compared with their respective control groups. Regarding reduced glutathione content, an increase was observed in the Swiss strain mice (p < 0.05), while a decrease was observed in the C3H (p < 0.05) and BALB/c (p < 0.001) strain mice as compared with their respective control groups. The reduced glutathione/reduced glutathione ratio showed a reduction in the Swiss and C57BL/6 (p < 0.05) strain mice as compared with their respective control groups. CONCLUSIONS: The genetic background of mice can influence the antioxidant response after exposure to cigarette smoke and seems to be a determinant factor for redox imbalance in Swiss and C57BL/6 strain mice. Understanding antioxidant responses and genetic background of C3H and BALB/c strain mice might provide important information regarding cardiac resistance to cigarette smoke.

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Review Article

Is there evidence favoring the use of beta-blockers and dobutamine in acute heart failure?

Luiz Carlos Santana Passos et al. Andréa Cristina Costa Barbosa Márcio Galvão Oliveira Edval Gomes Santos Jr

Several studies have reported the benefits of beta-blockers (BB) for patients presenting with systolic heart failure. however, many patients hospitalized as a result of acute heart failure are already using BB and require dobutamine for arterial hypotension and low cardiac output. Therefore, a decision must be made regarding whether BB should be maintained or even started in such cases. The aim of this study was to establish whether there is evidence supporting the safety andyeffectiveness of BB together with dobutamine for patients presenting with acute decompensated heart failure (ADHF). We conducted a search of the English-language literature in the databases MEDLINE, ISI Web of Science, Virtual Health Library, Cochrane Library and the CAPES Portal of Scientific Journals to identify related studies. Additional literature was obtained through the review of relevant references in the identified articles. The expected outcomes included information on the prognosis (in-hospital and on follow-up mortality, number of days of hospitalization and readmission),yeffectiveness and safety (worsening of symptoms, shock, intolerance) of the concomitant use of these drugs in hospitalized patients with ADHF and low cardiac output. This review included nine studies. however, no randomized clinical trials on this subject were found. Most studies include a low number of patients, and no studies addressing the safety of the concomitant use of these drugs were found. The resulting data suggest that a careful literature review did not supply evidence for the systematic use of BB in patients with low cardiac output syndrome who require dobutamine for inotropic support.

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Artigo Original

Impact on hypertension reclassification by Ambulatory Blood Pressure Monitoring (ABPM) according to the V Brazilian Guidelines on ABPM

Daniel Forestiero et al. Juliana Lustoza Mauad Camila Forestiero Mario Lins Peixoto … Fabio Peixoto Ganassin Carolina Gonzaga Antonio Carlos Cordeiro Gabriel Doreto Rodrigues Tiago Bueno da Silveira Celso Amodeo

BACKGROUND: New recommendations on reference values for normal test results in ambulatory blood pressure monitoring (ABPM) were proposed by the V Brazilian Guidelines on Ambulatory Blood Pressure Monitoring, based mainly on the IDACO study. Objectives: This epidemiological study is aimed at evaluating the impact of adopting these new standards in an arterial hypertension referral center. METHODS: The results of 1,567 ABPM tests carried out between 2005 and 2010 were analyzed; 481 patients were excluded from the sample for not meeting minimum quality criteria of the test. Reference values from the IV Brazilian Guidelines on ABPM (2005) were used for the classification of these tests regarding the abnormality and compared with the changes proposed by the V Brazilian Guidelines on ABPM (2011). Statistical analysis was performed by Pearson’s chi-square method and p values < 0.05 were considered statistically significant. RESULTS: For the 1,086 tests evaluated, there was a significant difference in the proportion of patients with altered ABPM results, especially for the variable systolic pressure in the sleeping period: 49% when adopting the cutoff values of 2005 and 71% when adopting the values of 2011, with statistical significance, p < 0.0001. CONCLUSIONS: The recommendations of the new guidelines had a great impact on the hypertension classification by ABPM test results in the study population. The question of thresholds of these tests for therapeutic targets of patients known to be hypertensive is still open and requires further studies, preferably national ones, for better definition of the subject.

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Case Report

Non-Hodgkin lymphoma as an uncommon cause of acute heart failure

Francisca Caetano et al. Paula Mota Joana Trigo Susana Basso … Luís Francisco Araújo António Leitão-Marques

CASE REPORT

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