2013;100(6) – ABC CARDIOL

Atherothrombosis and its complications are currently the leading cause of worldwide mortality and its incidence is increasing . Platelets play an essential role in the pathogenesis of atherothrombotic events, justifying the use of antiplatelet agents in their prevention. Thus, it is essential to know the efficacy and safety profile of these drugs in primary and secondary prevention of atherothrombotic events. In this context, this review was performed with the aim of describing and summarizing the outcomes of the main trials involving the use of antiplatelet agents in the two levels of prevention, and evaluating the effectiveness and major adverse events related to therapy.

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Case Report

Stent dislodgement in the treatment of left main coronary artery dissection

Gilberto Guilherme Ajjar Marchiori et al. George César Ximenes Meireles Sérgio Kreimer Micheli Zanoti Galon

CASE REPORT

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Correlação Clínico-Radiográfica

Case 3/2013: a newborn with aortic valve stenosis mimicking hypoplastic left heart

Edmar Atik

CLINICORADIOLOGICAL SESSION

Case 3/2013 – a newborn with aortic valve stenosis mimicking hypoplastic left heart

[…]

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Artigo Original

World soccer cup as a trigger of cardiovascular events

Daniel Guilherme Suzuki Borges et al. Rosane Aparecida Monteiro André Schmidt Antonio Pazin-Filho

BACKGROUND: Acute coronary syndromes are the major cause of death in Brazil and in the world. External stimuli, known also as triggers, such as emotional state and activity, may generate physiopathological changes that can trigger acute coronary syndromes. Among the studied triggers, the impact of stressful events, such as soccer championships, are controversial in literature and there is no effective data on the Brazilian population. OBJECTIVE: To evaluate the acute effects of environmental stress induced by soccer games of the World Soccer Cup on increased incidence of cardiovascular diseases in Brazil. METHODS: Public data were obtained from the Unified Health System (Sistema Único de Saúde), regarding hospital admissions that had the International Code Disease of acute coronary syndromes from May to August, in 1998, 2002, 2006 and 2010 (155,992 admissions). Analysis was restricted to patients older than 35 years and admitted by clinical specialties. The incidence of myocardial infarction, angina and mortality were compared among days without World Cup soccer games (Group I: 144,166; 61.7 ± 12.3; 59.4% males); on days when there were no Brazil’s soccer team matches (Group II: 9,768; 61.8±12.3; 60.0% males); and days when there were Brazil’s soccer team matches (Group III; 2,058; 61.6±12.6; 57.8% males). Logistic regression was used to adjust to age, gender, population density and number of medical assistance units. RESULTS: The incidence of myocardial infarction increased during the period of World Cup soccer games (1.09; 95%CI = 1.05-1.15) and days when there were Brazil’s matches (1.16; 95%CI = 1.06-1.27). There was no impact on mortality during the Cup (1.00; CI95% = 0.93-1.08) and Brazil’s matches (1.04; 95%CI = 0.93-1.22). CONCLUSION: World Cup soccer games and, specially, Brazil’s matches have an impact on the incidence of myocardial infarction, but not on in-hospital mortality.

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Artigo Original

Acute coronary syndrome behavior: results of a Brazilian registry

Leopoldo Soares Piegas et al. Álvaro Avezum Hélio Penna Guimarães Antonio José Muniz … Helder J. L. Reis Elizabete Silva dos Santos Marcos Knobel Roberta de Souza

BACKGROUND: Brazil lacks published multicenter registries of acute coronary syndrome. OBJECTIVE: The Brazilian Registry of Acute Coronary Syndrome is a multicenter national study aiming at providing data on clinical aspects, management and hospital outcomes of acute coronary syndrome in our country. METHODS: A total of 23 hospitals from 14 cities, participated in this study. Eligible patients were those who came to the emergency wards with suspected acute coronary syndrome within the first 24 hours of symptom onset, associated with compatible electrocardiographic alterations and/or altered necrosis biomarkers. Follow-up lasted until hospital discharge or death, whichever occurred first. RESULTS: Between 2003 and 2008, 2,693 ACS patients were enrolled, of which 864 (32.1%) were females. T he final diagnosis was unstable angina in 1,141 patients, (42.4%), with a mortality rate of 3.06%, non-ST elevation acute myocardial infarction (AMI) in 529 (19.6%), with mortality of 6.8%, ST-elevation AMI 950 (35.3%), with mortality of 8.1% and non-confirmed diagnosis 73 (2.7%), with mortality of 1.36%. The overall mortality was 5.53%. The multiple logistic regression model identified the following as risk factors for death regarding demographic factors and interventions: female gender (OR=1.45), diabetes mellitus (OR=1.59), body mass index (OR=1.27) and percutaneous coronary intervention (OR=0.70). A second model for death due to major complications identified: cardiogenic shock/acute pulmonary edema (OR=4.57), reinfarction (OR=3.48), stroke (OR=21.56), major bleeding (OR=3.33), cardiopulmonary arrest (OR=40.27) and Killip functional class (OR=3.37). CONCLUSION: The Brazilian Registry of Acute Coronary Syndrome data do not differ from other data collected abroad. The understanding of their findings may help promote better planning and management of acute coronary syndrome care in public and private health services.

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Artigo Original

Renal dysfunction and inflammatory markers in hypertensive patients seen in a university hospital

Fátima Lúcia Machado Braga et al. Ilma Kruze Grande de Arruda Alcides da Silva Diniz Poliana Coelho Cabral … Maria da Conceição Chaves de Lemos Marcus Davis Machado Braga Hilton de Castro Chaves Júnior

BACKGROUND: Today, chronic kidney diseases represent a great challenge to public health as regards the acquisition of knowledge to support interventions that can slow the progression of renal function loss. OBJECTIVE: To analyze the magnitude of the renal function deficit in hypertensive adult patients and its relationship with the following inflammatory markers: high-sensitivity C reactive protein, erythrocyte sedimentation rate, and neutrophil/lymphocyte ratio. METHODS: Cross-sectional study including 1,273 adult hypertensive patients of both genders, of whom 1,052 had renal function deficit, and 221 had no deficit, as diagnosed by the Modification of Diet in Renal Disease equation. The odds ratio (OR) and the prevalence ratio (PR) were used to determine the probability of the occurrence of inflammatory activity in renal disease. RESULTS: Renal function deficit was diagnosed in 82.6% of the patients assessed, and most of the sample (70.8%) was classified as in stage 2 of chronic kidney disease. In the regression model, metabolic syndrome (PRadjusted = 1.09 [95%CI: 1.04-1.14]), high-sensitivity C reactive protein (PRadjusted = 1.54 [95%CI: 1.40-1.69]) and erythrocyte sedimentation rate (PRadjusted = 1.20 [95%CI: 1.12-1.28]) remained independently associated with the renal function deficit. However, considering the individuals classified as in stage 2 of renal function deficit, the chance of abnormalities in inflammatory markers were OR = 10.25 (95%CI: 7.00-15.05) for high-sensitivity C reactive protein, OR = 8.50 (95%CI: 5.70-12.71) for neutrophil/lymphocyte ratio, and OR = 7.18 (95%CI: 4.87-10.61) for erythrocyte sedimentation rate. CONCLUSION: The results show an association of inflammatory activity and metabolic syndrome with renal function deficit.

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Artigo Original

Impact of ventricular geometric pattern on cardiac remodeling after myocardial infarction

Elaine Farah et al. Daniéliso R. Fusco Paulo R. R. Okumoto Marcos F. Minicucci … Paula S. Azevedo Beatriz B. Matsubara Katashi Okoshi Siméia G. Zanati Sergio A. R. Paiva Leonardo A. M. Zornoff

BACKGROUND: The relevance of left ventricular (LV) geometric pattern after myocardial infarction is not known. OBJECTIVES: To analyze the presence of different LV geometric patterns and teir impact as a predictor of remodeling in patients with myocardial infarction. METHODS: Patients with anterior acute myocardial infarction (n = 80) were divided according to the geometric pattern: normal (normal left ventricular mass index [LVMI] and normal relative wall thickness [RWT]), concentric remodeling (normal LVMI and increased RWT), concentric hypertrophy (increased LVMI and RWT) and eccentric hypertrophy (increased LVMI and normal RWT). After six months, echocardiographic assessment was repeated. RESULTS: Four patients died. Of the survivors, 41 showed remodeling (R +), whereas 39 did not (R-). Considering the geometric pattern, the cases were distributed as follows: 24 patients with normal pattern, 13 with concentric remodeling, 29 with concentric hypertrophy and 14 with eccentric hypertrophy. Patients who showed remodeling had larger infarction sizes analyzed by peak CPK (R + = 4,610 (1,688-7,970), R- = 1,442 (775-4247), p <0.001) and CK-MB (R + = 441 (246 – 666), R- = 183 (101-465), p <0.001), trend towards higher prevalence of concentric remodeling (R+ = 10, R- = 3, p = 0.08) and lower prevalence of eccentric hypertrophy (R + = 2 R- = 12, p = 0.006). In the multivariate regression analysis, infarction size was a predictor (OR = 1.01, p = 0.020) and eccentric hypertrophy was a protective factor (OR = 0.189, p = 0.046) of ventricular remodeling after coronary occlusion. CONCLUSION: The LV geometric pattern of can have an impact on the remodeling process in patients with myocardial infarction.

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Artigo Original

Cardiovascular magnetic resonance imaging-derived mitral valve geometry in determining mitral regurgitation severity

Andre Mauricio Fernandes et al. Vikas Rathi Robert W. Biederman Mark Doyle … June A. Yamrozik Ronald B. Willians Vinayak Hedge Saundra Graunt Roque Aras Jr.

BACKGROUND: Mitral regurgitation is the most common valvular heart disease worldwide. Magnetic resonance may be a useful tool to analyze mitral valve parameters. OBJECTIVE: To distinguish mitral valve geometric patterns in patients with different severities of mitral regurgitation (MR) based on cardiovascular magnetic resonance imaging. METHODS: Sixty-three patients underwent cardiovascular magnetic resonance imaging. Mitral valve parameters analyzed were: tenting area (mm2) and angle (degrees), ventricle height (mm), tenting height (mm), anterior leaflet, posterior leaflet length and annulus diameter (mm). Patients were divided into two groups, one including patients who required mitral valve surgery and another which did not. RESULTS: Thirty-six patients had trace to mild (1-2+) MR and 27 had moderate to severe MR (3-4+). Ten (15.9%) out of 63 patients underwent surgery. Patients with more severe MR had a larger left ventricle end systolic diameter (38.6 ± 10.2 vs 45.4 ± 16.8, p<0.05) and left end diastolic diameter (52.9 ± 6.8 vs 60.1 ± 12.3, p= 0.005). On multivariate analysis, the tenting area was the strongest determinant of MR severity (r= 0.62, p=0.035). Annulus length (36.1 ± 4.7 vs 41 ± 6.7, p< 0.001), tenting area (190.7 ± 149.7 vs 130 ± 71.3, p= 0.048) and posterior leaflet length (15.1 ± 4.1 vs 12.2 ± 3.5, p= 0.023) were larger on patients requiring mitral valve surgery. CONCLUSIONS: Tenting area, annulus and posterior leaflet length are possible determinants of MR severity. These geometric parameters could be used to determine severity and could, in the future, direct specific patient care based on individual mitral apparatus anatomy.

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Artigo Original

Right ventricular assessment by tissue-Doppler echocardiography in acute pulmonary embolism

Ana Clara Tude Rodrigues et al. Adriana Cordovil Claudia Monaco Laise Guimarães … Alexandre Cury Gustavo A F Naccarato Edgar Lira-Filho Claudio Henrique Fischer Marcelo Luiz Campos Vieira Samira Morhy

BACKGROUND: Assessment of the right ventricular (RV) function by echocardiography in patients with pulmonary thromboembolism (PTE) is complex and frequently qualitative. Tissue Doppler has been used for the semiquantitative assessment of this chamber, although with some limitations. OBJECTIVE: To evaluate RV function in PTE using tissue-Doppler echocardiography, in addition to atrial natriuretic peptide (BNP). METHODS: Patients with PTE were studied using tissue-Doppler echocardiography and BNP up to 24 hours after diagnosis; myocardial velocities (s’), strain, strain rate and RV myocardial performance index were obtained. RV dysfunction was diagnosed by chamber hypokinesia, abnormal septal motion and a RV/LV ratio >1. According to their BNP levels, the patients were divided into Group I, BNP 50 pg/mL. RESULTS: Of 118 patients, 100 (60 men, age = 55 ± 17 years) were analyzed; RV dysfunction was observed in 28%, more frequently in group II (19 vs. 9 patients, p < 0.001). Patients in group II were older (64 ± 19 vs. 50 ± 15 years), and had lower s' velocity (10.5 ± 3.5 vs. 13.2 ± 3.1 cm/s), and higher pulmonary pressure (48 ± 11 vs. 35 ± 11 mmHg), p < 0.001. The cut-off point of s' for RV dysfunction was 10.8 cm/s (specificity = 85%, sensitivity = 54%), with moderate correlation between BNP and s' wave (r = -0.39). CONCLUSION: In PTE, RV dysfunction on echocardiography is accompanied by BNP elevation; although tissue-Doppler imaging adequately confirms the presence of RV dysfunction, it has a limited sensitivity for this diagnosis.

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Review Article

Phenotypic characteristics of resistant hypertension in the Brazilian population

Ana Paula Cabral de Faria et al. Andréa Rodrigues Sabbatini Antonio Coca Heitor Moreno-Junior

Resistant hypertension (RH) is defined as blood pressure that remains above target in spite of the concurrent use of three or more classes of antihypertensive drugs at optimized doses (UCRH), with one of them being a diuretic. Moreover, patients whose blood pressure is controlled while using four or more antihypertensive medications are also considered controlled resistant hypertensive (CRH) subjects. Although this definition may be useful in terms of categorizing a larger group of resistant hypertensive individuals, as these two subgroups share high cardiovascular risk, some important clinical and pathophysiologic particularities need to be better evaluated, before considering resistant controlled and uncontrolled patients as part of the same group. We compared cardiovascular characteristics of these two subgroups with resistant hypertension. In spite of some similar features, the UCRH subgroup has cardiovascular phenotypes with worse prognosis, such as increased vascular stiffness and left ventricular hypertrophy, as well as more impaired endothelial function and lower nocturnal blood pressure dipping, among others. Considering these differences, the UCRH subgroup is associated with greater cardiovascular risk and may be considered as more resistant to antihypertensive treatment. In addition to the importance of better prevention and treatment of resistant hypertension by identifying early risk factors and optimizing drug therapy, some clinical implications must be considered when managing controlled and uncontrolled patients as similar to the resistant hypertension group.

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Artigo Original

Prognostic value of perioperative N-terminal pro-B-type natriuretic peptide in noncardiac surgery

Flávia Kessler Borges et al. Mariana Vargas Furtado Ana Paula Webber Rossini Carolina Bertoluci … Vinícius Leite Gonzalez Eduardo Gehling Bertoldi Denis Maltz Grutcki Leandro Gazziero Rech Mariana Magalhães Carisi Anne Polanczyk

BACKGROUND: Preoperative NT-proBNP has been shown to predict adverse cardiac outcomes, although recent studies suggested that postoperative NT-proBNP determination could provide additional information in patients submitted to noncardiac surgery. OBJECTIVE: To evaluate the prognostic value of perioperative NT-proBNP in intermediate and high risk cardiovascular patients undergoing noncardiac surgery. METHODS: This study prospectively enrolled 145 patients aged >45 years, with at least one Revised Cardiac Risk Index risk factor and submitted to intermediate or high risk noncardiac surgery. NT-proBNP levels were measured pre- and postoperatively. Short-term cardiac outcome predictors were evaluated by logistic regression models. RESULTS: During a median follow-up of 29 days, 17 patients (11.7%) experienced major adverse cardiac events (MACE- 14 nonfatal myocardial infarctions, 2 nonfatal cardiac arrests and 3 cardiac deaths). The optimum discriminatory threshold levels for pre- and postoperative NT-proBNP were 917 and 2962 pg/mL, respectively. Pre- and postoperative NT-proBNP (OR 4.7; 95% CI 1.62-13.73; p=0.005 and OR 4.5; 95% CI 1.53-13.16; p=0.006) were significantly associated with MACE. Preoperative NT-proBNP was significantly and independently associated with adverse cardiac events in multivariate regression analysis (adjusted OR 4.2; 95% CI 1.38-12.62; p=0.011). CONCLUSION: NT-proBNP is a powerful short-term marker of perioperative cardiovascular events in high risk patients. Postoperative levels were less informative than preoperative levels. A single preoperative NT-proBNP measurement should be considered in the preoperative risk assessment.

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Artigo Original

Non invasive assessment of left ventricular filling pressure and remodeling after acute myocardial infarction

Silvio Henrique Barberato et al. Admar Moraes de Souza Costantino Ortiz Costantini Costantino Roberto Costantini

BACKGROUND: Left ventricular (LV) dilation after acute myocardial infarction (AMI) is an important determinant of prognosis. The ratio of early mitral inflow velocity (E) and peak early diastolic annular velocity (e’) provides the best single index for noninvasive detection of acute elevation of LV filling pressure. OBJECTIVE: To assess whether E/e’ ratio predicts LV remodeling after properly treated AMI compared with traditional clinical, laboratory and echocardiographic data. METHODS: Comprehensive echocardiograms were performed in a series of consecutive patients with first AMI successfully treated with primary percutaneous transluminal angioplasty (PTCA), both 48 hours after intervention and 60 days later. Mean E/e’ was determined from four sites of the mitral annulus. LV remodeling was defined as more than 15% increase in end-systolic volume estimated by Simpson method. Statistical analysis included Student’s t test, receiver-operator curves (ROC) and multivariate logistic regression (all significant with p < 0.05). RESULTS: Fifty-five patients were included, with mean age 58 ± 11 years, 43 men. The group of patients who underwent LV remodeling (n = 13) had higher baseline E/e' than those without (13 ± 4 versus 8.5 ± 2, p 15 as a predictor of remodeling (AUC = 0.81, p = 0.001). In addition, regression analysis (comprising clinical, laboratory and echocardiographic variables along with AMI site) confirmed the independent value of E/e’ in the prediction of LV remodeling (odds ratio 1.42, p = 0.01). CONCLUSION: The E/e’ ratio is a useful predictor of LV remodeling after AMI, indicating patients with increased cardiovascular risk.

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Artigo Original

Correlation of risk scores with coronary anatomy in non-ST-elevation acute coronary syndrome

Elizabete Silva dos Santos et al. Luciano de Figueiredo Aguiar Filho Daniela Menezes Fonseca Hugo José Londero … Rogério Martins Xavier Marcos Paulo Pereira Luiz Minuzzo Roberta de Souza Ari Timerman

BACKGROUND: The literature lacks studies regarding the correlation between risk scores and coronary anatomy in acute coronary syndrome (ACS) OBJECTIVE: Correlate risk scores with the severity of the coronary lesion in ACS with non-ST elevation. METHODS: A total of 582 patients were analyzed between July 2004 and October 2006. The correlation between TIMI risk scores and GRACE (hospital and six months) scores was performed for patients with coronary lesion > 50%, using Spearman´s non-parametric method. Multiple regression logistics was used to determine the predictive ability of the scores to discriminate to discriminate who will have a coronary lesion > 50%. RESULTS: Most subjects were male (319 or 54.8%), mean age of 59.9 (± 10.6) years. A positive correlation was observed between risk scores and >coronary lesion > 50% (TIMI r = 0.363 [p < 0.0001]; hospital GRACE r = 0.255 [p < 0.0001]; GRACE at six months r = 0.209 [ 50% was: TIMI = 0.704 [CI95% 0.656-0.752; p <0.0001]; hospital GRACE = 0.623 [CI95% 0.573-0.673; p < 0.0001]; GRACE at six months= 0.562 [CI95% 0.510-0.613; p ;= 0.0255]. Comparing the areas under the ROC curve, it was found: TIMI versus hospital GRACE: p = 0.01; TIMI versus GRACE at six months:p < 0.0001; hospital GRACE versus GRACE at six months: p = 0.0461. CONCLUSION: Risk scores correlate with the severity of coronary lesions, and the TIMI risk score showed the best predictive ability.

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Artigo Original

Adaptation and applicability of a diuretic algorithm for patients with heart failure

Maria Karolina Echer Ferreira Feijó et al. Andreia Biolo Eneida Rejane Rabelo-Silva

BACKGROUND: Congestive states can be identified and managed through algorithms such as the Diuretic Treatment Algorithm (DTA) to adjust the diuretic over the telephone, focused on the clinical evaluation. However, the DTA is currently available only in English. OBJECTIVE: To adapt the DTA and test its applicability for Brazil in outpatients with heart failure. METHODS: The stages of translation, synthesis, back-translation, review by an expert committee, and pre-test (clinical applicability by means of a random clinical trial) were followed. The Brazilian version of the DTA was called algoritmo de ajuste de diurético (AAD; as per its acronym in Portuguese, standing for diuretic adjustment algorithm). Patients were randomized to the intervention group (IG) – diuretic adjustment according to the AAD – or control group (CG) – conventional adjustment. The clinical congestion score (CCS) and weight values were obtained for both groups. Results: A total of 12 changes were made to the DTA. Thirty-four patients were included. For those with congestion, the increase in the diuretic as guided by the AAD solved their condition, reducing the CCS by two points for 50% of the sample -2 (-3.5; -1.0), while the median for the CG was 0 (-1.25; -1.0), (p < 0.001). The median for weight variation was greater in IG -1.4 (-1.7; -0.5) compared to the CG 0.1 (1.2; -0.6), p = 0.001. CONCLUSIONS: The AAD proved applicable in clinical practice after adaption and appears to result in better congestion management in patients with heart failure. The clinical effectiveness of the tool should be tested in a larger patient sample aiming at validating the instrument for Brazil (Universal Trial Number: U1111-1130-5749) (Arq Bras Cardiol. 2013; [online].ahead print, PP.0-0).

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