2013;101(1) – ABC CARDIOL

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Artigo Original

Cardiac I123-MIBG correlates better than ejection fraction with symptoms severity in systolic heart failure

Sandra M. Miranda et al. Samuel D. Moscavitch Larissa R. Carestiato Renata M. Felix … Ronaldo C. Rodrigues Leandro R. Messias Jader C. Azevedo Antonio Cláudio L. Nóbrega Evandro Tinoco Mesquita Claudio Tinoco Mesquita

BACKGROUND:The association of autonomic activation, left ventricular ejection fraction (LVEF) and heart failure functional class is poorly understood. OBJECTIVE: Our aim was to correlate symptom severity with cardiac sympathetic activity, through iodine-123-metaiodobenzylguanidine (123I-MIBG) scintigraphy and with LVEF in systolic heart failure (HF) patients without previous beta-blocker treatment. METHODS: Thirty-one patients with systolic HF, class I to IV of the New York Heart Association (NYHA), without previous beta-blocker treatment, were enrolled and submitted to 123I-MIBG scintigraphy and to radionuclide ventriculography for LVEF determination. The early and delayed heart/mediastinum (H/M) ratio and the washout rate (WR) were performed. RESULTS: According with symptom severity, patients were divided into group A, 13 patients in NYHA class I/II, and group B, 18 patients in NYHA class III/IV. Compared with group B patients, group A had a significantly higher LVEF (25% ± 12% in group B vs. 32% ± 7% in group A, p = 0.04). Group B early and delayed H/M ratios were lower than group A ratios (early H/M 1.49 ± 0.15 vs. 1.64 ± 0.14, p = 0.02; delayed H/M 1.39 ± 0.13 vs. 1.58 ± 0.16, p = 0.001, respectively). WR was significantly higher in group B (36% ± 17% vs. 30% ± 12%, p= 0.04). The variable that showed the best correlation with NYHA class was the delayed H/M ratio (r= -0.585; p=0.001), adjusted for age and sex. CONCLUSION: This study showed that cardiac 123I-MIBG correlates better than ejection fraction with symptom severity in systolic heart failure patients without previous beta-blocker treatment.

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Editorial

Detection of Subclinical Trastuzumab-Induced Cardiotoxicity in Patients with Breast Cancer

Marília Harumi Higuchi dos Santos

EDITORIAL

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Message from the Editor

Luiz Felipe P. Moreira

MESSAGE FROM THE EDITOR

Luiz Felipe P. Moreira

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Artigo Original

Myocardial infarction area quantification using high-resolution SPECT images in rats

Luciano Fonseca Lemos de Oliveira et al. Jorge Mejia Eduardo Elias Vieira de Carvalho Renata Maria Lataro … Sarita Nasbine Frassetto Rubens Fazan Jr Hélio Cesar Salgado Orfa Yineth Galvis-Alonso Marcus Vinícius Simões

BACKGROUND: Imaging techniques enable in vivo sequential assessment of the morphology and function of animal organs in experimental models. We developed a device for high-resolution single photon emission computed tomography (SPECT) imaging based on an adapted pinhole collimator. OBJECTIVE: To determine the accuracy of this system for quantification of myocardial infarct area in rats. METHODS: Thirteen male Wistar rats (250 g) underwent experimental myocardial infarction by occlusion of the left coronary artery. After 4 weeks, SPECT images were acquired 1.5 hours after intravenous injection of 555 MBq o f 99mTc-Sestamibi. The tomographic reconstruction was performed by using specially developed software based on the Maximum Likelihood algorithm. The analysis of the data included the correlation between the area of perfusion defects detected by scintigraphy and extent of myocardial fibrosis assessed by histology. RESULTS: The images showed a high target organ/background ratio with adequate visualization of the left ventricular walls and cavity. All animals presenting infarction areas were correctly identified by the perfusion images. There was no difference of the infarct area as measured by SPECT (21.1 ± 21.2%) and by histology (21.7 ± 22.0%; p=0.45). There was a strong correlation between individual values of the area of infarction measured by these two methods. CONCLUSION: The developed system presented adequate spatial resolution and high accuracy for the detection and quantification of myocardial infarction areas, consisting in a low cost and versatile option for high-resolution SPECT imaging of small rodents.

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Letter to the Editor

Poll: Jehovah's Witness patient among baixada santista and ABC paulista cardiologists

Antonio Mendes Neto et al. Max Grinberg

LETTER TO THE EDITOR

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Case Report

3D transesophageal echo in percutaneous correction of paraprosthetic regurgitation

David Costa de Souza Le Bihan et al. Leonardo Mello Guimarães de Toledo Rodrigo Bellio de Mattos Barretto Cesar Augusto Esteves … Jorge Eduardo Assef Amanda Guerra Moraes Rego Sousa

CASE REPORT

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Letter to the Editor

Right ventricular diastolic function in patients with thalassemia major

Sait Demirkol et al. Sevket Balta Mustafa Cakar

LETTER TO THE EDITOR

Right ventricular diastolic function in patients with thalassemia major

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Artigo Original

Anemia, heart failure and evidence-based clinical management

Camila Alves Pereira et al. Meliza Goi Roscani Silméia Garcia Zanati Beatriz Bojikian Matsubara

Anemia is a prevalent comorbidity and marker of a poorer prognosis in patients with heart failure (HF). Its clinical relevance, as well as its pathophysiology and the clinical management of these patients are important subjects in the specialized literature. In the present review, we describe the current concepts on the pathophysiology of anemia in HF, its diagnostic criteria, and the recommendations for iron supplementation. Also, we make a critical analysis of the major studies showing evidences on the benefits of this supplementation. The four main components of anemia are addressed: chronic disease, dilutional, “renal” and malabsorption. In patients with HF, the diagnostic criteria are the same as those used in the general population: serum ferritin levels lower than 30 mcg/L in patients without kidney diseases and lower than 100 mcg/L or serum ferritin levels between 100-299 mcg/L with transferring saturation lower than 20% in patients with chronic kidney diseases. Finally, the therapeutic possibilities for anemia in this specific patient population are discussed.

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Anatomopathological Session

Case 3: – congestive heart failure in male with systemic sclerosis

Caio Bosquiero Zanetti et al. Mariana Bittar Lopes André Marun Lyrio Pompeu Ribeiro de Campos … Rubens Bonfiglioli Maria Aparecida Barone Teixeira

ANATOMOPATHOLOGICAL SESSION

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Case Report

Transseptal coronary angioplasty in patients with severe peripheral vascular disease

Ricardo Wang et al. Newton Stadler Souza Filho Augusto Lima Filho Marcos Vinícius de Freitas Moreira

CASE REPORT

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Atualização

Epicardial fat: definition, measurements and systematic review of main outcomes

Angela Gallina Bertaso et al. Daniela Bertol Bruce Bartholow Duncan Murilo Foppa

Epicardial fat (EF) is a visceral fat deposit, located between the heart and the pericardium, which shares many of the pathophysiological properties of other visceral fat deposits, It also potentially causes local inflammation and likely has direct effects on coronary atherosclerosis. Echocardiography, computed tomography and magnetic resonance imaging have been used to evaluate EF, but variations between methodologies limit the comparability between these modalities. We performed a systematic review of the literature finding associations of EF with metabolic syndrome and coronary artery disease. The summarization of these associations is limited by the heterogeneity of the methods used and the populations studied, where most of the subjects were at high cardiovascular disease risk. EF is also associated with other known factors, such as obesity, diabetes mellitus, age and hypertension, which makes the interpretation of its role as an independent risk marker intricate. Based on these data, we conclude that EF is a visceral fat deposit with potential implications in coronary artery disease. We describe the reference values of EF for the different imaging modalities, even though these have not yet been validated for clinical use. It is still necessary to better define normal reference values and the risk associated with EF to further evaluate its role in cardiovascular and metabolic risk assessment in relation to other criteria currently used.

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Point of view

Risk of excessive sodium intake in the use of a thickener for dysphagia

Tatiana Magalhães de Almeida et al. Michele F. Canfild Germini Cristiane Kovacs Ana Margaret N.G.F. Soares … Daniel Magnoni Amanda G.M.R. Sousa

VIEWPOINT

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Artigo Original

Stress echocardiography and major cardiac events in patients with normal exercise test

Flávia Ricci Calasans et al. Bruno Fernandes de Oliveira Santos Débora Consuelo Rocha Silveira Ana Carla Pereira de Araújo … Luiza Dantas Melo José Augusto Barreto-Filho Antônio Carlos Sobral Sousa Joselina Luzia Menezes Oliveira

BACKGROUND: Exercise test (ET) is the preferred initial noninvasive test for the diagnosis and risk stratification of coronary artery disease (CAD), however, its lower sensitivity may fail to identify patients at greater risk of adverse events. OBJECTIVE: To assess the value of stress echocardiography (SE) for predicting all-cause mortality and major cardiac events (MACE) in patients with intermediate pretest probability of CAD and a normal ET. METHODS: 397 patients with intermediate CAD pretest probability , estimated by the Morise score, and normal ET who underwent SE were studied. The patients were divided into two groups according to the absence (G1) or presence (G2) of myocardial ischemia on SE .End points evaluated were all-cause mortality and MACE, defined as cardiac death and nonfatal acute myocardial infarction (AMI). RESULTS: G1 group was comprised of 329 (82.8%) patients. The mean age of the patients was 57.37 ± 11 years and 44.1% were male. During a mean follow-up of 75.94 ± 17.24 months, 13 patients died, three of them due to cardiac causes, and 13 patients suffered nonfatal AMI. Myocardial ischemia remained an independent predictor of MACE (HR 2.49; [CI] 95% 1.74-3.58). The independent predictors for all-cause mortality were male gender (HR 9.83; [CI] 95% 2.15-44.97) and age over 60 years (HR 4.57; [CI] 95% 1.39-15.23). CONCLUSION: Positive SE for myocardial ischemia is a predictor of MACE in the studied sample, which helps to identify a subgroup of patients at higher risk of events despite having normal ET.

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Artigo Original

Comparison of diagnostic criteria for acute kidney injury in cardiac surgery

Márcio Campos Sampaio et al. Carlos Alberto Gonçalves Máximo Carolina Moreira Montenegro Diandro Marinho Mota … Tatiana Rocha Fernandes Antonio Carlos Mugayar Bianco Celso Amodeo Antonio Carlos Cordeiro

BACKGROUND: There is considerable controversy regarding the diagnosis of Acute Kidney Injury (AKI), and there are over 30 different definitions. OBJECTIVE: To evaluate the incidence and risk factors for the development of AKI following cardiac surgery according to the RIFLE, AKIN and KDIGO criteria, and compare the prognostic power of these criteria. METHODS: Cross-sectional study that included 321 consecutively patients (median age 62 [53-71] years; 140 men) undergoing cardiac surgery between June 2011 and January 2012. The patients were followed for up to 30 days, for a composite outcome (mortality, need for dialysis and extended hospitalization). RESULTS: The incidence of AKI ranged from 15% – 51%, accordingly to the diagnostic criterion adopted. While age was associated with risk of AKI in the three criteria, there were variations in the remaining risk factors. During follow-up, 89 patients developed the outcome and all criteria were associated with increased risk in the univariate Cox analysis and after adjustment for age, gender, diabetes, and type of surgery. However, after further adjustment for extracorporeal circulation and the presence of low cardiac output, only AKI diagnosed by the KDIGO criterion maintained this significant association (HR= 1.89 [95% CI: 1.18 – 3.06]). CONCLUSION: The incidence and risk factors for AKI after cardiac surgery vary significantly according to the diagnostic criteria used. In our analysis, AKI the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.

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Artigo Original

Correlation between plaque composition as assessed by virtual histology and C-reactive protein

Dimytri Alexandre de Alvim Siqueira et al. Amanda Guerra Moraes R. Sousa José de Ribamar Costa Junior Ricardo Alves da Costa … Rodolfo Staico Luis Fernando Leite Tanajura Marinella Patrizia Centemero Fausto Feres Alexandre Antonio Cunha Abizaid J. Eduardo Moraes R. Sousa

BACKGROUND: Previous studies have shown that coronary plaque composition plays a pivotal role in plaque instability, and imaging modalities and serum biomarkers have been investigated to identify vulnerable plaque. Virtual histology IVUS (VH-IVUS) characterizes plaque components as calcified, fibrotic, fibrofatty, or necrotic core. C-reactive protein (hsCRP) is an independent risk factor and a powerful predictor of future coronary events. However, a relationship between inflammatory response indicated by CRP and plaque characteristics in ACS patients remains not well established. OBJECTIVE: To determine, by using VH-IVUS, the relation between coronary plaque components and plasma high-sensitivity CRP levels in patients with acute coronary syndromes (ACS). METHODS: 52 patients with ACS were enrolled in this prospective study. Electrocardiographically-gated VH-IVUS were performed in the culprit lesion before PCI. Blood sample was drawn from all patients before the procedure and after 24 hours, and hs-CRP levels were determined. RESULTS: Mean age was 55.3±4.9 years, 76.9% were men and 30.9% had diabetes. Mean MLA was 3.9±1.3 mm², and plaque burden was 69±11.3%, as assessed by IVUS. VH-IVUS analysis at the minimum luminal site identified plaque components: fibrotic (59.6±15.8%), fibrofatty (7.6±8.2%), dense calcium (12.1±9.2%) and necrotic core (20.7±12.7%). Plasma hs-CRP (mean 16.02±18.07 mg/L) did not correlate with necrotic core (r=-0.089, p = 0.53) and other plaque components. CONCLUSIONS: In this prospective study with patients with ACS, the predominant components of the culprit plaque were fibrotic and necrotic core. Serum hs C-reactive protein levels did not correlate with plaque composition.

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Artigo Original

Morphological and functional measurements of the heart obtained by magnetic resonance imaging in Brazilians

Robson Macedo et al. Juliano Lara Fernandes Solange Souza Andrade Carlos Eduardo Rochitte … Kênio Costa Lima Álvaro Campos Cavalcanti Maciel Fernanda Cunha Maciel Geraldo Souza Pinho Alves Otávio Rizzi Coelho Rosiane Viana Zuza Diniz

BACKGROUND: Still today, measurements used as a reference in the cardiac magnetic resonance imaging have been obtained mainly from studies carried out in North-American and European populations. OBJECTIVE: To obtain measurements of the diastolic diameter, systolic diameter, end diastolic volume, end systolic volume, ejection fraction, and myocardial mass of the left and right ventricles in Brazilians. METHODS: 54 men and 53 women, with mean age of 43.4 ± 13.1 years, asymptomatic, with no cardiomyopathies, have been subjected to the cardiac magnetic resonance imaging, using a balanced steady state free precession technique. RESULTS: The averages and the standard deviations of the parameters for the left ventricle have been: diastolic diameter = 4.8 ± 0.5 cm; systolic diameter = 3.0 ± 0.6 cm; end diastolic volume = 128.4 ± 29.6 mL; end systolic volume = 45.2 ± 16.6 mL; ejection fraction = 65.5 ± 6.3%; mass = 95.2 ± 30.8 g. For the right ventricle, they have been: diastolic diameter = 3.9 ± 1.3 cm; systolic diameter = 2.5 ± 0.5 cm; end diastolic volume = 126.5 ± 30.7 mL; end systolic volume = 53.6 ± 18.4 mL; ejection fraction = 58.3 ± 8.0%, and mass = 26.1 ± 6.1 g. The masses and the volumes were significantly greater in the men, except for the end systolic volume of the left ventricle. The ejection fraction of the right ventricle has been significantly greater in the women. There has been a significant and inverted correlation of the systolic volume of the right volume with the progression of the age. CONCLUSION: This study has described, for the first time, cardiac measurements obtained through the cardiac magnetic resonance imaging in Brazilians, asymptomatic, with no cardiomyopathies, showing differences in accordance with gender and age.

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Artigo Original

3D Echo pilot study of geometric Left Ventricular changes after acute myocardial infarction

Marcelo Luiz Campos Vieira et al. Wercules Antonio Oliveira Adriana Cordovil Ana Clara Tude Rodrigues … Cláudia Gianini Mônaco Tânia Afonso Edgar Bezerra Lira Filho Marco Perin Cláudio Henrique Fischer Samira Saady Morhy

BACKGROUND: Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO). OBJECTIVE: To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment. METHODS: Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event. RESULTS: Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001. CONCLUSION: In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.

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Artigo Original

Association between birth weight and cardiovascular risk factors in adolescents

Maria Amenaide Carvalho Alves de Sousa et al. Isabel Cristina Britto Guimarães Carla Daltro Armênio Costa Guimarães

BACKGROUND: Birth weight (BW) is a medium- and long-term risk determinant of cardiovascular risk factors. OBJECTIVE: To assess the association between BW and cardiovascular risk factors in adolescents of the city of Salvador, Bahia state. METHODS: Cross-sectional study with comparison of BW groups. Sample comprising 250 adolescents classified according to the BMI as follows: high-normal (> 50th percentile and 85th percentile and 95th percentile). The risk variables compared were as follows: waist circumference (WC); arterial blood pressure; lipid profile; glycemia; serum insulin; HOMA-IR; and metabolic syndrome. The BW was informed by parents and classified as follows: low (BW 2,500g and 4,000g). RESULTS: One hundred and fifty-three (61.2%) girls, age 13.74 ± 2.03 years, normal BW 80.8%, low BW 8.0%, and high BW 11.2%. The high BW group as compared with the normal BW group showed a higher frequency of obesity (42.9%, p=0.005), elevated SBP and DBP (42.9%, p=0.000 and 35.7%, p=0.007, respectively), and metabolic syndrome (46.4%, p=0.002). High BW adolescents as compared with normal BW adolescents had a prevalence ratio for high SBP 3.3 (95% CI: 1.7-6.4) and obesity 2.6 (95% CI: 1.3-5.2). The WC of high BW adolescents was 83.3 ± 10.1 (p=0.038). The lipid profile showed no statistically significant differences. CONCLUSION: Our findings suggest that obesity, elevated SBP and DBP, and metabolic syndrome during adolescence might be associated with high BW.

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Artigo Original

Relationship between left atrial volume and diastolic dysfunction in 500 Brazilian patients

Lilia Maria Mameri El Aouar et al. Diana Meyerfreud Pedro Magalhães Sérgio Lamêgo Rodrigues … Marcelo Perim Baldo Yara Brasil Sumaya Mameri El Aouar Nabih Amin El Aouar José Geraldo Mill Orlando Campos Filho

BACKGROUND: Left atrial volume index (LAVI) increase has been associated to left ventricle (LV) diastolic dysfunction (DD), a marker of cardiovascular events (atrial fibrillation, stroke, heart failure, death). OBJECTIVE: To evaluate the relationship between LAVI and diferente grades od DD in Brazilian patients submitted to echocardiogram, studying LAVI increase determinants in this sample. METHODS: We have selected 500 outpatients submitted to echocardiography, after excluding arrhythmia, valvar or congenital cardiopathy, permanent pacemaker or inadequate ecocardiographic window. LAVI was obtained according to Simpson’s method. DD was classified according to current guidelines. The clinical and echocardiographic variables were submitted to linear regression multivariate analysis. RESULTS: Mean age was 52 ± 15 years old, 53% were male, 55% had arterial hypertension, 9% had coronary artery disease, 8% were diabetic, 24% were obese, 47% had LV hypertrophy. The mean ejection fraction of the left ventricle was 69.6 ± 7,2%. The prevalence of DD in this sample was 33.8% (grade I: 66%, grade II: 29% e grade III: 5%). LAVI increased progressively according to DD grade: 21 ± 4 mL/m² (absent), 26 ± 7 mL/m² (grade I), 33 ± 5 mL/m² (grade II), 50 ± 5 mL/m2 (grade III) (p < 0,001). In this sample, LAVI increase independent predictors were age, left ventricular mass, relative wall thickness, LV ejection fraction and E/e' ratio. CONCLUSION: DD contributes to left atrial remodeling. LAVI increases as an expression of DD severity and is independently associated to age, left ventricle hypertrophy, systolic dysfunction and increased LV filling pressures.

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Artigo Original

Effectiveness of a myocardial infarction protocol in reducing door-to-ballon time

Luis Cláudio Lemos Correia et al. Mariana Brito Felipe Kalil Michael Sabino … Guilherme Garcia Felipe Ferreira Iracy Matos Peter Jacobs Liliana Ronzoni Márcia Noya-Rabelo

BACKGROUND: An adequate door-to-balloon time (<120 minutes) is the necessary condition for the efficacy of primary angioplasty in infarction to translate into effectiveness. OBJECTIVE: To describe the effectiveness of a quality of care protocol in reducing the door-to-balloon time. METHODS: Between May 2010 and August 2012, all individuals undergoing primary angioplasty in our hospital were analyzed. The door time was electronically recorded at the moment the patient took a number to be evaluated in the emergency room, which occurred prior to filling the check-in forms and to the triage. The balloon time was defined as the beginning of artery opening (introduction of the first device). The first 5 months of monitoring corresponded to the period of pre-implementation of the protocol. The protocol comprised the definition of a flowchart of actions from patient arrival at the hospital, the team's awareness raising in relation to the prioritization of time, and provision of a periodic feedback on the results and possible inadequacies. RESULTS: A total of 50 individuals were assessed. They were divided into five groups of 10 sequential patients (one group pre- and four groups post-protocol). The door-to-balloon time regarding the 10 cases recorded before protocol implementation was 200 ± 77 minutes. After protocol implementation, there was a progressive reduction of the door-to-balloon time to 142±78 minutes in the first 10 patients, then to 150±50 minutes, 131±37 minutes and, finally, 116±29 minutes in the three sequential groups of 10 patients, respectively. Linear regression between sequential patients and the door-to-balloon time (r = – 0.41) showed a regression coefficient of – 1.74 minutes. CONCLUSION: The protocol implementation proved effective in the reduction of the door-to-balloon time.

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