2013;101(3) – ABC CARDIOL

Case Report

Percutaneous management of coronary artery fistula in an adult and clinical outcome

Fabio Solano F. Souza et al. André Goyanna Humberto Álvaro Gonçalves Adriano Lopes Avelar … Antônio Gilson Lapa Godinho Nilson Borges Ramos

CASE REPORT

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Clinical Update

Hypertension control in brazilian publications

Natália de Alencar Pinho et al. Angela Maria Geraldo Pierin

Hypertension is a major public health problem due to its high prevalence and cardiovascular complications. Its treatment is aimed at reducing cardiovascular morbidity and mortality, its goal being to maintain blood pressure levels below 140/90 mm Hg. Hypertension control in Brazil is low, and nationwide rates are unknown. The objective of this review was to provide an overview on hypertension control in Brazil from publications in a database. We identified 45 publications. In population-based studies, the highest control rate (57.6%) was reported in a multicenter study in 100 municipalities and the city of São José do Rio Preto, São Paulo state (52.4%), while the lowest rates (around 10%) were identified in microregions of the Rio Grande do Sul state and in the city of Tubarão, Santa Catarina state. In conclusion, the studies assessed showed a wide variation in hypertension control rates. It is worth noting that the comparison between studies was a major limiting factor, because of the different methods used.

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Ponto de Vista

On the gravity of the acute rheumatic fever in children from Pernambuco, Brazil

Lurildo Ribeiro Saraiva et al. Cleusa Lapa Santos Cristina Ventura Maria Auxiliadora Sobral … Breno Barbosa Giordano Bruno Parente Fernando Moraes

VIEWPOINT

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Case Report

Percutaneous treatment of refractory angina secondary to left subclavian artery stenosis in patients after coronary artery bypass grafting

Ernesto Misael Cintra Osterne et al. Evandro Cesar Vidal Osterne Vicente Paulo Motta Paulo Antonio Marra da Motta … Cecilio Kassem Salame Thomas Edson Cintra Osterne

CASE REPORT

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Anatomopathological Session

Case 4: 84-year old female with precordial pain and cardiac arrest with pulseless electrical activity

Bruna Affonso Madaloso et al. Luiz Alberto Benvenuti

ANATOMOPATHOLOGICAL SESSION

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Carta ao Editor

Feminization of medicine

Max Grinberg et al. Antonio Sergio de Santis Andrade Lopes

LETTER TO THE EDITOR

Feminization of medicine

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Carta ao Editor

Mean platelet volume may be associated with extent of coronary artery disease

Sait Demirkol et al. Sevket Balta Ugur Kucuk Hilal Olgun Kucuk

LETTER TO THE EDITOR

Mean platelet volume may be associated with extent of coronary artery disease

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Brief Communication

Prevalence of dyslipidemia in children with congenital heart disease

Gabriela Fuenmayor et al. Ana Carolina Costa Redondo Karen Saori Shiraishi Rogerio Souza … Patrícia Figueiredo Elias Ieda Biscegli Jatene

Dyslipidemia is one of the main risk factors associated with cardiovascular diseases. Few data on the impacts of congenital heart diseases are available with regard to the prevalence of dyslipidemia in children. Our study evaluated the lipid profile in children with congenital heart disease at a referral center. From January 2011 to July 2012, 52 pediatric patients had their lipid, metabolic and clinical profiles traced. The mean age was 10.4 ± 2.8 years and male/female rate of 1.38:1. Our population had 53.8% patients with high levels of total cholesterol and 13.4% (CI 95 %, from 6.6 to 25.2%) of them also presenting LDL levels > 130 mg/dL, which characterizes dyslipidemia. The group of dyslipidemic patients presented only two obese individuals. Our data show that the presence of congenital heart disease does not lead to higher risk associated with the prevalence of dyslipidemia. Therefore, the screening of this specific population should follow the regular pediatric guidelines, which are also independent of the nutritional status of the children tested.

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Editorial

New DH-BSC recommendations on optimal management of hypertension in diabetics

Antonio Coca

EDITORIAL

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Artigo Original

Maternal restriction of polyphenols and fetal ductal dynamics in normal pregnancy: an open clinical trial

Paulo Zielinsky et al. Antônio Luiz Piccoli Jr. Izabele Vian Ana Maria Zílio … Alexandre Antônio Naujorks Luiz Henrique Nicoloso Carolina Weiss Barbisan Stefano Busato Mauro Lopes Caroline Klein

BACKGROUND:We have recently demonstrated reversal of fetal ductal constriction after dietary maternal restriction of polyphenol-rich foods (PRF), due to its inhibitory action on prostaglandin synthesis. OBJECTIVE: To test the hyphotesis that normal third trimester fetuses also improve ductus arteriosus dynamics after maternal restriction of polyphenols. METHODS: Open clinical trial with 46 fetuses with gestational age (GA) > 28 weeks submitted to 2 Doppler echocardiographic studies with an interval of at least 2 weeks, being the examiners blinded to maternal dietary habits. A validated food frequency questionnaire was applied and a diet based on polyphenol-poor foods (<30mg/100mg) was recommended. A control group of 26 third trimester fetuses was submitted to the same protocol. Statistics used t test for independent samples. RESULTS: Mean GA was 33±2 weeks. Mean daily maternal estimated polyphenol intake (DMPI) was 1277mg, decreasing to 126mg after dietary orientation (p=0.0001). Significant decreases in systolic (SDV) and diastolic (DDV) ductal velocities, and RV/LV diameters ratio, as well as increase in ductal PI were observed [DSV=1.2±0.4m/s (0.7-1.6) to 0.9±0.3m/s (0.6-1.3) (p=0.018); DDV=0.21±0.09m/s (0.15-0.32) to 0.18±0.06m/s (0.11-0.25) (p=0.016); RV/LV ratio =1.3±0.2 (0.9-1.4) to 1.1±0.2 (0.8-1.3) (p=0.004); ductal PI=2.2±0.03 (2.0-2.7) to 2.4±0.4(2.2-2.9) (p=0.04)]. In the control group, with GA of 32±4 weeks, there were no significant differences in DMPI, mean SDV, DDV, PI and RV/LV ratio. CONCLUSION: The oriented restriction of third trimester maternal ingestion of polyphenol-rich foods for a period of 2 weeks or more improve fetal ductus arteriosus flow dynamics and right ventricular dimensions.

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Artigo Original

Prospective validation of the dante pazzanese risk score in non-ST-segment elevation acute coronary syndrome

Elizabete Silva dos Santos et al. Luiz Minuzzo Roberta de Souza Ari Timerman

BACKGROUND: In non-ST-segment elevation acute coronary syndrome (ACS), the likelihood of adverse events should be estimated. Guidelines recommend risk stratification models for that purpose. The Dante Pazzanese risk score (DANTE score) is a simple risk stratification model composed with the following variables: age increase (0 to 9 points); history of diabetes mellitus (2 points) or stroke (4 points); no use of angiotensin-converting-enzyme inhibitor (1 point); creatinine elevation (0 to 10 points); combination of troponin elevation and ST-segment depression (0 to 4 points). OBJECTIVE: To validate the DANTE score in patients with non-ST-segment elevation ACS. METHODS: Prospective, observational study including 457 patients, from September 2009 to October 2010. The patients were grouped in risk categories according to the original model score as follows: very low; low; intermediate; and high. The predictive ability of the score was assessed by using C-statistics. RESULTS: The sample comprised 291 (63.7%) men, the mean age being 62.1 years (SD=11.04). The event death or (re)infarction in 30 days was observed in 17 patients (3.7%). Progressive increase in the proportion of events was observed as the score increased: very low risk = 0.0%; low risk = 3.9%; intermediate risk = 10.9%; high risk = 60.0%; p < 0.0001. C-statistics was 0.87 (95% CI: 0.81-0.94; p < 0.0001). CONCLUSION: DANTE score showed an excellent capacity to predict the specific events, and can be incorporated to the prognostic assessment of patients with non-ST-segment elevation ACS.

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Artigo Original

Effect of beta-carotene on oxidative stress and expression of cardiac connexin 43

Rosangela Novo et al. Paula S. Azevedo Marcos F. Minicucci Leonardo A. M. Zornoff Sergio A. R. Paiva

BACKGROUND: Intervention studies have shown an increased mortality in patients who received beta-carotene. However, the mechanisms involved in this phenomenon are still unknown. OBJECTIVE: Evaluate the influence of beta-carotene on oxidative stress and the expression of connexin 43 in rat hearts. METHODS: Wistar rats, weighing approximately 100 g, were allocated in two groups: Control Group (n=30), that received the diet routinely used in our laboratory, and Beta-Carotene Group (n = 28), which received beta-carotene (in crystal form, added and mixed to the diet) at a dose of 500 mg of beta-carotene/kg of diet. The animals received the treatment until they reached 200-250g, when they were sacrificed. Samples of blood, liver and heart were collected to perform Western blotting and immunohistochemistry for connexin 43; morphometric studies, dosages of beta-carotene by high-performance liquid chromatography as well as reduced glutathione, oxidized glutathione and lipids hydroperoxides were performed by biochemical analysis. RESULTS: Beta-carotene was detected only in the liver of Beta-Carotene Group animals (288 ± 94.7 µg/kg). Levels of reduced/oxidized glutathione were higher in the liver and heart of Beta-Carotene Group animals (liver – Control Group: 42.60 ± 1.62; liver – Beta-Carotene Group: 57.40 ± 5.90; p = 0.04; heart: – Control Group: 117.40 ± 1.01; heart – Beta-Carotene Group: 121.81 ± 1.32 nmol/mg protein; p = 0.03). The content of total connexin 43 was larger in Beta-Carotene Group. CONCLUSION: Beta-carotene demonstrated a positive effect, characterized by the increase of intercellular communication and improvement of anti-oxidizing defense system. In this model, mechanism does not explain the increased mortality rate observed with the beta-carotene supplementation in clinical studies. (Arq Bras Cardiol. 2013; [online].ahead print, PP.0-0)

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Review Article

P2Y12 platelet receptors: importance in percutaneous coronary intervention

Felipe Jose de Andrade Falcão et al. Leonardo Carvalho Mark Chan Cláudia Maria Rodrigues Alves … Antônio Carlos Camargo Carvalho Adriano Mendes Caixeta

Apart from their role in hemostasis and thrombosis, platelets are involved in many other biological processes such as wound healing and angiogenesis. Percutaneous coronary intervention is a highly thrombogenic procedure inducing platelets and monocytes activation through endothelial trauma and contact activation by intravascular devices. Platelet P2Y12 receptor activation by adenosine diphosphate facilitates non-ADP agonist-mediated platelet aggregation, dense granule secretion, procoagulant activity, and the phosphorylation of several intraplatelet proteins, making it an ideal drug target. However, not all compounds that target the P2Y12 receptor have similar efficacy and safety profiles. Despite targeting the same receptor, the unique pharmacologic properties of each of these P2Y12 receptor-directed compounds can lead to very different clinical effects.

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Artigo Original

Assessment of patient knowledge of cardiac rehabilitation: Brazil vs Canada

Gabriela Lima de Melo Ghisi et al. Paul Oh Scott Thomas Magnus Benetti

BACKGROUND: Much of the relationship between health status and knowledge about health and disease can be attributed to the combined effects of disparate health-related behavior, environmental conditions, and socioeconomic structures as well as contact with and delivery of health care. OBJECTIVE: The aim of this study was to describe and compare knowledge of patients with coronary artery disease (CAD) enrolled in cardiac rehabilitation (CR) programs in Brazil and Canada about CAD-related factors. METHODS: Two samples of 300 Brazilian and 300 Canadian patients enrolled in CR were compared cross-sectionally. Brazilian patients were recruited from 2 CR centers in Southern Brazil, whereas Canadian patients were recruited from 1 CR center in Ontario. Knowledge was assessed using the Coronary Artery Disease Education Questionnaire (CADE-Q), psychometrically validated in Portuguese and English. The data were processed through descriptive statistics, post-hoc and the Student’s t-tests. RESULTS: The mean total knowledge score for the whole sample was 41.42 ± 9.3. Canadian respondents had significantly greater mean total knowledge scores than Brazilian respondents. The most highly knowledgeably domain in both samples was physical exercise. In 13 of 19 questions, Canadian respondents reported significantly greater knowledge scores than Brazilian respondents. CONCLUSIONS: Canadian outpatients reported significantly greater knowledge than their Brazilian counterparts. The results also suggest that having a structured educational curriculum in CR programs may contribute to increased patient knowledge, which may ultimately facilitate behavioral changes.

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Artigo Original

Magnetic resonance imaging evaluation of cardiac masses

Maria Fernanda Braggion-Santos et al. Marcel Koenigkam-Santos Sara Reis Teixeira Gustavo Jardim Volpe … Henrique Simão Trad André Schmidt

BACKGROUND: Cardiac tumors are extremely rare; however, when there is clinical suspicion, proper diagnostic evaluation is necessary to plan the most appropriate treatment. In this context, cardiovascular magnetic resonance imaging (CMRI) plays an important role, allowing a comprehensive characterization of such lesions. OBJECTIVE: To review cases referred to a CMRI Department for investigation of cardiac and paracardiac masses. To describe the positive case series with a brief review of the literature for each type of lesion and the role of cardiovascular magnetic resonance imaging in evaluation. METHODS: Between August 2008 and December 2011, all cases referred for CMRI with suspicion of tumor involving the heart were reviewed. Cases with positive histopathological diagnosis, clinical evolution or therapeutic response compatible with the clinical suspicion and imaging findings were selected. RESULTS: Among the 13 cases included in our study, eight (62%) had histopathological confirmation. We describe five benign tumors (myxomas, rhabdomyoma and fibromas), five malignancies (sarcoma, lymphoma, Richter syndrome involving the heart and metastatic disease) and three non-neoplastic lesions (pericardial cyst, intracardiac thrombus and infectious vegetation). CONCLUSIONS: CMRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, contributing to a more accurate diagnosis in a noninvasive manner and assisting in treatment planning, allowing safe clinical follow-up with good reproducibility.

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Artigo Original

ECG manifestations of the biggest outbreak of Chagas disease due to oral Infection in Latin-America

Juan Marques et al. Iván Mendoza Belkisyolé Noya Harry Acquatella … Igor Palacios María Marques-Mejias

BACKGROUND: Chagas disease affects more than 15 million people worldwide. Although vector-borne transmission has decreased, oral transmission has become important. Recently, our group published the clinical and epidemiological characteristics of the largest outbreak of orally transmitted Chagas disease reported till date. OBJECTIVE: To describe electrocardiographic changes occurring in the study population during the outbreak caused by ingestion of contaminated guava juice. METHODS: We evaluated 103 positive cases, of which 76 (74%) were aged 18 years (average age: 46 ± 11.8 years). All patients underwent clinical evaluations and ECG. If the patients had palpitations or evident alterations of rhythm at baseline, ambulatory ECG monitoring was performed. RESULTS: A total of 68 cases (66%; 53 children and 15 adults) had ECG abnormalities. Further, 69.7% (53/76) of those aged 18 years showed some ECG alteration (p = ns). ST-T abnormalities were observed in 37.86% cases (39/103) and arrhythmias were evident in 28.16% cases (29/103). ST alterations occurred in 72% of those aged 18 years (p < 0.0001). CONCLUSIONS: This study reports the largest number of cases in the same outbreak of acute Chagas disease caused by oral contamination, with recorded ECGs. ECG changes suggestive of acute myocarditis and arrhythmias were the most frequent abnormalities found.

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Artigo Original

Antioxidant micronutrients and cardiovascular risk in patients with diabetes: a systematic review

Roberta Aguiar Sarmento et al. Flávia Moraes Silva Graciele Sbruzzi Beatriz D'Agord Schaan Jussara Carnevale de Almeida

BACKGROUND: Inverse associations between micronutrient intake and cardiovascular outcomes have been previously shown, but did not focus on diabetic patients. OBJECTIVE: To systematically review the role of micronutrients in the development/presence of cardiovascular outcomes in patients with diabetes. METHODS: We searched Medline, Embase, and Scopus (January/1949-March/2012) for observational studies that evaluated micronutrients and cardiovascular outcomes in patients with diabetes, and then selected and extracted the data (two independent reviewers). RESULTS: From the 15 658 studies identified, five were included, comprising three case-control and two cohorts, with a follow-up of 7-15 years. A meta-analysis was not performed due to the different antioxidant micronutrients (types and measurement methods) and outcomes evaluated. The micronutrients assessed were vitamin C intake in diet and/or supplementation, chromium and selenium in toenail samples, and α-tocopherol and zinc in serum levels. Intake of >300 mg of vitamin C through supplementation was associated with increased risk of cardiovascular disease, coronary artery disease (CAD), and stroke (RR 1.69-2.37). High levels of α-tocopherol in serum were associated with 30% lower CAD risk in another study (HR 0.71; 95%CI 0.53-0.94). Among minerals (zinc, selenium, and chromium), an inverse association between zinc and CAD was observed; levels lower than 14.1 µmol/L were associated with an increased risk for CAD (RR 1.70; 95%CI 1.21-2.38). CONCLUSION: The information available on this issue is scarce. Further prospective studies are needed to elucidate the role of these nutrients in the cardiovascular risk of patients with diabetes.

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Artigo Original

Etanercept induces low QRS voltage and autonomic dysfunction in mice with experimental Chagas disease

Héctor Rodríguez-Angulo et al. Oscar García Endher Castillo Edward Cardenas … Juan Marques Alfredo Mijares

BACKGROUND: Chagas disease is a tropical parasitic disease caused by the flagellate protozoan Trypanosoma cruzi. Chagasic cardiomyopathy is characterized by disorders of autonomic regulation and action potential conduction in the acute and chronic phases of infection. Although tumor necrosis factor alpha (TNF-α) has been linked to cardiomyopathy in experimental models and in patients with Chagas disease, other reports suggest that TNF-α may exert anti-parasitic actions during the acute phase of infection. OBJECTIVES: This study aimed to determine the effects of a soluble TNF-α agonist, etanercept, on electrocardiographic parameters in the acute phase of experimental infection with Trypanosoma cruzi. METHODS: Electrocardiograms were obtained from untreated infected mice and infected mice who were treated with etanercept 7 days after infection. ECG wave and heart rate variability parameters were determined using Chart for Windows. RESULTS: Etanercept treatment resulted in a low QRS voltage and decreased heart rate variability compared with no treatment. However, the treated mice exhibited a delay in the fall of the survival curve during the acute phase. CONCLUSION: The results of this study suggest that although etanercept treatment promotes survival in mice infected with a virulent T. cruzi strain, TNF-α blockade generates a low voltage complex and autonomic dysfunction during the acute phase of infection. These findings indicate that mortality during the acute phase can be attributed to a systemic inflammatory response rather than cardiac dysfunction.)

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Artigo Original

Catheter ablation of arrhythmias exclusively using electroanatomic mapping: a series of cases

Leonardo Martins Pires et al. Tiago Luiz Luz Leiria Marcelo Lapa Kruse Rafael Ronsoni … Caroline Saltz Gensas Gustavo Glotz de Lima

BACKGROUND: Catheter ablation is a treatment that can cure various cardiac arrhythmias. Fluoroscopy is used to locate and direct catheters to areas that cause arrhythmias. However, fluoroscopy has several risks. Electroanatomic mapping (EAM) facilitates three-dimensional imaging without X-rays, which reduces risks associated with fluoroscopy. OBJECTIVE: We describe a series of patient cases wherein cardiac arrhythmia ablation was exclusively performed using EAM. METHODS: Patients who presented with cardiac arrhythmias that were unresponsive to pharmacological therapy were prospectively selected between March 2011 and March 2012 for arrhythmia ablation exclusively through EAM. Patients with indications for a diagnostic electrophysiology study and ablation of atrial fibrillation, left atrial tachyarrhythmias as well as hemodynamically unstable ventricular arrhythmia were excluded. We documented the procedure time, success rate and complications as well as whether fluoroscopy was necessary during the procedure. RESULTS: In total, 11 patients were enrolled in the study, including seven female patients (63%). The mean age of the patients was 50years (SD ±16.5). Indications for the investigated procedures included four cases (35%) of atrial flutter, three cases (27%) of pre-excitation syndrome, two cases (19%) of paroxysmal supraventricular tachycardia and two cases (19%) of ventricular extrasystoles. The mean procedure duration was 86.6 min (SD ± 26 min). Immediate success (at discharge) of the procedure was evident for nine patients (81%). There were no complications during the procedures. CONCLUSION: This study demonstrates the feasibility of performing an arrhythmia ablation exclusively using EAM with satisfactory results.

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Artigo Original

Correlation between the intima-media thickness of the proximal and distal common carotids

Leonard Hermann Roelke et al. Sergio Lamego Rodrigues Paulo Andrade Lotufo Jose Geraldo Mill

BACKGROUND: Increased IMT (intima-media thickness) in carotids is used as an early atherosclerosis marker and to evaluate the risk of cardiovascular problems. Ultrasound is used in the evaluation because it is accessible and low cost. Measurements for different carotid regions are described. OBJECTIVE:To compare the proximal and distal region IMTs for the bilateral common carotid and guide its use in clinical practice. METHODS: The IMT was measured in the proximal and distal common carotid arteries of 798 individuals (35-74 years old) of both genders using high-resolution ultrasound. Pearson’s correlation coefficient was used to establish associations. The analyses were initially performed for the entire sample as well as subgroups with IMT 0.90 mm for at least one measurement site. The statistical significance was p < 0.05. RESULTS: The correlations investigated were significant. In the group with an IMT 0.90 mm, the correlations were significantly reduced to between 0.20 and 0.40. CONCLUSION: The data suggest that the IMT is more uniform along the carotid during early development and tends develop focally as it progresses. Therefore, in clinical evaluations of patients, the common carotid length should be investigated bilaterally to better use the available software and discern the IMT.

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