2014;102(2) – ABC CARDIOL

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Letter to the Editor

Chronotropic Incompetence in Diabetic Elderly on Echocardiography

Eduardo Maffini da Rosa et al. Roberta Casanova Wilhelms Rodrigo Borges Brandão

Dear editor,

We congratulate the authors of the article on the prognosis of chronotropic incompetence in diabetic elderly undergoing physical stress echocardiography, published in the Arq Bras Cardiol. 2013;100(5):429-43.

When chronotropic deficit is observed on pharmacological stress echocardiography, a relationship is observed with neither prognosis nor prevalence of coronary artery disease, but with sinus node disorders, extrasystoles or dysautonomia, which might be due to dobutamine effects ^, . We would like to know whether, in those authors’ opinion, the chronotropic deficit can play any prognostic role in pharmacological stress echocardiography.

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Carta ao Editor

Reply

Eduardo Maffini da Rosa et al. Roberta Casanova Wilhelms Rodrigo Borges Brandão

Our group has experience with chronotropic incompetence (CI) by using physical stress echocardiography as the diagnostic method; according to already performed cohorts, CI has shown prognostic value. That is the preferred method for individuals with preserved physical capacity.

Despite the well-known clinical implications, the underlying mechanism of CI has not been well clarified, autonomic dysfunction being the most frequently found hypothesis in the studies. The use of dobutamine is known to involve an autonomic system participant, the myocardial beta 1 adrenergic receptor, and is more restrictive than physical effort, which involves all the complexity of the system.

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Artigo Original

Acute Effects of Continuous Positive Air way Pressure on Pulse Pressure in Chronic Heart Failure

Mônica Quintão et al. Sérgio Chermont Luana Marchese Lúcia Brandão … Sabrina Pereira Bernardez Evandro Tinoco Mesquita Nazareth de Novaes Rocha Antônio Claudio L. Nóbrega

Background:

Patients with heart failure (HF) have left ventricular dysfunction and reduced mean arterial pressure (MAP). Increased adrenergic drive causes vasoconstriction and vessel resistance maintaining MAP, while increasing peripheral vascular resistance and conduit vessel stiffness. Increased pulse pressure (PP) reflects a complex interaction of the heart with the arterial and venous systems. Increased PP is an important risk marker in patients with chronic HF (CHF). Non-invasive ventilation (NIV) has been used for acute decompensated HF, to improve congestion and ventilation through both respiratory and hemodynamic effects. However, none of these studies have reported the effect of NIV on PP.

Objective:

The objective of this study was to determine the acute effects of NIV with CPAP on PP in outpatients with CHF.

Methods:

Following a double-blind, randomized, cross-over, and placebo-controlled protocol, twenty three patients with CHF (17 males; 60 ± 11 years; BMI 29 ± 5 kg/cm², NYHA class II, III) underwent CPAP via nasal mask for 30 min in a recumbent position. Mask pressure was 6 cmH₂O, whereas placebo was fixed at 0-1 cmH₂O. PP and other non invasive hemodynamics variables were assessed before, during and after placebo and CPAP mode.

Results:

CPAP decreased resting heart rate (Pre: 72 ± 9; vs. Post 5 min: 67 ± 10 bpm; p < 0.01) and MAP (CPAP: 87 ± 11; vs. control 96 ± 11 mmHg; p < 0.05 post 5 min). CPAP decreased PP (CPAP: 47 ± 20 pre to 38 ± 19 mmHg post; vs. control: 42 ± 12 mmHg, pre to 41 ± 18 post p < 0.05 post 5 min).

Conclusion:

NIV with CPAP decreased pulse pressure in patients with stable CHF. Future clinical trials should investigate whether this effect is associated with improved clinical outcome.

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Special Article

I Brazilian Position Paper on Prehypertension, White Coat Hypertension and Masked Hypertension: Diagnosis and Management

Alexandre Alessi et al. Andréa Araujo Brandão Annelise Machado Gomes de Paiva Armando da Rocha Nogueira … Audes Feitosa Carolina de Campos Gonzaga Celso Amodeo Decio Mion Dilma do Socorro Moraes de Souza Eduardo Barbosa Emilton Lima Junior Fernando Nobre Flavio Dani Fuchs Hilton Chaves Junior Jamil Cherem Schneider João Gemelli José Fernando Villela-Martin Luiz Cesar Nazario Scala Marco Antonio Mota Gomes Marcus Vinicus Bolivar Malachias Nelson Siqueira de Morais Osni Moreira Filho Oswaldo Passarelli Junior Paulo Cesar Brandão Veiga Jardim Roberto Dischinger Miranda Rui Póvoa Sandra Cristina Fuchs Sergio Baiocchi Thiago Veiga Jardim Weimar Kunz Sebba Barroso

Introduction

Arterial blood pressure (BP) is a very useful variable in clinical practice. Its measurement is simple, inexpensive and easy; it is worth noting that BP should be accurately obtained, following the recommendations of the VI Brazilian Guidelines on Hypertension (DBH VI).

Office BP measurement is the central parameter for the diagnosis, treatment and follow-up of systemic arterial hypertension (SAH), being directly, continuously and independently related to the risk of fatal and non-fatal cardiovascular (CV) events ^– .

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Viewpoint

Detailing the Writing of Scientific Manuscripts: 25-30 Paragraphs

Claudio Gil Soares de Araújo

Unfolding the sections

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Case Report

Clinically Manifested Myocarditis in Acute Rheumatic Fever José

José L. Xavier Jr. et al. Alexandre de Matos Soeiro Antonio S. S. A. Lopes Guilherme S. Spina … Carlos V. Serrano Jr. Múcio T. Oliveira Jr.

Introduction

The development of acute myocarditis in the postoperative period of cardiac surgery is a challenge for the doctor who treats this type of patient. In most cases, myocarditis can be only a consequence of procedural-related inflammation. However, differential diagnoses must be observed. Among them, rheumatic fever must be considered as an important mechanism. Although its cardiac manifestation is predominantly related to the involvement of the valvular apparatus, its diagnosis is essentially clinical and it can acutely impair the myocardium. In this context, the occurrence of acute rheumatic myocarditis is rare and its immunosuppressive treatment remains uncertain.

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Letter to the Editor

Trastuzumab Cardiotoxicity in Patients with Breast Cancer

Aguinaldo Figueiredo Freitas Jr et al. Salvador Rassi

Dear Editor,

We read the article “Detection of Subclinical Trastuzumab-Induced Cardiotoxicity in Patients with Breast Cancer”. Cardio-oncology is a current challenge for cardiologists, due to the high prevalence of cardiovascular toxicity secondary to chemotherapy agents, in addition to the need to determine effective measures to reduce the incidence of that complication ^– .

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Anatomopathological Session

Case 1/2014 – Syncope Due to Cardiogenic Shock in a 25-year-old Male Patient

Tiago Rodrigues Politi et al. Paulo Gutierrez

Clinical aspects

This is a case of a male patient, 25 years of age with no previously described clinical history that sought medical attention complaining of malaise and feeling faint. The clinical picture had started 1 hour before he sought the local hospital emergency room. The patient clinical evolution was dramatic, presenting at the examination as shock, initially of undetermined etiology, going to aortic dissection and cardiac tamponade, and culminating in death within hours of symptom onset, before any surgical intervention. Acute dissection of the ascending aorta was then identified, with rapid and catastrophic clinical deterioration, a determining factor for the diagnosis to be attained as early as possible, as well as an early and accurate intervention.

Acute aortic dissection is a cardiovascular emergency with high mortality, ranging from 50 to 68% in 48 hours, 70% at 1 week and 85% in 1 month. The intimal tear is transversal, located in 70% of cases in the aorta ascending (just above the aortic valve), 20% in the descending aorta after the aortic arch, and 10% in the transverse aorta. Once started, the dissection progression can be distal, retrograde or occur in both directions and be of varying extension ^, . In the present case, the aortic dissection started in the ascending portion, retrograde, with bending of the anterior plan between the true and false lumen, generating a mechanical obstruction to the left ventricular outflow tract ().

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Artigo Original

Time of Exercise as Indicator of Quality Control in Ergometry Services

Romeu Sergio Meneghelo et al. Samira Saady Morhy Paola Zucchi

Background:

The search for quality requires assessment tools in the various subdivisions of a health complex. In diagnostic medicine, they are scarce and in ergometry suggestions of indicators were not found.

Objective:

To establish indicator for quality control on ergometry based on III Guidelines of the Brazilian Cardiology Society About Ergometric Test; to verify the percentage of tests that have presented the indicator within the compliance in two services of the same institution before and after the publication of the document.

Methods:

A critical analysis of the guidelines in the search for indicator that would present: accuracy, reliability, simplicity, validity, sensitivity and ability to quantitatively measure the variations in the behavior of quality criteria and that would be applicable to all tests. The indicator was applied in tests of 2010 and 2011 prior to the publication, and after it was adopted by two services of the same institution.

Results:

The indicator that has met the criteria was the percentage of ergometric tests with exercise duration between 8 and 12 minutes. In the years 2010 and 2011, respectively, the percentage of ergometric tests within compliance were 85.5% and 86.1% (p = 0.068) at the General Hospital, and 81.5% and 85.7% (p <0.001) the Service of Periodic Health Assessment.

Conclusion:

The exercise time between 8 and 12 minutes can be used as a quality criterion in ergometric and services where it was applied, at least 80% of the ergometric tests were compliant.

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Artigo Original

Coronary Flow Velocity Reserve during Dobutamine Stress Echocardiography

José Sebastião de Abreu et al. José Wellington Oliveira Lima Tereza Cristina Pinheiro Diógenes Jordana Magalhães Siqueira … Nayara Lima Pimentel Pedro Sabino Gomes Neto Marília Esther Benevides de Abreu José Nogueira Paes Júnior

Background:

A coronary flow velocity reserve (CFVR) ≥ 2 is adequate to infer a favorable prognosis or the absence of significant coronary artery disease.

Objective:

To identify parameters which are relevant to obtain CFVR (adequate or inadequate) in the left anterior descending coronary artery (LAD) during dobutamine stress echocardiography (DSE).

Methods:

100 patients referred for detection of myocardial ischemia by DSE were evaluated; they were instructed to discontinue the use of β-blockers 72 hours prior to the test. CFVR was calculated as a ratio of the diastolic peak velocity (cm/s) (DPV) on DSE (DPV-DSE) to baseline DPV at rest (DPV-Rest). In group I, CFVR was < 2 and, in group II, CFVR was ≥ 2. The Fisher's exact test and Student's t test were used for the statistical analyses. P values < 0.05 were considered statistically significant.

Results:

At rest, the time (in seconds) to obtain Doppler in LAD in groups I and II was not different (53±31 vs. 45±32; p=0.23). During DSE, LAD was recorded in 92 patients. Group I patients were older (65.9±9.3 vs. 61.2±10.8 years; p=0.04), had lower ejection fraction (61±10 vs. 66±6%; p=0.005), higher DPV-Rest (36.81±08 vs. 25.63 ± 06cm/s; p<0.0001) and lower CFVR (1.67 ± 0.24 vs. 2.53 ± 0.57; p<0.0001), but no difference was observed regarding DPVDSE (61.40±16 vs. 64.23±16cm/s; p=0.42). β-blocker discontinuation was associated with a 4-fold higher chance of a CFVR < 2 (OR= 4; 95% CI [1.171-13.63], p=0.027).

Conclusion:

DPV-Rest was the main parameter to determine an adequate CFVR. β-blocker discontinuation was significantly associated with inadequate CFVR. The high feasibility and the time to record the LAD corroborate the use of this methodology.

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Review Article

Quality of Life and Congenital Heart Disease in Childhood and Adolescenc

Juliana Bertoletti et al. Giovana Caroline Marx Sérgio Pedro Hattge Júnior Lucia Campos Pellanda

Advances in cardiac surgery techniques and early diagnosis have enabled the increased survival of individuals with congenital heart disease. The investigation of the quality of life in children and adolescents with congenital heart disease provides complementary information to clinical data that can assist in decision making on the part of health professionals. Although many studies have been conducted to investigate the quality of life of children and adolescents with congenital heart disease, the results prove to be contradictory; while some studies show that congenital heart disease can impact the quality of life, others describe a better perception of quality of life among children and adolescents who suffer from the disease when compared with healthy control subjects. The purpose of this study is to review the literature on the assessment of health related quality of life in children and adolescents with congenital heart disease, in order to systematize the existing knowledge on this topic today. It is observed that research seeks to investigate aspects of personality in cardiac patients, their coping strategies used and perceived social support, aiming at better understanding the association of these variables with the level of quality of life in this population.

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Artigo Original

Hypertrophic response of the Association of Thyroid Hormone and Exercise in the Heart of Rats

Fernanda Rodrigues de Souza et al. Elmiro Santos Resende Leandro Lopes Alexandre Gonçalves … Rafaella Chagas Thiago Fidale Poliana Rodrigues

Background:

Cardiac hypertrophy is a component of cardiac remodeling occurring in response to an increase of the activity or functional overload of the heart.

Objective:

Assess hypertrophic response of the association of thyroid hormone and exercise in the rat heart.

Methods:

We used 37 Wistar rats, male, adults were randomly divided into four groups: control, hormone (TH), exercise (E), thyroid hormone and exercise (H + E); the group received daily hormone levothyroxine sodium by gavage at a dose of 20 μg thyroid hormone/100g body weight, the exercise group took swimming five times a week, with additional weight corresponding to 20% of body weight for six weeks; in group H + E were applied simultaneously TH treatment groups and E. The statistics used was analysis of variance, where appropriate, by Tukey test and Pearson correlation test.

Results:

The T4 was greater in groups TH and H + E. The total weight of the heart was greater in patients who received thyroid hormone and left ventricular weight was greater in the TH group. The transverse diameter of cardiomyocytes increased in groups TH, E and H + E. The percentage of collagen was greater in groups E and H + E Correlation analysis between variables showed distinct responses.

Conclusion:

The association of thyroid hormone with high-intensity exercise produced cardiac hypertrophy, and generated a standard hypertrophy not directly correlated to the degree of fibrosis.

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Artigo Original

Value of coronary artery calcium score to predict severity or complexity of coronary artery disease

Tayyar Gökdeniz et al. Ezgi Kalaycıoğlu Ahmet Çağrı Aykan Faruk Boyacı … Turan Turhan İlker Gül Gökhan Çavuşoğlu İhsan Dursun

BACKGROUND:

Prediction of severity or complexity of coronary artery disease (CAD) is valuable owing to increased risk for cardiovascular events. Although the association between total coronary artery calcium (CAC) score and severity of CAD, Gensini score was not used, it has been previously demonstrated. There is no information about the association between total CAC score and complexity of CAD.

OBJECTIVES:

To investigate the association between severity or complexity of coronary artery disease (CAD) assessed by Gensini score and SYNTAX score (SS), respectively, and coronary artery calcium (CAC) score, which is a noninvasive method for CAD evaluation in symptomatic patients with accompanying significant CAD.

METHODS:

Two-hundred-fourteen patients were enrolled. Total CAC score was obtained before angiography. Severity and complexity of CAD was assessed by Gensini score and SS, respectively. Associations between clinical and angiographic parameters and total CAC score were analyzed.

RESULTS:

Median total CAC score was 192 (23.0-729.8), and this was positively correlated with both Gensini score (r: 0.299, p<0.001) and SS (r: 0.577, p<0.001). At multivariate analysis, it was independently associated with age (ß: 0.154, p: 0.027), male gender (ß: 0.126, p: 0.035) and SS (ß: 0.481, p 809 for SS >32 (high SS tertile).

CONCLUSION:

In symptomatic patients with accompanying significant CAD, total CAC score was independently associated with SS and patients with SS >32 may be detected through high Agatston score.

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Artigo Original

Gene expression related to oxidative stress in the heart of mice after intestinal ischemia

Frederico Somaio Neto et al. Adauto Tsutomu Ikejiri Paulo Roberto Bertoletto José Carlos Bertoletto Chaves … Roberto Teruya Djalma José Fagundes Murched Omar Taha

BACKGROUND:

Intestinal ischemia-reperfusion is a frequent clinical event associated to injury in distant organs, especially the heart.

OBJECTIVE:

To investigate the gene expression of oxidative stress and antioxidant defense in the heart of inbred mice subjected to intestinal ischemia and reperfusion (IR).

METHODS:

Twelve mice (C57BL / 6) were assigned to: IR Group (GIR) with 60 minutes of superior mesenteric artery occlusion followed by 60 minutes of reperfusion; Control Group (CG) which underwent anesthesia and laparotomy without IR procedure and was observed for 120 minutes. Intestine and heart samples were processed using the RT-qPCR / Reverse transcriptase-quantitative Polymerase Chain Reaction method for the gene expression of 84 genes related to oxidative stress and oxidative defense (Student’s “t” test, p < 0.05).

RESULTS:

The intestinal tissue (GIR) was noted to have an up-regulation of 65 genes (74.71%) in comparison to normal tissue (CG), and 37 genes (44.04%) were hyper-expressed (greater than three times the threshold allowed by the algorithm). Regarding the remote effects of intestinal I/R in cardiac tissue an up-regulation of 28 genes (33.33%) was seen, but only eight genes (9.52%) were hyper-expressed three times above threshold. Four (7.14%) of these eight genes were expressed in both intestinal and cardiac tissues. Cardiomyocytes with smaller and pyknotic nuclei, rich in heterochromatin with rare nucleoli, indicating cardiac distress, were observed in the GIR.

CONCLUSION:

Intestinal I/R caused a statistically significant over expression of 8 genes associated with oxidative stress in remote myocardial tissue.

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Artigo Original

Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation

Matheus Miranda et al. Nelson Américo Hossne Jr. João Nelson Rodrigues Branco Guilherme Flora Vargas … José Honório de Almeida Palma da Fonseca José Osmar Medina de Abreu Pestana Yara Juliano Enio Buffolo

Background:

Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high.

Objective:

Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients.

Methods:

Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012.

Results:

High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality.

Conclusion:

Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.

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Artigo Original

Influence of Term of Exposure to High-Fat Diet-Induced Obesity on Myocardial Collagen Type I and III

Danielle Cristina Tomaz da Silva et al. Ana Paula Lima-Leopoldo André Soares Leopoldo Dijon Henrique Salomé de Campos … André Ferreira do Nascimento Sílvio Assis de Oliveira Junior Carlos Roberto Padovani Antonio Carlos Cicogna

BACKGROUND:

Obesity is a risk factor for many medical complications; medical research has shown that hemodynamic, morphological and functional abnormalities are correlated with the duration and severity of obesity.

OBJECTIVE:

Present study determined the influence of term of exposure to high-fat diet-induced obesity on myocardial collagen type I and III.

METHODS:

Thirty-day-old male Wistar rats were randomly distributed into two groups: a control (C) group fed a standard rat chow and an obese (Ob) group alternately fed one of four palatable high-fat diets. Each diet was changed daily, and the rats were maintained on their respective diets for 15 (C₁₅ and Ob₁₅) and 30 (C₃₀ and Ob₃₀) consecutive weeks. Obesity was determined by adiposity index.

RESULTS:

The Ob₁₅ group was similar to the C₁₅ group regarding the expression of myocardial collagen type I; however, expression in the Ob₃₀ group was less than C₃₀ group. The time of exposure to obesity was associated with a reduction in collagen type I in Ob₃₀ when compared with Ob₁₅. Obesity did not affect collagen type III expression.

CONCLUSION:

This study showed that the time of exposure to obesity for 30 weeks induced by unsaturated high-fat diet caused a reduction in myocardial collagen type I expression in the obese rats. However, no effect was seen on myocardial collagen type III expression.

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Artigo Original

High blood Pressure in children and its correlation with three definitions of obesity in childhood

Leonardo Iezzi de Moraes et al. Thaís Coutinho Nicola Julyanna Silva Araújo de Jesus Eduardo Roberty Badiani Alves … Nayara Paula Bernurdes Giovaninni Daniele Gasparini Marcato Jéssica Dutra Sampaio Jeanne Teixeira Bessa Fuly Everlayny Fiorot Costalonga

BACKGROUND:

Several authors have correlated the increase of cardiovascular risk with the nutritional status, however there are different criteria for the classification of overweight and obesity in children.

OBJECTIVES:

To evaluate the performance of three nutritional classification criteria in children, as definers of the presence of obesity and predictors of high blood pressure in schoolchildren.

METHODS:

Eight hundred and seventeen children ranging 6 to 13 years old, enrolled in public schools in the municipality of Vila Velha (ES) were submitted to anthropometric evaluation and blood pressure measurement. The classification of the nutritional status was established by two international criteria (CDC/NCHS 2000 and IOTF 2000) and one Brazilian criterion (Conde e Monteiro 2006).

RESULTS:

The prevalence of overweight was higher when the criterion of Conde e Monteiro (27%) was used, and inferior by the IOTF (15%) criteria. High blood pressure was observed in 7.3% of children. It was identified a strong association between the presence of overweight and the occurrence of high blood pressure, regardless of the test used (p < 0.001). The test showing the highest sensitivity in predicting elevated BP was the Conde e Monteiro (44%), while the highest specificity (94%) and greater overall accuracy (63%), was the CDC criterion.

CONCLUSIONS:

The prevalence of overweight in Brazilian children is higher when using the classification criterion of Conde e Monteiro, and lower when the criterion used is IOTF. The Brazilian classification criterion proved to be the most sensitive predictor of high BP risk in this sample.

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