2014;102(4) – ABC CARDIOL

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Artigo Original

Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Sebastián Lluberas et al. Alexandre Abizaid Dimytri Siqueira Auristela Ramos … J. Ribamar Costa Jr. Magaly Arrais Antônio Kambara David Le Bihan Amanda Sousa J. Eduardo Sousa

Background:

Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk.

Objectives:

To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation.

Methods:

From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation.

Results:

Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly.

Conclusions:

Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up.

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Artigo Original

Cost-Effectiveness of Different Diagnostic Strategies in Suspected Stable Coronary Artery Disease in Portugal

António Miguel Ferreira et al. Hugo Marques Pedro Araújo Gonçalves Nuno Cardim

Background:

Cost-effectiveness is an increasingly important factor in the choice of a test or therapy.

Objective:

To assess the cost-effectiveness of various methods routinely used for the diagnosis of stable coronary disease in Portugal.

Methods:

Seven diagnostic strategies were assessed. The cost-effectiveness of each strategy was defined as the cost per correct diagnosis (inclusion or exclusion of obstructive coronary artery disease) in a symptomatic patient. The cost and effectiveness of each method were assessed using Bayesian inference and decision-making tree analyses, with the pretest likelihood of disease ranging from 10% to 90%.

Results:

The cost-effectiveness of diagnostic strategies was strongly dependent on the pretest likelihood of disease. In patients with a pretest likelihood of disease of ≤50%, the diagnostic algorithms, which include cardiac computed tomography angiography, were the most cost-effective. In these patients, depending on the pretest likelihood of disease and the willingness to pay for an additional correct diagnosis, computed tomography angiography may be used as a frontline test or reserved for patients with positive/inconclusive ergometric test results or a calcium score of >0. In patients with a pretest likelihood of disease of ≥ 60%, up-front invasive coronary angiography appears to be the most cost-effective strategy.

Conclusions:

Diagnostic algorithms that include cardiac computed tomography angiography are the most cost-effective in symptomatic patients with suspected stable coronary artery disease and a pretest likelihood of disease of ≤50%. In high-risk patients (pretest likelihood of disease ≥ 60%), up-front invasive coronary angiography appears to be the most cost-effective strategy. In all pretest likelihoods of disease, strategies based on ischemia appear to be more expensive and less effective compared with those based on anatomical tests.

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Erratum

Erratum

December 2013, vol. 101 (6), Suppl. 2, page 1-63

The “Brazilian Guideline for Cardiovascular Prevention,” published as supplement number two in the December 2013 issue of Arquivos Brasileiros de Cardiologia [Arq Bras Cardiol. 2013; 101 (6Supl.2):1-63], was adjusted as follows: Dr. Fernando Henpin Yue Cesena (CESENA FHY) did not participate in the preparation of the contents of the guideline and had his name removed.

[…]

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Letter to the Editor

Patients' use of the Internet

George Barreto Miranda et al. João Ricardo Cordeiro Max Grinberg

Dear Editor,

In Brazil, a country where digital inclusion at home is growing, there is a lack of data on the patients’ use of the Internet for health information. A survey conducted among 118 patient in the Heart Valve Diseases Outpatient Clinic of InCor, resulted in the findings shown in .

[…]

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Letter to the Editor

Analysis of the Article Correlation Between the Intima-Media Thickness of the Proximal and Distal Common Carotids

Eduardo Maffini da Rosa et al. Gerson Deutner da Silva Jaqueline de Lima Paim

Dear Editor,

We totally agree with the authors regarding the need to screen the entire extension of the carotid arteries (common, internal and external). However, we would add the importance of screening them slowly and in the coronal plane, and of measuring the site where the intima-media thickness is visually greater. During the assessment, the coronal view of the vessel allows including the carotid lateral walls, adding accuracy to the examination.

[…]

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Clinicoradiological Session

Case 3/2014 – 26-year-old Man with Pulmonary Atresia and Ventricular Septal Defect in Late Postoperative Evolution

Complementary tests

Electrocardiogram: Showed sinus rhythm, moderate right ventricular (RV) overload without right bundle branch block. Rs morphology in V1 and qRs in V6. Until six years ago, maintained rsr’ morphology in V1. QRS duration was 0.94 from the total correction. AP: +70º, AQRS: +90º, AT: +70º.

Chest radiography: Shows normal cardiac silhouette, rounded shape and normal pulmonary vasculature ().

[…]

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Viewpoint

Ischemia-Guided Myocardial Revascularization: the Oculo-ischemic Reflex

Luis Cláudio Lemos Correia et al. Márcia Noya-Rabelo José Augusto Barreto-Filho

The COURAGE trial

The most cited clinical trial in that scenario is the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, which has compared randomly and by intention to treat the initial management of stent coronary intervention versus control, and both groups underwent optimized clinical treatment. That study was negative for its primary objective, evidencing identical incidence of death or myocardial infarction in both groups. Thus, the only reason to perform percutaneous coronary intervention in stable disease is to control clinically relevant symptoms.

Regarding the paradigm that revascularization should be performed in case of myocardial ischemia, it is important to assess if the conclusion of the COURAGE trial is valid for ischemia identified on complementary tests. Of the patients undergoing myocardial scintigraphy in the COURAGE trial (61% of that trial sample), 89% had ischemia, and 67% showed ischemia in multiple coronary territories. Because the election of patients to undergo scintigraphy has not been based on disease severity, their data allowed us to infer that the inclusion criteria of the COURAGE trial were sufficient to select patients with a significant ischemic load.

[…]

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Case Report

Toxic Dilated Cardiomyopathy: Recognizing a Potentially Reversible Disease

Inês Rangel et al. Marta Amorim Alexandra Gonçalves Carla Sousa … Paulo Bettencourt Maria Júlia Maciel

Introduction

The use of illicit drugs has increased in recent years. Related to this increase, there is a growing need to recognise and properly treat the adverse effects associated with the consumption of these drugs.

These substances can induce several cardiovascular (CV) complications, being this acute or chronic. Some of them are the ischemic and arrhythmic events, the development of dilated cardiomyopathy (DCM) and the left ventricular systolic dysfunction (LVSD).

[…]

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Artigo Original

Metabolic Syndrome, Strain, and Reduced Myocardial Function: Multi-Ethnic Study of Atherosclerosis

André Luiz Cerqueira de Almeida et al. Gisela Teixido-Tura Eui-Young Choi Anders Opdahl … Verônica R. S. Fernandes Colin O. Wu David A. Bluemke João A. C. Lima

Background:

Subclinical cardiovascular disease is prevalent in patients with Metabolic Syndrome (MetSyn). Left ventricular (LV) circumferential strain (ε_CC) and longitudinal strain (ε_LL), assessed by Speckle Tracking Echocardiography (STE), are indices of systolic function: shortening is indicated by negative strain, and thus, the more negative the strain, the better the LV systolic function. They have been used to demonstrate subclinical ventricular dysfunction in several clinical disorders.

Objective:

We hypothesized that MetSyn is associated with impaired myocardial function, as assessed by STE.

Methods:

We analyzed Multi-Ethnic Study of Atherosclerosis (MESA) participants who underwent STE and were evaluated for all MetSyn components.

Results:

Among the 133 participants included [women: 63%; age: 65 ± 9 years (mean ± SD)], the prevalence of MetSyn was 31% (41/133). Individuals with MetSyn had lower ε_CC and lower ε_LL than those without MetSyn (-16.3% ± 3.5% vs. -18.4% ± 3.7%, p < 0.01; and -12.1% ± 2.5% vs. -13.9% ± 2.3%, p < 0.01, respectively). The LV ejection fraction (LVEF) was similar in both groups (p = 0.09). In multivariate analysis, MetSyn was associated with less circumferential myocardial shortening as indicated by less negative ε_CC (B = 2.1%, 95%CI:0.6 3.5, p < 0.01) even after adjusting for age, ethnicity, LV mass, and LVEF). Likewise, presence of MetSyn (B = 1.3%, 95%CI:0.3 2.2, p < 0.01) and LV mass (B = 0.02%, 95% CI: 0.01-0.03, p = 0.02) were significantly associated with less longitudinal myocardial shortening as indicated by less negative ε_LL after adjustment for ethnicity, LVEF, and creatinine.

Conclusion:

Left ventricular ε_CC and ε_LL, markers of subclinical cardiovascular disease, are impaired in asymptomatic individuals with MetSyn and no history of myocardial infarction, heart failure, and/or LVEF < 50%.

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Artigo Original

Excess Weight, Anthropometric Variables and Blood Pressure in Schoolchildren aged 10 to 18 years

Vânia Ames Schommer et al. Sandra Mari Barbiero Cláudia Ciceri Cesa Rosemary Oliveira … Anelise Damiani Silva Lucia Campos Pellanda

Background:

The prevalence of hypertension among children and adolescents is estimated to range between 1% and 13%. Excess weight and central obesity are related to blood pressure levels in adults, and may be important in the early pathogenesis of SH when present in childhood.

Objectives:

To study the association between anthropometric variables and blood pressure levels in schoolchildren from the 5^th and 8^th grades, and to identify which parameter was more strongly correlated with blood pressure levels.

Methods:

Contemporary cross-sectional study with probabilistic population-based cluster sampling of schoolchildren enrolled from the 5^th to the 8^th grades in public elementary schools of Porto Alegre. Data on familial risk factors and anthropometry were collected. Statistical analysis included correlations and cluster-adjusted confidence intervals.

Results:

The mean age of participants was 12.57 (± 1.64) years, and 55.2% of them were females. Abnormal blood pressure levels were found in 11.3% of the sample and borderline values, in 16.2%. Among the anthropometric variables analyzed, hip circumference was the one with the strongest correlation with increased blood pressure (r = 0.462, p < 0.001), followed by waist circumference (r = 0.404, p < 0.001) and abdominal skinfold (r = 0.291, p < 0.001).

Conclusion:

We observed an association of waist circumference and skinfolds with increased blood pressure levels in the schoolchildren of the sample. Therefore, it is of the utmost importance that early measurements of blood pressure, and waist and hip circumferences become a routine in health services in order to prevent this condition.

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Artigo Original

Use of Evidence-Based Interventions in Acute Coronary Syndrome – Subanalysis of the ACCEPT Registry

Ricardo Wang et al. Fernando Carvalho Neuenschwander Augusto Lima Filho Celsa Maria Moreira … Elizabete Silva dos Santos Helder Jose Lima Reis Edson Renato Romano Luiz Alberto Piva e Mattos Otávio Berwanger Jadelson Pinheiro de Andrade

Background:

The recommendations in guidelines are based on evidence; however, there is a gap between recommendations and clinical practice.

Objective:

To describe the practice of prescribing evidence-based treatments for patients with acute coronary syndrome in Brazil.

Methods:

This study carried out a subanalysis of the ACCEPT registry, assessing epidemiological data and the prescription rate of acetylsalicylic acid, p2y12 inhibitors, antithrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (IAT1RB), and statins. In addition, the quality of myocardial reperfusion in ST-segment elevation myocardial infarction was evaluated.

Results:

This study assessed 2,453 patients. The prescription rates of acetylsalicylic acid, p2y12 inhibitors, antithrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors/IAT1RB, and statins were as follows: in 24 hours – 97.6%, 89.5%, 89.1%, 80.2%, 67.9% and 90.6%; and at six months – 89.3%, 53.6%, 0%, 74.4%, 57.6% and 85.4%, respectively. Regarding ST-segment elevation myocardial infarction, only 35.9% and 25.3% of the patients underwent primary angioplasty and thrombolysis, respectively, within the recommended times.

Conclusion:

This registry showed high initial prescription rates of antiplatelet drugs, antithrombotic drugs, and statins, and lower prescription rates of beta-blockers and angiotensin-converting enzyme inhibitors/IAT1RB. Independently of the class, the use of all drugs decreased by six months. Most patients with ST-segment elevation myocardial infarction did not undergo myocardial reperfusion within the time recommended.

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Artigo Original

Renal Denervation Using an Irrigated Catheter in Patients with Resistant Hypertension: A Promising Strategy?

Luciana Armaganijan et al. Rodolfo Staico Aline Moraes Alexandre Abizaid … Dalmo Moreira Celso Amodeo Márcio Sousa Flávio Borelli Dikran Armaganijan J. Eduardo Sousa Amanda Sousa

Background:

Systemic hypertension is an important public health problem and a significant cause of cardiovascular mortality. Its high prevalence and the low rates of blood pressure control have resulted in the search for alternative therapeutic strategies. Percutaneous renal sympathetic denervation emerged as a perspective in the treatment of patients with resistant hypertension.

Objective:

To evaluate the feasibility and safety of renal denervation using an irrigated catheter.

Methods:

Ten patients with resistant hypertension underwent the procedure. The primary endpoint was safety, as assessed by periprocedural adverse events, renal function and renal vascular abnormalities at 6 months. The secondary endpoints were changes in blood pressure levels (office and ambulatory monitoring) and in the number of antihypertensive drugs at 6 months.

Results:

The mean age was 47.3 (± 12) years, and 90% of patients were women. In the first case, renal artery dissection occurred as a result of trauma due to the long sheath; no further cases were observed after technical adjustments, thus showing an effect of the learning curve. No cases of thrombosis/renal infarction or death were reported. Elevation of serum creatinine levels was not observed during follow-up. At 6 months, one case of significant renal artery stenosis with no clinical consequences was diagnosed. Renal denervation reduced office blood pressure levels by 14.6/6.6 mmHg, on average (p = 0.4 both for systolic and diastolic blood pressure). Blood pressure levels on ambulatory monitoring decreased by 28/17.6 mmHg (p = 0.02 and p = 0.07 for systolic and diastolic blood pressure, respectively). A mean reduction of 2.1 antihypertensive drugs was observed.

Conclusion:

Renal denervation is feasible and safe in the treatment of resistant systemic arterial hypertension. Larger studies are required to confirm our findings.

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Artigo Original

Alimentary Habits, Physical Activity, and Framingham Global Risk Score in Metabolic Syndrome

Thays Soliman Soares et al. Carla Haas Piovesan Andréia da Silva Gustavo Fabrício Edler Macagnan … Luiz Carlos Bodanese Ana Maria Pandolfo Feoli

Background:

Metabolic syndrome is a complex disorder represented by a set of cardiovascular risk factors. A healthy lifestyle is strongly related to improve Quality of Life and interfere positively in the control of risk factors presented in this condition.

Objective:

To evaluate the effect of a program of lifestyle modification on the Framingham General Cardiovascular Risk Profile in subjects diagnosed with metabolic syndrome.

Methods:

A sub-analysis study of a randomized clinical trial controlled blind that lasted three months. Participants were randomized into four groups: dietary intervention + placebo (DIP), dietary intervention + supplementation of omega 3 (fish oil 3 g/day) (DIS3), dietary intervention + placebo + physical activity (DIPE) and dietary intervention + physical activity + supplementation of omega 3 (DIS3PE). The general cardiovascular risk profile of each individual was calculated before and after the intervention.

Results:

The study included 70 subjects. Evaluating the score between the pre and post intervention yielded a significant value (p < 0.001). We obtained a reduction for intermediate risk in 25.7% of subjects. After intervention, there was a significant reduction (p < 0.01) on cardiovascular age, this being more significant in groups DIP (5.2%) and DIPE (5.3%).

Conclusion:

Proposed interventions produced beneficial effects for reducing cardiovascular risk score. This study emphasizes the importance of lifestyle modification in the prevention and treatment of cardiovascular diseases.

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Artigo Original

Duke Activity Status Index for Cardiovascular Diseases: Validation of the Portuguese Translation

Mariana A. Coutinho-Myrrha et al. Rosângela C. Dias Aline A. Fernandes Christiano G. Araújo … Mark A. Hlatky Danielle G. Pereira Raquel R. Britto

Background:

The Duke Activity Status Index (DASI) assesses the functional capacity of patients with cardiovascular disease (CVD), but there is no Portuguese version validated for CVD.

Objectives:

To translate and adapt cross-culturally the DASI for the Portuguese-Brazil language, and to verify its psychometric properties in the assessment of functional capacity of patients with CVD.

Methods:

The DASI was translated into Portuguese, then checked by back-translation into English and evaluated by an expert committee. The pre-test version was first evaluated in 30 subjects. The psychometric properties and correlation with exercise testing was performed in a second group of 67 subjects. An exploratory factor analyses was performed in all 97 subjects to verify the construct validity of the DASI.

Results:

The intraclass correlation coefficient for test-retest reliability was 0.87 and for the inter-rater reliability was 0.84. Cronbach’s α for internal consistency was 0.93. The concurrent validity was verified by significant positive correlations of DASI scores with the VO₂max (r = 0.51, p < 0.001). The factor analysis yielded two factors, which explained 54% of the total variance, with factor 1 accounting for 40% of the variance. Application of the DASI required between one and three and a half minutes per patient.

Conclusions:

The Brazilian version of the DASI appears to be a valid, reliable, fast and easy to administer tool to assess functional capacity among patients with CVD.

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Artigo Original

Construction and Validation of a Questionnaire about Heart Failure Patients' Knowledge of Their Disease

Christiani Decker Batista Bonin et al. Rafaella Zulianello dos Santos Gabriela Lima de Melo Ghisi Ariany Marques Vieira … Ricardo Amboni Magnus Benetti

Background:

The lack of tools to measure heart failure patients’ knowledge about their syndrome when participating in rehabilitation programs demonstrates the need for specific recommendations regarding the amount or content of information required.

Objectives:

To develop and validate a questionnaire to assess heart failure patients’ knowledge about their syndrome when participating in cardiac rehabilitation programs.

Methods:

The tool was developed based on the Coronary Artery Disease Education Questionnaire and applied to 96 patients with heart failure, with a mean age of 60.22 ± 11.6 years, 64% being men. Reproducibility was obtained via the intraclass correlation coefficient, using the test-retest method. Internal consistency was assessed by use of Cronbach’s alpha, and construct validity, by use of exploratory factor analysis.

Results:

The final version of the tool had 19 questions arranged in ten areas of importance for patient education. The proposed questionnaire had a clarity index of 8.94 ± 0.83. The intraclass correlation coefficient was 0.856, and Cronbach’s alpha, 0.749. Factor analysis revealed five factors associated with the knowledge areas. Comparing the final scores with the characteristics of the population evidenced that low educational level and low income are significantly associated with low levels of knowledge.

Conclusion:

The instrument has satisfactory clarity and validity indices, and can be used to assess the heart failure patients’ knowledge about their syndrome when participating in cardiac rehabilitation programs.

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Review Article

Cardiac Mechanics Evaluated by Speckle Tracking Echocardiography

Maria Cristina Donadio Abduch et al. Adriano Mesquita Alencar Wilson Mathias Jr. Marcelo Luiz de Campos Vieira

Natural myocardial markers, or speckles, originated from constructive and destructive interference of ultrasound in the tissues may provide early diagnosis of myocardial changes and be used in the prediction of some cardiac events. Due to its relatively temporal stability, speckles can be tracked by dedicated software along the cardiac cycle, enabling the analysis of the systolic and diastolic function. They are identified by either conventional 2D grey scale and by 3D echo, conferring independence of the insonation angle, thus allowing assessment of cardiac mechanics in the three spatial planes: longitudinal, circumferential, and radial. The purposes of the present paper are: to discuss the role and the meaning of cardiac strain obtained by speckle tracking during the evaluation of cardiac physiology and to discuss clinical applications of this novel echocardiographic technology.

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