2015;104(3) – ABC CARDIOL

ABC

ABC Family | ABC

Viewpoint

The New Faces of Medicine – a Journey and a Perspective

Professor Protásio da Luz, basic science and clinical researcher and renowned cardiologist, offers us his newest book The New Faces of Medicine. It is a presentation of his vision of the scientific and humanistic bases of medicine, its evolution and its future.

With expressive illustrations, the book presents us with the importance of the connection of technique with the human, of science with the relationship of physicians and patients. “It’s not the anamnesis yet. It’s just the first approach to know the person.” This seemingly trivial sentence contains deep wisdom and experience of the professional and professor of medicine practicing one of the major goals of the university: to propagate knowledge for improvement of students and physicians in general.

[…]

Read Full Article

Case Report

Left Ventricular Assist Device Followed by Heart Transplantation

Bruno Biselli et al. Silvia Moreira Ayub-Ferreira Monica Samuel Avila Fábio Antonio Gaiotto … Fabio Biscegli Jatene Edimar Alcides Bocchi

Introduction

Heart failure (HF) is the major cause of cardiovascular hospitalization in Brazil. It is estimated that approximately 1%–2% of the population present with HF and 50% of these individuals have a decreased ejection fraction.

In the last 30 years, despite the substantial improvement in the treatment of chronic HF, the quality of life and survival rates of affected patients are limited. In addition, most of these patients are refractory to standard treatment and hospitalization, and rates of death or rehospitalization within 6 months are approximately 50%.

[…]

Read Full Article

Letter to the Editor

Subclinical Atherosclerosis in Patients with Chronic Non-Dialytic Renal Disease

Wagner Ramos Borges et al. Roque Aras Junior João Lima

Cardiovascular diseases are currently the major cause of morbidity and mortality. Atherosclerosis alone is their most important cause and is characterized by a progressive multifactorial disease caused by genetic and acquired factors such as lipid accumulation, development of fibrosis and artery obstruction. The risk among patients with chronic renal failure (CRF) is higher than that among the general population, with a high prevalence of coronary artery disease (40%) and mortality from 10 to 20 times higher, especially among those in a hemodialysis program, accounting for 50% of deaths in dialytic patients^,. Investigation and assessment of subclinical atherosclerosis using imaging methods (calcium score in coronary CT scan, ultrasonography or angiography) may be used to identify and stratify the atherosclerotic risk, considering that the atherosclerotic plaque burden correlates with the risk of coronary events, especially in patients with chronic dialytic renal failure.

Measurement of the myointimal thickness is a safe, low-cost, easy-access method to identify patients with subclinical or obstructive disease. Groot et al. showed that myointimal thickness of up to 0.8 mm could be considered normal, and higher values would characterize early stages of arterial wall thickening. In patients with non-dialytic CRF, there is a high prevalence of myointimal thickening in the different age ranges, thus showing an active process of subclinical atherosclerosis. However, the lack of a standard reference table for the Brazilian population is a limitation for inferences.

[…]

Read Full Article

Correlação Clínico-Radiográfica

Case 3/2015 A 32-year-old Female Patient with Coarctation of the Aorta, Bicuspid Aortic Valve and Dilatation of the Ascending Aorta

Edmar Atik et al. Raul Arrieta Roberto Kalil Filho

Laboratory tests

Electrocardiogram showed normal sinus rhythm with no signs of chamber overload. The Sokolow index was 34 mm and there was no ventricular repolarization abnormalities. PA: +60º; QRSA: +70º; TA: +40º.

Chest radiograph showed normal cardiac silhouette (cardiothoracic ratio of 0.47). The pulmonary vascular network was normal and the arch of the pulmonary artery was concave. The right upper arch was elongated, suggesting dilatation of the ascending aorta (AscAo). The posterior aortic arch was somewhat prominent and the descending aorta (DescAo) was dilated. Hyperdensity was observed in some ribs ().

[…]

Read Full Article

Editorial

Adib Domingos Jatene, 1929-2014

Or simply Adib to me, was born in Xapuri (AC). At birth, a voice (that of God!) made itself heard in the following words: “Maktub: this newborn will distinguish himself among many and, like few others, will know how to lead himself and lead those who seek him. The work that will be imposed will be twice the common, and his dynamism, his reputation and his intelligence will take him to the pinnacle of glory.”

Adib was born of Lebanese parents; his father, a merchant, who traded with rubber tappers, died of yellow fever when Adib was two years old.

[…]

Read Full Article

Image

Reel Syndrome: an Unusual Complication of Cardiac Pacemaker Implantation

Salvador Alandete Germán et al. Ronny Rodelo Haad

A 67-year-old woman who underwent pacemaker implantation 4 days ago (A) consulted the emergency department with complaints of perception of muscle contractions on the right side of her chest. She did not have chest pain, dyspnea, or palpitations. Physical examination did not reveal any relevant findings. Electrocardiogram showed an absence of sensing or stimulation of the right atrium and right ventricle. Chest X-ray showed the displacement of the leads into the right atrium and the superior vena cava (B). Thus, she was referred to the cardiology department for lead repositioning.

A few months later, the patient presented with the same symptoms. A repeat chest X-ray showed a similar displacement of both the leads (C).

[…]

Read Full Article

Brief Communication

Electrical Properties of Isolated Cardiomyocytes in a Rat Model of Thiamine Deficiency

Artur Santos-Miranda et al. Jader Santos Cruz Danilo Roman-Campos

In modern society, thiamine deficiency (TD) remains an important medical condition linked to altered cardiac function. There have been contradictory reports about the impact of TD on heart physiology, especially in the context of cardiac excitability. In order to address this particular question, we used a TD rat model and patch-clamp technique to investigate the electrical properties of isolated cardiomyocytes from epicardium and endocardium. Neither cell type showed substantial differences on the action potential waveform and transient outward potassium current. Based on our results we can conclude that TD does not induce major electrical remodeling in isolated cardiac myocytes in either endocardium or epicardium cells.

Read Full Article

Revisão

Hypertension in Patients with Cancer

Vinicius Barbosa de Souza et al. Eduardo Nani Silva Mario Luiz Ribeiro Wolney de Andrade Martins

There is a known association between chemotherapy and radiotherapy for treatment of cancer patients and development or worsening of hypertension. The aim of this article is to review this association. A literature search was conducted for articles reporting this association on the databases PubMed, SciELO and LILACS between 1993 and 2013. There was a high coprevalence of hypertension and cancer, since both diseases share the same risk factors, such as sedentary lifestyle, obesity, smoking, unhealthy diet and alcohol abuse. The use of chemotherapy and adjuvant drugs effective in the treatment of cancer increased the survival rate of these patients and, consequently, increased the incidence of hypertension. We described the association between the use of angiogenesis inhibitors (bevacizumab, sorafenib and sunitinib), corticosteroids, erythropoietin and non-steroidal anti-inflammatory drugs with the development of hypertension. We also described the relationship between hypertension and carotid baroreceptor injury secondary to cervical radiotherapy. Morbidity and mortality increased in patients with cancer and hypertension without proper antihypertensive treatment. We concluded that there is need for early diagnosis, effective monitoring and treatment strategies for hypertension in cancer patients in order to reduce cardiovascular morbidity and mortality.

Read Full Article

Original Article

Chronic Stress Improves NO- and Ca2+ Flux-Dependent Vascular Function: A Pharmacological Study

Thiago Bruder-Nascimento et al. Dijon Henrique Salome Campos Antônio Carlose Cicogna

Background:

Stress is associated with cardiovascular diseases.

Objective:

This study aimed at assessing whether chronic stress induces vascular alterations, and whether these modulations are nitric oxide (NO) and Ca2+ dependent.

Methods:

Wistar rats, 30 days of age, were separated into 2 groups: control (C) and Stress (St). Chronic stress consisted of immobilization for 1 hour/day, 5 days/week, 15 weeks. Systolic blood pressure was assessed. Vascular studies on aortic rings were performed. Concentration-effect curves were built for noradrenaline, in the presence of L-NAME or prazosin, acetylcholine, sodium nitroprusside and KCl. In addition, Ca²⁺ flux was also evaluated.

Results:

Chronic stress induced hypertension, decreased the vascular response to KCl and to noradrenaline, and increased the vascular response to acetylcholine. L-NAME blunted the difference observed in noradrenaline curves. Furthermore, contractile response to Ca²⁺ was decreased in the aorta of stressed rats.

Conclusion:

Our data suggest that the vascular response to chronic stress is an adaptation to its deleterious effects, such as hypertension. In addition, this adaptation is NO- and Ca²⁺-dependent. These data help to clarify the contribution of stress to cardiovascular abnormalities. However, further studies are necessary to better elucidate the mechanisms involved in the cardiovascular dysfunction associated with stressors. (Arq Bras Cardiol. 2014; [online].ahead print, PP.0-0)

Read Full Article

Original Article

Right Ventricular Doppler Echocardiographic Study of Indeterminate Form of Chagas Disease

Rogério Gomes Furtado et al. Daniela do Carmo Rassi Frota João Batista Masson Silva Minna Moreira Dias Romano … Oswaldo César de Almeida Filho André Schmidt Salvador Rassi

Background:

Patients with indeterminate form of Chagas disease/cardiac normality (ICD/CN) exhibited normal electrocardiograms and chest X-rays; however, more sophisticated tests detected some degree of morphological and functional changes in the heart.

Objective:

To assess the prevalence of systolic and diastolic dysfunction of the right ventricle (RV) in patients with ICD/CN.

Methods:

This was a case–control and prevalence study. Using Doppler two-dimensional echocardiography (2D), 92 patients were assessed and divided into two groups: group I (normal, n = 31) and group II (ICD/CN, n = 61).

Results:

The prevalence of RV systolic dysfunction in patients in groups I and II was as follows: fractional area change (0.0% versus 0.6%), mobility of the tricuspid annulus (0.0% versus 0.0%), and S-wave tissue Doppler (6.4% versus 26.0%, p = 0.016). The prevalence of global disorders such as the right myocardial performance index using tissue Doppler (16.1% versus 27.8%, p = 0.099) and pulsed Doppler (61.3% versus 68%, p = 0.141) and diastolic disorders such as abnormal relaxation (0.0% versus 6.0%), pseudonormal pattern (0.0% versus 0.0%), and restrictive pattern (0.0% versus 0.0%) was not statistically different between groups.

Conclusion:

The prevalence of RV systolic dysfunction was estimated to be 26% (S wave velocity compared with other variables), suggesting incipient changes in RV systolic function in the ICD/CN group.

Read Full Article

Original Article

Role of microRNAs 221/222 on Statin Induced Nitric Oxide Release in Human Endothelial Cells

Alvaro Cerda et al. Cristina Moreno Fajardo Rodrigo Gouveia Basso Mario Hiroyuki Hirata Rosario Dominguez Crespo Hirata

Background:

Nitric oxide (NO) has been largely associated with cardiovascular protection through improvement of endothelial function. Recently, new evidence about modulation of NO release by microRNAs (miRs) has been reported, which could be involved with statin-dependent pleiotropic effects, including anti-inflammatory properties related to vascular endothelium function.

Objective:

To evaluate the effects of cholesterol-lowering drugs including the inhibitors of cholesterol synthesis, atorvastatin and simvastatin, and the inhibitor of cholesterol absorption ezetimibe on NO release, NOS3 mRNA expression and miRs potentially involved in NO bioavailability.

Methods:

Human umbilical vein endothelial cells (HUVEC) were exposed to atorvastatin, simvastatin or ezetimibe (0 to 5.0 μM). Cells were submitted to total RNA extraction and relative quantification of NOS3 mRNA and miRs -221, -222 and -1303 by qPCR. NO release was measured in supernatants by ozone-chemiluminescence.

Results:

Both statins increased NO levels and NOS3 mRNA expression but no influence was observed for ezetimibe treatment. Atorvastatin, simvastatin and ezetimibe down-regulated the expression of miR-221, whereas miR-222 was reduced only after the atorvastatin treatment. The magnitude of the reduction of miR-221 and miR-222 after treatment with statins correlated with the increment in NOS3 mRNA levels. No influence was observed on the miR-1303 expression after treatments.

Conclusion:

NO release in endothelial cells is increased by statins but not by the inhibitor of cholesterol absorption, ezetimibe. Our results provide new evidence about the participation of regulatory miRs 221/222 on NO release induction mediated by statins. Although ezetimibe did not modulate NO levels, the down-regulation of miR-221 could involve potential effects on endothelial function.

Read Full Article

Original Article

Prevalence of Burnout Syndrome in Patients Admitted with Acute Coronary Syndrome

Ana Cláudia Giaxa Prosdócimo et al. Luciane Boreki Lucina Olandoski Marcia Priscila Megda João Jobs … Nicolle Amboni Schio Fernanda Fachin Baldanzi Costantino Ortiz Costantini Ana Maria Teresa Benevides-Pereira Luiz Cesar Guarita-Souza José Rocha Faria-Neto

Background:

Burnout Syndrome is the extreme emotional response to chronic occupational stress, manifesting as physical and mental exhaustion. Although associated with higher prevalence of cardiovascular risk factors, no study so far has evaluated whether the Burnout Syndrome could be a prevalent factor in non-elderly individuals active in the labor market, admitted for acute coronary syndrome (ACS).

Objective:

To evaluate the prevalence of the Burnout Syndrome in non-elderly, economically active patients, hospitalized with ACS.

Methods:

Cross-sectional study conducted in a tertiary and private cardiology center, with economically active patients aged <65 years, hospitalized with diagnosis of ACS. The Burnout Syndrome was evaluated with the Burnout Syndrome Inventory (BSI), which assesses workplace conditions and four dimensions that characterize the syndrome: emotional exhaustion (EE), emotional distancing (EmD), dehumanization (De) and professional fulfillment (PF). The Lipp’s Stress Symptoms Inventory for Adults (LSSI) was applied to evaluate global stress.

Results:

Of 830 patients evaluated with suspected ACS, 170 met the study criteria, 90% of which were men, overall average age was 52 years, and 40.5% had an average income above 11 minimum wages. The prevalence of the Burnout Syndrome was 4.1%. When we evaluated each dimension individually, we found high EE in 34.7%, high De in 52.4%, high EDi in 30.6%, and low PF in 5.9%. The overall prevalence of stress was 87.5%.

Conclusion:

We found a low prevalence of Burnout Syndrome in an economically active, non-elderly population among patients admitted for ACS in a tertiary and private hospital.

Read Full Article

Original Article

Hypotensive Response Magnitude and Duration in Hypertensives: Continuous and Interval Exercise

Raphael Santos Teodoro de Carvalho et al. Cássio Mascarenhas Robert Pires Gustavo Cardoso Junqueira Dayana Freitas Leila Maria Marchi-Alves

Background:

Although exercise training is known to promote post-exercise hypotension, there is currently no consistent argument about the effects of manipulating its various components (intensity, duration, rest periods, types of exercise, training methods) on the magnitude and duration of hypotensive response.

Objective:

To compare the effect of continuous and interval exercises on hypotensive response magnitude and duration in hypertensive patients by using ambulatory blood pressure monitoring (ABPM).

Methods:

The sample consisted of 20 elderly hypertensives. Each participant underwent three ABPM sessions: one control ABPM, without exercise; one ABPM after continuous exercise; and one ABPM after interval exercise. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and double product (DP) were monitored to check post-exercise hypotension and for comparison between each ABPM.

Results:

ABPM after continuous exercise and after interval exercise showed post-exercise hypotension and a significant reduction (p < 0.05) in SBP, DBP, MAP and DP for 20 hours as compared with control ABPM. Comparing ABPM after continuous and ABPM after interval exercise, a significant reduction (p < 0.05) in SBP, DBP, MAP and DP was observed in the latter.

Conclusion:

Continuous and interval exercise trainings promote post-exercise hypotension with reduction in SBP, DBP, MAP and DP in the 20 hours following exercise. Interval exercise training causes greater post-exercise hypotension and lower cardiovascular overload as compared with continuous exercise.

Read Full Article

Original Article

Correlation between C-Reactive Protein in Peripheral Vein and Coronary Sinus in Stable and Unstable Angina

Weverton Ferreira Leite et al. José Antonio Franchini Ramires Luiz Felipe Pinho Moreira Célia Maria Cassaro Strunz José Armando Mangione

Background:

High sensitivity C-reactive protein (hs-CRP) is commonly used in clinical practice to assess cardiovascular risk. However, a correlation has not yet been established between the absolute levels of peripheral and central hs-CRP.

Objective:

To assess the correlation between serum hs-CRP levels (mg/L) in a peripheral vein in the left forearm (LFPV) with those in the coronary sinus (CS) of patients with coronary artery disease (CAD) and a diagnosis of stable angina (SA) or unstable angina (UA).

Methods:

This observational, descriptive, and cross-sectional study was conducted at the Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, and at the Hospital Beneficência Portuguesa de Sao Paulo, where CAD patients referred to the hospital for coronary angiography were evaluated.

Results:

Forty patients with CAD (20 with SA and 20 with UA) were included in the study. Blood samples from LFPV and CS were collected before coronary angiography. Furthermore, analysis of the correlation between serum levels of hs-CRP in LFPV versus CS showed a strong linear correlation for both SA (r = 0.993, p < 0.001) and UA (r = 0.976, p < 0.001) and for the entire sample (r = 0.985, p < 0.001).

Conclusion:

Our data suggest a strong linear correlation between hs-CRP levels in LFPV versus CS in patients with SA and UA.

Read Full Article

Original Article

Serum Potassium Levels Inversely Correlate with D-Dimer In Patients with Acute-Onset Atrial Fibrillation

Gianfranco Cervellin et al. Laura Bonfanti Alessandra Picanza Giuseppe Lippi

Background:

D-dimer values are frequently increased in patients with atrial fibrillation (AF) compared to subjects in sinus rhythm. Hypokalemia plays a role in several cardiovascular diseases, but little is known about the association with AF.

Objective:

D-dimer values are frequently increased in patients with atrial fibrillation (AF) compared with subjects in sinus rhythm. Hypokalemia plays a role in several cardiovascular diseases, but little is known about the association with AF. The aim of this study was to investigate correlations between D-dimer and serum potassium in acute-onset AF (AAF).

Methods:

To investigate the potential correlation between the values of serum potassium and D-dimer in patients with AAF, we retrospectively reviewed clinical and laboratory data of all emergency department visits for AAF in 2013.

Results:

Among 271 consecutive AAF patients with D-dimer assessments, those with hypokalemia (n = 98) had significantly higher D-dimer values than normokalemic patients (139 versus 114 ng/mL, p = 0.004). The rate of patients with D-dimer values exceeding the diagnostic cut-off was higher in the group of patients with hypokalemia than in those with normal serum potassium (26.5% versus 16.2%; p = 0.029). An inverse and highly significant correlation was found between serum potassium and D-dimer (r = −0.21; p < 0.001), even after adjustments for age and sex (beta coefficient −94.8; p = 0.001). The relative risk for a positive D-dimer value attributed to hypokalemia was 1.64 (95% CI, 1.02 to 2.63; p = 0.040). The correlation remained statistically significant in patients free from antihypertensive drugs (r = −0.25; p = 0.018), but not in those taking angiotensin-receptor blockers, angiotensin-converting enzyme inhibitors, or diuretics.

Conclusions:

The inverse correlation between values of potassium and D-dimer in patients with AAF provides important and complementary information about the thromboembolic risk of these patients.

Read Full Article

Original Article

Vascular Response of Ruthenium Tetraamines in Aortic Ring from Normotensive Rats

Ana Gabriela Conceição-Vertamatti et al. Luiz Alberto Ferreira Ramos Ivy Calandreli Aline Nunes Chiba … Douglas Wagner Franco Elia Tfouni Dora Maria Grassi-Kassisse

Background:

Ruthenium (Ru) tetraamines are being increasingly used as nitric oxide (NO) carriers. In this context, pharmacological studies have become highly relevant to better understand the mechanism of action involved.

Objective:

To evaluate the vascular response of the tetraamines trans-[Ru^II(NH₃)₄(Py)(NO)]³⁺, trans-[Ru^II(Cl)(NO) (cyclan)](PF₆)₂, and trans-[Ru^II(NH₃)₄(4-acPy)(NO)]³⁺.

Methods:

Aortic rings were contracted with noradrenaline (10⁻⁶ M). After voltage stabilization, a single concentration (10⁻⁶ M) of the compounds was added to the assay medium. The responses were recorded during 120 min. Vascular integrity was assessed functionally using acetylcholine at 10⁻⁶ M and sodium nitroprusside at 10⁻⁶ M as well as by histological examination.

Results:

Histological analysis confirmed the presence or absence of endothelial cells in those tissues. All tetraamine complexes altered the contractile response induced by norepinephrine, resulting in increased tone followed by relaxation. In rings with endothelium, the inhibition of endothelial NO caused a reduction of the contractile effect caused by pyridine NO. No significant responses were observed in rings with endothelium after treatment with cyclan NO. In contrast, in rings without endothelium, the inhibition of guanylate cyclase significantly reduced the contractile response caused by the pyridine NO and cyclan NO complexes, and both complexes caused a relaxing effect.

Conclusion:

The results indicate that the vascular effect of the evaluated complexes involved a decrease in the vascular tone induced by norepinephrine (10⁻⁶ M) at the end of the incubation period in aortic rings with and without endothelium, indicating the slow release of NO from these complexes and suggesting that the ligands promoted chemical stability to the molecule. Moreover, we demonstrated that the association of Ru with NO is more stable when the ligands pyridine and cyclan are used in the formulation of the compound.

Read Full Article