2015;104(4) – ABC CARDIOL

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Incremental Value Of 3D Transesophageal Echocardiography for The Assessment of Mitral Valve Prolapse

Viviane Tiemi Hotta et al. Mirian Magalhães Pardi Valdir Ambrósio Moisés

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Case Report

Sickle-cell Anemia and Latent Diastolic Dysfunction: Echocardiographic Alterations

André Fattori et al. Daniela Camargo Oliveira Roger Frigério Castilho Otávio Rizzi Coelho

Introduction

Sickle-cell anemia (SCA) is a disease that can cause systemic complications, such as multiple organ dysfunction due to vaso-occlusion and endothelial activation. The genetic cause of the disease is a substitution of the amino acid glutamic acid for valine in the position 6 of the beta globin chain. Stress factors in the vascular microenvironment (cellular dehydration, hypoxemia, increased corpuscular hemoglobin concentration, decreased red blood cell transit time in the microcirculation, and decreased blood pH) trigger intracellular hemoglobin polymerization, forming paracrystalline structures that cause sickling of erythrocytes and increased blood viscosity, hemolysis, and vaso-occlusion^,. Simultaneously, free hemoglobin in the plasma sequesters nitric oxide (NO), leading to decreased NO bioavailability and increased endothelial adhesion (in physiological conditions, NO inhibits of platelet aggregation, platelet activation, transcription of platelet adhesion proteins).

The increase in cardiac output (CO), the afterload reduction due to the peripheral vasodilation as a response to hypoxemia, the increase in blood viscosity secondary to the morphological alterations, and the loss of the deformability of the sickle red blood cells are factors involved with the systolic ventricular overload and progressive enlargement of the cardiac chambers^–.

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Viewpoint

Correct Anatomical Orientation of the Heart and Reflections on the Nomenclature Used in Daily Practice

Viviane Tiemi Hotta et al. Vera Demarchi Aiello

Closing remarks

This study does not intend to exhaust the subject nor recommend an immediate change in the current nomenclature. It aims to acknowledge and educate the reader about the frequent use of terms that are not completely adequate in describing the cardiac morphology evaluated with different imaging techniques. The nomenclature based on the correct anatomical orientation significantly facilitates the spatial location of the cardiac structures and the relationship of the heart with the other organs. It also allows the exchange and comparison of information between different imaging techniques and guides diagnostic and therapeutic procedures, e.g., in electrophysiology or multimodal examination.

However, the adoption of changes in nomenclature already established by usage will require increased user awareness and recognition of the need for change and efforts towards the implementation and acceptance of these changes.

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Letter to the Editor

Left Atrial Volume Index as Predictor of Events in Acute Coronary Syndrome

Luciano Barros Pires et al. Rodrigo Pires dos Santos

Dear Editor,

The Left Atrial Volume Index (LAVi) is a measurement that has gained importance in daily clinical practice due to evidence of its capacity to predict mortality, in patients followed after an Acute Myocardial Infarction (AMI), as well as in the general population.

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Clinicoradiological Session

Case 4/2015 A 48-year-old Male Patient with Coarctation of the Aorta, Bicuspid Aortic Valve and Normal Ascending Aorta

Edmar Atik et al. Raul Arrieta Otávio Rizzi Coelho

Laboratory tests

Electrocardiogram: Normal sinus rhythm, no chamber overload. Sokoloff index = 20 mm; mild ventricular repolarization abnormality. Left anterior hemiblock and septal fibrosis. PA: +60º; QRSA: -45º; TA: +100º ().

Chest radiograph: Normal cardiac silhouette (cardiothoracic ratio: 0.48). Normal pulmonary vascular network and concave arch of pulmonary artery. The posterior aortic arch was not bulged; hyperdensity in some rib borders ().

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Original Article

Quality of Life on Arterial Hypertension: Validity of Known Groups of MINICHAL

Ana Lúcia Soares Soutello et al. Roberta Cunha Matheus Rodrigues Fernanda Freire Jannuzzi Thaís Moreira São-João … Gabriela Giordano Martinix Wilson Nadruz Jr. Maria-Cecília Bueno Jayme Gallani

Introductions:

In the care of hypertension, it is important that health professionals possess available tools that allow evaluating the impairment of the health-related quality of life, according to the severity of hypertension and the risk for cardiovascular events. Among the instruments developed for the assessment of health-related quality of life, there is the Mini-Cuestionario of Calidad de Vida en la Hipertensión Arterial (MINICHAL) recently adapted to the Brazilian culture.

Objective:

To estimate the validity of known groups of the Brazilian version of the MINICHAL regarding the classification of risk for cardiovascular events, symptoms, severity of dyspnea and target-organ damage.

Methods:

Data of 200 hypertensive outpatients concerning sociodemographic and clinical information and health-related quality of life were gathered by consulting the medical charts and the application of the Brazilian version of MINICHAL. The Mann-Whitney test was used to compare health-related quality of life in relation to symptoms and target-organ damage. The Kruskal-Wallis test and ANOVA with ranks transformation were used to compare health-related quality of life in relation to the classification of risk for cardiovascular events and intensity of dyspnea, respectively.

Results:

The MINICHAL was able to discriminate health-related quality of life in relation to symptoms and kidney damage, but did not discriminate health-related quality of life in relation to the classification of risk for cardiovascular events.

Conclusion:

The Brazilian version of the MINICHAL is a questionnaire capable of discriminating differences on the health‑related quality of life regarding dyspnea, chest pain, palpitation, lipothymy, cephalea and renal damage.

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Original Article

Blood Pressure Variation Throughout Pregnancy According to Early Gestational BMI: A Brazilian Cohort

Fernanda Rebelo et al. Dayana Rodrigues Farias Roberta Hack Mendes Michael Maia Schlüssel Gilberto Kac

Background:

The maternal cardiovascular system undergoes progressive adaptations throughout pregnancy, causing blood pressure fluctuations. However, no consensus has been established on its normal variation in uncomplicated pregnancies.

Objective:

To describe the variation in systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels during pregnancy according to early pregnancy body mass index (BMI).

Methods:

SBP and DBP were measured during the first, second and third trimesters and at 30-45 days postpartum in a prospective cohort of 189 women aged 20-40 years. BMI (kg/m²) was measured up to the 13th gestational week and classified as normal-weight (<25.0) or excessive weight (≥25.0). Longitudinal linear mixed-effects models were used for statistical analysis.

Results:

A decrease in SBP and DBP was observed from the first to the second trimester (β_SBP=-0.394; 95%CI: -0.600- -0.188 and β_DBP=-0.617; 95%CI: -0.780- -0.454), as was an increase in SBP and DBP up to 30-45 postpartum days (β_SBP=0.010; 95%CI: 0.006-0.014 and β_DBP=0.015; 95%CI: 0.012-0.018). Women with excessive weight at early pregnancy showed higher mean SBP in all gestational trimesters, and higher mean DBP in the first and third trimesters. Excessive early pregnancy BMI was positively associated with prospective changes in SBP (β_SBP=7.055; 95%CI: 4.499-9.610) and in DBP (β_DBP=3.201; 95%CI: 1.136-5.266).

Conclusion:

SBP and DBP decreased from the first to the second trimester and then increased up to the postpartum period. Women with excessive early pregnancy BMI had higher SBP and DBP than their normal-weight counterparts throughout pregnancy, but not in the postpartum period.

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Review Article

Treatment of Dyslipidemia with Statins and Physical Exercises: Recent Findings of Skeletal Muscle Responses

Mariana Rotta Bonfim et al. Acary Souza Bulle Oliveira Sandra Lia do Amaral Henrique Luiz Monteiro

Statin treatment in association with physical exercise practice can substantially reduce cardiovascular mortality risk of dyslipidemic individuals, but this practice is associated with myopathic event exacerbation. This study aimed to present the most recent results of specific literature about the effects of statins and its association with physical exercise on skeletal musculature. Thus, a literature review was performed using PubMed and SciELO databases, through the combination of the keywords “statin” AND “exercise” AND “muscle”, restricting the selection to original studies published between January 1990 and November 2013. Sixteen studies evaluating the effects of statins in association with acute or chronic exercises on skeletal muscle were analyzed. Study results indicate that athletes using statins can experience deleterious effects on skeletal muscle, as the exacerbation of skeletal muscle injuries are more frequent with intense training or acute eccentric and strenuous exercises. Moderate physical training, in turn, when associated to statins does not increase creatine kinase levels or pain reports, but improves muscle and metabolic functions as a consequence of training. Therefore, it is suggested that dyslipidemic patients undergoing statin treatment should be exposed to moderate aerobic training in combination to resistance exercises three times a week, and the provision of physical training prior to drug administration is desirable, whenever possible.

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Original Article

Progression of Blood Pressure and Cardiovascular Outcomes in Hypertensive Patients in a Reference Center

Gilberto Campos Guimarães Filho et al. Ana Luiza Lima Sousa Thiago de Souza Veiga Jardim Weimar Sebba Barroso Souza Paulo César Brandão Veiga Jardim

Background:

Hypertension is a public health problem, considering its high prevalence, low control rate and cardiovascular complications.

Objective:

Evaluate the control of blood pressure (BP) and cardiovascular outcomes in patients enrolled at the Reference Center for Hypertension and Diabetes, located in a medium-sized city in the Midwest Region of Brazil.

Methods:

Population-based study comparing patients enrolled in the service at the time of their admission and after an average follow-up of five years. Participants were aged ≥18 years and were regularly monitored at the Center up to 6 months before data collection. We assessed demographic variables, BP, body mass index, risk factors, and cardiovascular outcomes.

Results:

We studied 1,298 individuals, predominantly women (60.9%), and with mean age of 56.7±13.1 years. Over time, there was a significant increase in physical inactivity, alcohol consumption, diabetes, dyslipidemia, and excessive weight. As for cardiovascular outcomes, we observed an increase in stroke and myocardial revascularization, and a lower frequency of chronic renal failure. During follow-up, there was significant improvement in the rate of BP control (from 29.6% to 39.6%; p = 0.001) and 72 deaths, 91.7% of which were due to cardiovascular diseases.

Conclusion:

Despite considerable improvements in the rate of BP control during follow-up, risk factors worsened and cardiovascular outcomes increased.

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Original Article

Subclinical Ventricular Dysfunction Detected by Speckle Tracking Two Years after Use of Anthracycline

André Luiz Cerqueira de Almeida et al. Viviane Almeida Silva Alberto Teófilo de Souza Filho Vinicius Guedes Rios … João Ricardo Pinto Lopes Samuel Oliveira de Afonseca Daniel de Castro Araújo Cunha Murilo Oliveira da Cunha Mendes Danilo Leal Miranda Edval Gomes dos Santos Júnior

Background:

Heart failure is a severe complication associated with doxorubicin (DOX) use. Strain, assessed by two-dimensional speckle tracking (2D-STE), has been shown to be useful in identifying subclinical ventricular dysfunction.

Objectives:

a) To investigate the role of strain in the identification of subclinical ventricular dysfunction in patients who used DOX; b) to investigate determinants of strain response in these patients.

Methods:

Cross-sectional study with 81 participants: 40 patients who used DOX ±2 years before the study and 41 controls. All participants had left ventricular ejection fraction (LVEF) ≥55%. Total dose of DOX was 396mg (242mg/ms²). The systolic function of the LV was evaluated by LVEF (Simpson), as well as by longitudinal (ε_LL), circumferential (ε_CC), and radial (ε_RR) strains. Multivariate linear regression (MLR) analysis was performed using ε_LL (model 1) and ε_CC (model 2) as dependent variables.

Results:

Systolic and diastolic blood pressure values were higher in the control group (p < 0.05). ε_LL was lower in the DOX group (-12.4 ±2.6%) versus controls (-13.4 ± 1.7%; p = 0.044). The same occurred with ε_CC: -12.1 ± 2.7% (DOX) versus -16.7 ± 3.6% (controls; p < 0.001). The S’ wave was shorter in the DOX group (p = 0.035). On MLR, DOX was an independent predictor of reduced ε_CC (B = -4.429, p < 0.001). DOX (B = -1.289, p = 0.012) and age (B = -0.057, p = 0.029) were independent markers of reduced ε_LL.

Conclusion:

a) ε_LL, ε_CC and the S’ wave are reduced in patients who used DOX ±2 years prior to the study despite normal LVEF, suggesting the presence of subclinical ventricular dysfunction; b) DOX was an independent predictor of reduced ε_CC; c) prior use of DOX and age were independent markers of reduced ε_LL.

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Original Article

Comparison between MDCT and Grayscale IVUS in a Quantitative Analysis of Coronary Lumen in Segments with or without Atherosclerotic Plaques

João L. A. A. Falcão et al. Breno A. A. Falcão Swaminatha V Gurudevan Carlos M. Campos … Expedito R. Silva Roberto Kalil-Filho Carlos E. Rochitte Afonso A. Shiozaki Otavio R. Coelho-Filho Pedro A. Lemos

Background:

The diagnostic accuracy of 64-slice MDCT in comparison with IVUS has been poorly described and is mainly restricted to reports analyzing segments with documented atherosclerotic plaques.

Objectives:

We compared 64-slice multidetector computed tomography (MDCT) with gray scale intravascular ultrasound (IVUS) for the evaluation of coronary lumen dimensions in the context of a comprehensive analysis, including segments with absent or mild disease.

Methods:

The 64-slice MDCT was performed within 72 h before the IVUS imaging, which was obtained for at least one coronary, regardless of the presence of luminal stenosis at angiography. A total of 21 patients were included, with 70 imaged vessels (total length 114.6 ± 38.3 mm per patient). A coronary plaque was diagnosed in segments with plaque burden > 40%.

Results:

At patient, vessel, and segment levels, average lumen area, minimal lumen area, and minimal lumen diameter were highly correlated between IVUS and 64-slice MDCT (p < 0.01). However, 64-slice MDCT tended to underestimate the lumen size with a relatively wide dispersion of the differences. The comparison between 64-slice MDCT and IVUS lumen measurements was not substantially affected by the presence or absence of an underlying plaque. In addition, 64-slice MDCT showed good global accuracy for the detection of IVUS parameters associated with flow-limiting lesions.

Conclusions:

In a comprehensive, multi-territory, and whole-artery analysis, the assessment of coronary lumen by 64-slice MDCT compared with coronary IVUS showed a good overall diagnostic ability, regardless of the presence or absence of underlying atherosclerotic plaques.

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Original Article

Insulin Resistance, Dyslipidemia and Cardiovascular Changes in a Group of Obese Children

António Pires et al. Paula Martins Ana Margarida Pereira Patricia Vaz Silva … Joana Marinho Margarida Marques Eduardo Castela Cristina Sena Raquel Seiça

Introduction:

Obesity-related comorbidities are present in young obese children, providing a platform for early adult cardiovascular disorders.

Objectives:

To compare and correlate markers of adiposity to metabolic disturbances, vascular and cardiac morphology in a European pediatric obese cohort.

Methods:

We carried out an observational and transversal analysis in a cohort consisting of 121 obese children of both sexes, between the ages of 6 and 17 years. The control group consisted of 40 children with normal body mass index within the same age range. Markers of adiposity, plasma lipids and lipoproteins, homeostasis model assessment-insulin resistance, common carotid artery intima-media thickness and left ventricular diameters were analyzed.

Results:

There were statistically significant differences between the control and obese groups for the variables analyzed, all higher in the obese group, except for age, high-density lipoprotein cholesterol and adiponectin, higher in the control group. In the obese group, body mass index was directly correlated to left ventricular mass (r=0.542; p=0.001), the homeostasis model assessment-insulin resistance (r=0.378; p=<0.001) and mean common carotid artery intima-media thickness (r=0.378; p=<0.001). In that same group, insulin resistance was present in 38.1%, 12.5% had a combined dyslipidemic pattern, and eccentric hypertrophy was the most common left ventricular geometric pattern.

Conclusions:

These results suggest that these markers may be used in clinical practice to stratify cardiovascular risk, as well as to assess the impact of weight control programs.

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Original Article

Influence of Spironolactone on Matrix Metalloproteinase-2 in Acute Decompensated Heart Failure

João Pedro Ferreira et al. Mário Santos José Carlos Oliveira Irene Marques … Paulo Bettencourt Henrique Carvalho

Background:

Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment.

Objective:

Our aim was to test the influence of spironolactone in MMP2 levels.

Methods:

Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group).

Results:

Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant.

Conclusion:

MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.

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Original Article

Infant Mortality in Novo Hamburgo: Associated Factors and Cardiovascular Causes

Camila de Andrade Brum et al. Airton Tetelbom Stein Lucia Campos Pellanda

Background:

Infant mortality has decreased in Brazil, but remains high as compared to that of other developing countries. In 2010, the Rio Grande do Sul state had the lowest infant mortality rate in Brazil. However, the municipality of Novo Hamburgo had the highest infant mortality rate in the Porto Alegre metropolitan region.

Objective:

To describe the causes of infant mortality in the municipality of Novo Hamburgo from 2007 to 2010, identifying which causes were related to heart diseases and if they were diagnosed in the prenatal period, and to assess the access to healthcare services.

Methods:

This study assessed infants of the municipality of Novo Hamburgo, who died, and whose data were collected from the infant death investigation records.

Results:

Of the 157 deaths in that period, 35.3% were reducible through diagnosis and early treatment, 25% were reducible through partnership with other sectors, 19.2% were non-preventable, 11.5% were reducible by means of appropriate pregnancy monitoring, 5.1% were reducible through appropriate delivery care, and 3.8% were ill defined. The major cause of death related to heart disease (13.4%), which was significantly associated with the variables ‘age at death’, ‘gestational age’ and ‘birth weight’. Regarding access to healthcare services, 60.9% of the pregnant women had a maximum of six prenatal visits.

Conclusion:

It is mandatory to enhance prenatal care and newborn care at hospitals and basic healthcare units to prevent infant mortality.

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