2015;104(6) – ABC CARDIOL

Letter to the Editor

An Issue Waiting to be Clarified: Effects of the QT Prolonging Drugs on Tp-e Interval

Omer Yiginer et al. Mehmet Dogan Emrah Erdal

We read the article ‘Impact of Psychotropic Drugs on QT Interval Dispersion in Adult Patients’ by Claudio et al. with great interest. They investigated in this study the effects of psychotropic drugs on QT interval (QTI), corrected QT interval (QTc), and QT dispersion (QTd). They concluded that psychotropic drugs increased QTd and QTc interval.

QTd is the most frequently used non-invasive method to quantify electrical myocardial heterogeneity. However, there are variable results in studies related to QTI due to the technical limitations in measurements. It is well-known that the reproducibility of QTI measurements is low both in manual and automatic measurements. In this study, the measurements were performed digitally by four cardiologists using the Preview software with a magnification of 300%. We appreciated the method used in this study in order to obtain more accurate data. It is recommended that measurements be done digitally at least by two cardiologists.

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Clinicoradiological Session

Case 5/2015 Late Outcome of Corrected Aortopulmonary Window in A 23-Year-Old Female Patient Who Underwent Surgery in Childhood

Edmar Atik

Laboratory tests

ECG () at 22 years of age showed normal sinus rhythm with no signs of overload, and normal ventricular repolarization. PA = +10º , QRSA = +50º , TA = +50º (lower tracing). ECG prior to operation, at 10 months of age (upper tracing), showed marked left ventricular overload, with QRSA = +70º , PA = +20º and TA = +80º ; RS morphology (amplitudes of 24 and 30 mm) from V1 to V3 and QRs (amplitudes of 10, 50 and 3 mm) from V4 to V6; Sokolow index of 90 mm; no ventricular repolarization abnormalities.

Chest radiograph showed normal cardiac silhouette (cardiothoracic ratio = 0.46) and pulmonary vasculature (). In the image prior to surgery, these parameters were markedly increased, with a cardiothoracic ratio of 0.85 ().

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Case Report

Acute Myocardial Infarction and Severe Prosthetic Dysfunction after Bentall Procedure

Viviane Tiemi Hotta et al. Pedro Gabriel de Melo Barros Paulo Sampaio Gutierrez Angela Cristina Pasiani Bolonhez … Wilson Mathias Ricardo Ribeiro Dias

Introduction

Coronary artery anastomotic dehiscence is a rare complication following aortic procedures. A 59-year-old male previously underwent replacement of the ascending aorta and aortic valve because of ascending aorta aneurysm and severe aortic regurgitation. Eight years after the procedure, he presented with acute myocardial infarction. Transesophageal echocardiography (TEE) and coronary angiography revealed coronary artery dehiscence. This finding rarely occurs after a Bentall procedure; however, if it does, it usually occurs in the early postoperative period and is associated with an infectious etiology. In this case, coronary dehiscence presented with myocardial infarction years after the procedure and was first suspected after TEE.

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Editorial

Distance Psychotherapy – New Reality

Protásio L. da Luz et al. Mayra L. Gagliani Bellkiss W. Romano

High technology progresses fast in the medical area. The most recent advance is the “big data” study, in which multiple technologies are applied to populations in order to incorporate genetic data, biological markers and imaging, to assess risks and predict the occurrence of clinical phenomena. That is a global, multidisciplinary and multinational view, which supports and helps the implementation of preventive actions.

Psychology practice in Brazil, however, still resists to this modernity. Face-to-face psychotherapy is the only modality of treatment accepted by the Brazilian Federal Council of Psychology. However, distance counseling, via Internet or mobile phone, has been increasingly used in the USA, Europe and Oceania. Epstein et al. have reported the increasing use of “e-therapy”, as well as the exponential growth of related publications. In New Zealand, Gibson et al. have reported the experience of adolescents with mobile phone therapy. Eight aspects were identified by adolescents as advantageous: privacy, autonomy, control, anonymity, easy access, personalization, individualization of language, and connection.

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Original Article

APOE and LDLR Gene Polymorphisms and Dyslipidemia Tracking. Rio de Janeiro Study

Rossana Ghessa Andrade de Freitas et al. Erika Maria Gonçalves Campana Roberto Pozzan Andréa Araujo Brandão … Ayrton Pires Brandão Maria Eliane Campos Magalhães Dayse Aparecida da Silva

Background:

Studies show an association between changes in apolipoprotein E (ApoE) and LDLR receptor with the occurrence of dyslipidemia.

Objectives:

To investigate the association between polymorphisms of the APOE (ε2, ε3, ε4) and LDLR (A370T) genes with the persistence of abnormal serum lipid levels in young individuals followed up for 17 years in the Rio de Janeiro Study.

Methods:

The study included 56 individuals (35 males) who underwent three assessments at different ages: A1 (mean age 13.30 ± 1.53 years), A2 (22.09 ± 1.91 years) and A3 (31.23 ± 1.99 years). Clinical evaluation with measurement of blood pressure (BP) and body mass index (BMI) was conducted at all three assessments. Measurement of waist circumference (WC) and serum lipids, and analysis of genetic polymorphisms by PCR-RFLP were performed at A2 and A3. Based on dyslipidemia tracking, three groups were established: 0 (no abnormal lipid value at A2 and A3), 1 (up to one abnormal lipid value at A2 or A3) and 2 (one or more abnormal lipid values at A2 and A3).

Results:

Compared with groups 0 and 1, group 2 presented higher mean values of BP, BMI, WC, LDL-c and TG (p < 0.01) and lower mean values of HDL-c (p = 0.001). Across the assessments, all individuals with APOE genotypes ε2/ε4 and ε4/ε4 maintained at least one abnormal lipid variable, whereas those with genotype ε2/ε3 did not show abnormal values (χ2 = 16.848, p = 0.032). For the LDLR genotypes, there was no significant difference among the groups.

Conclusions:

APOE gene polymorphisms were associated with dyslipidemia in young individuals followed up longitudinally from childhood.

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Original Article

Circulatory and Ventilatory Power: Characterization in Patients with Coronary Artery Disease

Viviane Castello-Simões et al. Vinicius Minatel Marlus Karsten Rodrigo Polaquini Simões … Natália Maria Perseguini Juliana Cristina Milan Ross Arena Laura Maria Tomazi Neves Audrey Borghi-Silva Aparecida Maria Catai

Background:

Circulatory power (CP) and ventilatory power (VP) are indices that have been used for the clinical evaluation of patients with heart failure; however, no study has evaluated these indices in patients with coronary artery disease (CAD) without heart failure.

Objective:

To characterize both indices in patients with CAD compared with healthy controls.

Methods:

Eighty-seven men [CAD group = 42 subjects and healthy control group (CG) = 45 subjects] aged 40–65 years were included. Cardiopulmonary exercise testing was performed on a treadmill and the following parameters were measured: 1) peak oxygen consumption (VO₂), 2) peak heart rate (HR), 3) peak blood pressure (BP), 4) peak rate-pressure product (peak systolic HR x peak BP), 5) peak oxygen pulse (peak VO₂/peak HR), 6) oxygen uptake efficiency (OUES), 7) carbon dioxide production efficiency (minute ventilation/carbon dioxide production slope), 8) CP (peak VO₂ x peak systolic BP) and 9) VP (peak systolic BP/carbon dioxide production efficiency).

Results:

The CAD group had significantly lower values for peak VO₂ (p < 0.001), peak HR (p < 0.001), peak systolic BP (p < 0.001), peak rate-pressure product (p < 0.001), peak oxygen pulse (p = 0.008), OUES (p < 0.001), CP (p < 0.001), and VP (p < 0.001) and significantly higher values for peak diastolic BP (p = 0.004) and carbon dioxide production efficiency (p < 0.001) compared with CG. Stepwise regression analysis showed that CP was influenced by group (R² = 0.44, p < 0.001) and VP was influenced by both group and number of vessels with stenosis after treatment (interaction effects: R² = 0.46, p < 0.001).

Conclusion:

The indices CP and VP were lower in men with CAD than healthy controls.

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Original Article

Heart Rate Variability Correlates to Functional Aerobic Impairment in Hemodialysis Patients

Maria Angela Magalhães de Queiroz Carreira et al. André Barros Nogueira Felipe Montes Pena Marcio Galindo Kiuchi … Ronaldo Campos Rodrigues Rodrigo da Rocha Rodrigues Jorge Paulo Strogoff de Matos Jocemir Ronaldo Lugon

Background:

Autonomic dysfunction (AD) is highly prevalent in hemodialysis (HD) patients and has been implicated in their increased risk of cardiovascular mortality.

Objective:

To correlate heart rate variability (HRV) during exercise treadmill test (ETT) with the values obtained when measuring functional aerobic impairment (FAI) in HD patients and controls.

Methods:

Cross-sectional study involving HD patients and a control group. Clinical examination, blood sampling, transthoracic echocardiogram, 24-hour Holter, and ETT were performed. A symptom-limited ramp treadmill protocol with active recovery was employed. Heart rate variability was evaluated in time domain at exercise and recovery periods.

Results:

Forty-one HD patients and 41 controls concluded the study. HD patients had higher FAI and lower HRV than controls (p<0.001 for both). A correlation was found between exercise HRV (SDNN) and FAI in both groups. This association was independent of age, sex, smoking, body mass index, diabetes, and clonidine or beta-blocker use, but not of hemoglobin levels.

Conclusion:

No association was found between FAI and HRV on 24-hour Holter or at the recovery period of ETT. Of note, exercise HRV was inversely correlated with FAI in HD patients and controls. (Arq Bras Cardiol. 2015; [online]. ahead print, PP.0-0)

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Original Article

Post-Acute Coronary Syndrome Alcohol Abuse: Prospective Evaluation in the ERICO Study

Abner Morilha et al. Samuel Karagulian Paulo A. Lotufo Itamar S. Santos … Isabela M. Benseñor Alessandra C. Goulart

Background:

Some studies have indicated alcohol abuse as one of the contributors to the development of cardiovascular disease, particularly coronary heart disease. However, this relationship is controversial.

Objective:

To investigate the relationship between post-acute coronary syndrome (ACS) alcohol abuse in the Acute Coronary Syndrome Registry Strategy (ERICO Study).

Methods:

146 participants from the ERICO Study answered structured questionnaires and underwent laboratory evaluations at baseline, 30 days and 180 days after ACS. The Alcohol Use Disorders Identification Test (AUDIT) was applied to assess harmful alcohol consumption in the 12 months preceding ACS (30 day-interview) and six months after that.

Results:

The frequencies of alcohol abuse were 24.7% and 21.1% in the 12 months preceding ACS and six months after that, respectively. The most significant cardiovascular risk factors associated with high-risk for alcohol abuse 30 days after the acute event were: male sex (88.9%), current smoking (52.8%) and hypertension (58.3%). Six months after the acute event, the most significant results were replicated in our logistic regression, for the association between alcohol abuse among younger individuals [35-44 year-old multivariate OR: 38.30 (95% CI: 1.44-1012.56) and 45-54 year-old multivariate OR: 10.10 (95% CI: 1.06-96.46)] and for smokers [current smokers multivariate OR: 51.09 (95% CI: 3.49-748.01) and past smokers multivariate OR: 40.29 (95% CI: 2.37-685.93)].

Conclusion:

Individuals younger than 54 years and smokers showed a significant relation with harmful alcohol consumption, regardless of the ACS subtype.

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Original Article

Depression as a Clinical Determinant of Dependence and Low Quality of Life in Elderly Patients with Cardiovascular Disease

Giselle Helena de Paula Rodrigues et al. Otavio Celso Eluf Gebara Catia Cilene da Silva Gerbi Humberto Pierri Mauricio Wajngarten

Background:

The aging process promotes a progressive increase in chronic-degenerative diseases. The effect of these diseases on the functional capacity has been well recognized. Another health parameter concerns “quality of life related to health”. Among the elderly population, cardiovascular diseases stand out due to the epidemiological and clinical impact. Usually, these diseases have been associated with others. This set of problems may compromise both independence and quality of life in elderly patients who seek cardiologic treatment. These health parameters have not been well contemplated by cardiologists.

Objective:

Evaluating, among the elderly population with cardiovascular disease, which are the most relevant clinical determinants regarding dependence and quality of life.

Methods:

This group was randomly and consecutively selected and four questionnaires were applied: HAQ, SF-36, PRIME-MD e Mini Mental State.

Results:

The study included 1,020 elderly patients, 63.3% women. The group had been between 60 and 97 years-old (mean: 75.56 ± 6.62 years-old). 61.4% were independent or mild dependence. The quality of life total score was high (HAQ: 88.66 ± 2.68). 87.8% of patients had a SF-36 total score > 66. In the multivariate analysis, the association between diagnoses and high degrees of dependence was significant only for previous stroke (p = 0.014), obesity (p < 0.001), lack of physical activity (p = 0.016), osteoarthritis (p < 0.001), cognitive impairment (p < 0.001), and major depression (p < 0.001). Analyzing the quality of life, major depression and physical illness for depression was significantly associated with all domains of the SF-36.

Conclusion:

Among an elderly outpatient cardiology population, dependence and quality of life clinical determinants are not cardiovascular comorbidities, especially the depression.

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Original Article

Assessment of Autonomic Function by Phase Rectification of RRInterval Histogram Analysis in Chagas Disease

Olivassé Nasari Junior et al. Paulo Roberto Benchimol-Barbosa Roberto Coury Pedrosa Jurandir Nadal

Background:

In chronic Chagas disease (ChD), impairment of cardiac autonomic function bears prognostic implications. Phase‑rectification of RR-interval series isolates the sympathetic, acceleration phase (AC) and parasympathetic, deceleration phase (DC) influences on cardiac autonomic modulation.

Objective:

This study investigated heart rate variability (HRV) as a function of RR-interval to assess autonomic function in healthy and ChD subjects.

Methods:

Control (n = 20) and ChD (n = 20) groups were studied. All underwent 60-min head-up tilt table test under ECG recording. Histogram of RR-interval series was calculated, with 100 ms class, ranging from 600–1100 ms. In each class, mean RR-intervals (MNN) and root-mean-squared difference (RMSNN) of consecutive normal RR-intervals that suited a particular class were calculated. Average of all RMSNN values in each class was analyzed as function of MNN, in the whole series (RMSNN_T), and in AC (RMSNN_AC) and DC (RMSNN_DC) phases. Slopes of linear regression lines were compared between groups using Student t-test. Correlation coefficients were tested before comparisons. RMSNN was log-transformed. (α < 0.05).

Results:

Correlation coefficient was significant in all regressions (p < 0.05). In the control group, RMSNN_T, RMSNN_AC, and RMSNN_DCsignificantly increased linearly with MNN (p < 0.05). In ChD, only RMSNN_AC showed significant increase as a function of MNN, whereas RMSNN_T and RMSNN_DC did not.

Conclusion:

HRV increases in proportion with the RR-interval in healthy subjects. This behavior is lost in ChD, particularly in the DC phase, indicating cardiac vagal incompetence.

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Original Article

Blood Pressure and Hemodynamic Adaptations after a Training Program in Young Individuals with Down Syndrome

Bruna Barboza Seron et al. Karla Fabiana Goessler Everaldo Lambert Modesto Eloise Werle Almeida Márcia Greguol

Background:

Cardiovascular diseases affect people worldwide. Individuals with Down Syndrome (DS) have an up to sixteen-time greater risk of mortality from cardiovascular diseases.

Objective:

To evaluate the effects of aerobic and resistance exercises on blood pressure and hemodynamic variables of young individuals with DS.

Methods:

A total of 29 young individuals with DS participated in the study. They were divided into two groups: aerobic training (AT) (n = 14), and resistance training (TR) (n = 15). Their mean age was 15.7 ± 2.82 years. The training program lasted 12 weeks, and had a frequency of three times a week for AT and twice a week for RT. AT was performed in treadmill/ bicycle ergometer, at an intensity between 50%-70% of the HR reserve. RT comprised nine exercises with three sets of 12 repetition-maximum. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) and hemodynamic variables were assessed beat-to-beat using the Finometer device before/after the training program. Descriptive analysis, the Shapiro-Wilk test to check the normality of data, and the two-way ANOVA for repeated measures were used to compare pre- and post-training variables. The Pearson’s correlation coefficient was calculated to correlate hemodynamic variables. The SPSS version 18.0 was used with the significance level set at p < 0.05.

Results:

After twelve weeks of aerobic and/or resistance training, significant reductions in variables SBP, DBP and MBP were observed.

Conclusion:

This study suggests a chronic hypotensive effect of moderate aerobic and resistance exercises on young individuals with DS.

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Original Article

I Brazilian Registry of Heart Failure – Clinical Aspects, Care Quality and Hospitalization Outcomes

Denilson Campos de Albuquerque et al. João David de Souza Neto Fernando Bacal Luiz Eduardo Paim Rohde … Sabrina Bernardez-Pereira Otavio Berwanger Dirceu Rodrigues Almeida Investigadores Estudo BREATHE

Background:

Heart failure (HF) is one of the leading causes of hospitalization in adults in Brazil. However, most of the available data is limited to unicenter registries. The BREATHE registry is the first to include a large sample of hospitalized patients with decompensated HF from different regions in Brazil.

Objective:

Describe the clinical characteristics, treatment and prognosis of hospitalized patients admitted with acute HF.

Methods:

Observational registry study with longitudinal follow-up. The eligibility criteria included patients older than 18 years with a definitive diagnosis of HF, admitted to public or private hospitals. Assessed outcomes included the causes of decompensation, use of medications, care quality indicators, hemodynamic profile and intrahospital events.

Results:

A total of 1,263 patients (64±16 years, 60% women) were included from 51 centers from different regions in Brazil. The most common comorbidities were hypertension (70.8%), dyslipidemia (36.7%) and diabetes (34%). Around 40% of the patients had normal left ventricular systolic function and most were admitted with a wet-warm clinical-hemodynamic profile. Vasodilators and intravenous inotropes were used in less than 15% of the studied cohort. Care quality indicators based on hospital discharge recommendations were reached in less than 65% of the patients. Intrahospital mortality affected 12.6% of all patients included.

Conclusion:

The BREATHE study demonstrated the high intrahospital mortality of patients admitted with acute HF in Brazil, in addition to the low rate of prescription of drugs based on evidence.

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Review Article

Reverse Cardiac Remodeling: A Marker of Better Prognosis in Heart Failure

José Rosino de Araújo Rocha Reis Filho et al. Juliano Novaes Cardoso Cristina Martins dos Reis Cardoso Antonio Carlos Pereira-Barretto

In heart failure syndrome, myocardial dysfunction causes an increase in neurohormonal activity, which is an adaptive and compensatory mechanism in response to the reduction in cardiac output. Neurohormonal activity is initially stimulated in an attempt to maintain compensation; however, when it remains increased, it contributes to the intensification of clinical manifestations and myocardial damage. Cardiac remodeling comprises changes in ventricular volume as well as the thickness and shape of the myocardial wall. With optimized treatment, such remodeling can be reversed, causing gradual improvement in cardiac function and consequently improved prognosis.

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