2015;105(3) – ABC CARDIOL

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Case Report

Anabolic Drugs and Myocardial Infarction – A Clinical Case Report

Rui Pontes Santos et al. Adriana Pereira Henrique Guedes Carolina Lourenço … João Azevedo Paula Pinto

Introduction

In most cases of myocardial infarction (MI) in young people, traditional cardiovascular risk factors continue to be of utmost importance; but at this age, other causes should also be considered, such as drug abuse.

Anabolic steroids are synthetic derivatives of testosterone and are often illegally used by athletes to increase their physical performance. There is a correlation between the use of these drugs and increased cardiovascular risk. Human growth hormone (hGH) has also been used to increase physical performance, despite the risk of cardiovascular complications. Clenbuterol is a potent β2-agonist that also has anabolic effects. However, at present, little is known about its potential cardiovascular risk.

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Left Ventricular Pseudoaneurysm Secondary to Mitral Valve Endocarditis

Bruno Bochard-Villanueva et al. Jordi Estornell-Erill

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Anatomopathological Session

Case 3/2015 – 53-Year-Old Female with Cardiogenic Shock 12 Years after Surgical Correction of Endomyocardial Fibrosis

Michel Abi Kalansky Ponczek et al. Fernanda Seligmann Feitosa Léa Maria Macruz Ferreira Demarchi

Clinical aspects

At the age of 29 years, the patient developed palpitations, which, after 5 years, associated with dyspnea on exertion, which progressed slowly until the age of 39 years. In young patients, the major causes of heart failure (HF) are idiopathic dilated cardiomyopathy, myocarditis, Chagas disease, alcoholic cardiomyopathy, and, more rarely, ischemic heart disease. In addition, rarer causes of HF in patients of tropical and subtropical regions, such as EMF, are worthy of note.

When the patient first sought the hospital, she was diagnosed with EMF, which is an uncommon restrictive cardiomyopathy, accounting for 1.6% of the deaths due to cardiac disease in Brazil. It is more common in the eastern and central regions of Africa. Several cases have been reported in South America and India, and sporadic ones have been reported worldwide. In some places, EMF has an endemic distribution.

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Letter to the Editor

Therapeutic Adherence and Functional Capacity in Heart Failure

Márcia Maria Carneiro Oliveira et al. Elieusa e Silva Sampaio Roque Aras Júnior

Dear Editor,

Heart failure (HF) has become a major public health problem, as it is the final pathway of most heart diseases. One of the main factors that lead to decompensation in HF is poor patient adherence to treatment.

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Special Article

SBC Guidelines on Unstable Angina and Non-ST-Elevation Myocardial Infarction: Executive Summary

Gilson Soares Feitosa-Filho et al. Luciano Moreira Baracioli Carlos José Dornas G. Barbosa André Franci … Ari Timerman Leopoldo Soares Piegas José Antônio Marin-Neto José Carlos Nicolau

Part I – Risk stratification and management within 12 hours of hospital arrival

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Editorial

Public Health Policy Based on “Made-In-Brazil” Science: A Challenge for the Arquivos Brasileiros de Cardiologia

Jussiely Cunha Oliveira et al. José Augusto Barreto-Filho

Scrutinizing the quality of the Brazilian health system

Since the Brazilian 1998 Federal Constitution (Constitution of the Citizen) was signed and the Brazilian National Unified Health Care System (SUS) was created in 1990, the right to integral, universal, equalitarian and free access to health services of quality has been granted to all Brazilians. The State would have to finance, provide and operate the infrastructure necessary to fulfill the Law 8.080/1990. The constitutional recognition that health is a universal right was a substantial ideological advance. On paper, the public health model idealized for Brazil has become an example to the world. Approximately 75% of Brazilians are estimated to depend on the SUS for health care, while the remaining Brazilians have private complementary coverage.

If the objective is to generate relevant information to guide decision making regarding public policies on health, we should systematically dedicate ourselves to scientifically assess the health care outcomes of SUS. However, after 25 years from SUS implantation, there is little scientific evidence, especially that representing the continental country Brazil is, on the final health care outcomes of SUS. For example, representative data on post-acute myocardial infarction mortality, reperfusion treatment rate or hospital readmission rate in 30 days are not available. Moreover, little is known about the disparities of the health care outcomes between the SUS and the private health care system.

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Original Article

Lowering Pulmonary Wedge Pressure after Heart Transplant: Pulmonary Compliance and Resistance Effect

Nádia Moreira et al. Rui Baptista Susana Costa Fátima Franco … Mariano Pêgo Manuel Antunes

Abstract

Background:

Right ventricular (RV) afterload is an important risk factor for post-heart transplantation (HTx) mortality, and it results from the interaction between pulmonary vascular resistance (PVR) and pulmonary compliance (CPA). Their product, the RC time, is believed to be constant. An exception is observed in pulmonary hypertension because of elevated left ventricular (LV) filling pressures.

Objective:

Using HTx as a model for chronic lowering of LV filling pressures, our aim was to assess the variations in RV afterload components after transplantation.

Methods:

We retrospectively studied 159 patients with right heart catheterization before and after HTx. The effect of Htx on hemodynamic variables was assessed.

Results:

Most of the patients were male (76%), and the mean age was 53 ± 12 years. HTx had a significant effect on the hemodynamics, with normalization of the LV and RV filling pressures and a significant increase in cardiac output and heart rate (HR). The PVR decreased by 56% and CPA increased by 86%. The RC time did not change significantly, instead of increasing secondary to pulmonary wedge pressure (PWP) normalization after HTx as expected. The expected increase in RC time with PWP lowering was offset by the increase in HR (because of autonomic denervation of the heart). This effect was independent from the decrease of PWP.

Conclusion:

The RC time remained unchanged after HTx, notwithstanding the fact that pulmonary capillary wedge pressure significantly decreased. An increased HR may have an important effect on RC time and RV afterload. Studying these interactions may be of value to the assessment of HTx candidates and explaining early RV failure after HTx.

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Original Article

Ergospirometry and Echocardiography in Early Stage of Heart Failure with Preserved Ejection Fraction and in Healthy Individuals

Eduardo Lima Garcia et al. Márcio Garcia Menezes Charles de Moraes Stefani Luiz Cláudio Danzmann Marco Antonio Rodrigues Torres

Abstract

Background:

Heart failure with preserved ejection fraction is a syndrome characterized by changes in diastolic function; it is more prevalent among the elderly, women, and individuals with systemic hypertension (SH) and diabetes mellitus. However, in its early stages, there are no signs of congestion and it is identified in tests by adverse remodeling, decreased exercise capacity and diastolic dysfunction.

Objective:

To compare doppler, echocardiographic (Echo), and cardiopulmonary exercise test (CPET) variables – ergospirometry variables – between two population samples: one of individuals in the early stage of this syndrome, and the other of healthy individuals.

Methods:

Twenty eight outpatients diagnosed with heart failure according to Framingham’s criteria, ejection fraction > 50% and diastolic dysfunction according to the european society of cardiology (ESC), and 24 healthy individuals underwent Echo and CPET.

Results:

The group of patients showed indexed atrial volume and left ventricular mass as well as E/E’ and ILAV/A´ ratios significantly higher, in addition to a significant reduction in peak oxygen consumption and increased VE/VCO₂ slope, even having similar left ventricular sizes in comparison to those of the sample of healthy individuals.

Conclusion:

There are significant differences between the structural and functional variables analyzed by Echo and CPET when comparing two population samples: one of patients in the early stage of heart failure with ejection fraction greater than or equal to 50% and another of healthy individuals.

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Original Article

Co-administration of Apelin and T4 Protects Inotropic and Chronotropic Changes Occurring in Hypothyroid Rats

Zahra Akhondali et al. Mohammad Badavi Mahin Dianat Farzaneh Faraji

Abstract

Background:

One of the most important thyroid hormone targets is the cardiovascular system. Hemodynamic changes, such as decreased resting heart rate (HR), myocardial contractility, and cardiac output, and increased diastolic pressure and systemic vascular resistance, have been observed in hypothyroid patients. Moreover, in these patients, ECG changes include sinus bradycardia and low voltage complexes (P waves or QRS complexes).

Objective:

This study aimed at evaluating the prophylactic effect of apelin on HR changes and QRS voltage that occur in propylthiouracil (PTU)-induced hypothyroid rats.

Method:

In this study, 48 adult male Wistar rats weighing 170-235g were randomly divided into 6 groups: Control group (normal saline ip injection + tap water gavage); P group (PTU 0.05%, in drinking water); A group (apelin 200 µg.kg^-1.day^-1, ip); PA group [co-administration of PTU and apelin]; PT group [co-administration of PTU + T4 (0.2 mg/g per day, gavage)]; and PAT group (co-administration of PTU, apelin and T4). All experiments were performed for 28 consecutive days, and then the animals were anesthetized with an ip injection of ketamine (80 mg/kg) and xylazine (12 mg/kg). Lead II electrocardiogram was recorded to calculate HR and QRS voltage.

Results:

Heart rate and QRS voltage increased more significantly in the hypothyroid group that consumed both apelin and T4 (201 ± 4 beat/min, 0.71 ± 0.02 mv vs. hypothyroid 145 ± 9 beat/min, 0.563 ± 0.015 mv; respectively).

Conclusion:

The co-administration of apelin and T4 showed a protective effect on QRS voltage and HR in PTU‑induced hypothyroid rats.

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Original Article

Performance of Surgical Risk Scores to Predict Mortality after Transcatheter Aortic Valve Implantation

Leonardo Sinnott Silva et al. Paulo Ricardo Avancini Caramori Antonio Carlos Bacelar Nunes Filho Marcelo Katz … João Carlos Vieira da Costa Guaragna Pedro Lemos Valter Lima Alexandre Abizaid Flavio Tarasoutchi Fabio S. de Brito Jr

Abstract

Background:

Predicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge.

Objectives:

To evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI.

Methods:

The Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer–Lemeshow test) and discrimination [area under the receiver–operating characteristic curve (AUC)].

Results:

The mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer–Lemeshow test indicated acceptable calibration for all scores (p > 0.05).

Conclusions:

In this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

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Original Article

Experience of ECMO in Primary Graft Dysfunction after Orthotopic Heart Transplantation

Elson Borges Lima et al. Claudio Ribeiro da Cunha Vitor Salvatore Barzilai Marcelo Botelho Ulhoa … Maria Regina de Barros Camila Scatolin Moraes Letycia Chagas Fortaleza Nubia Wellerson Vieira Fernando Antibas Atik

Background:

Primary graft dysfunction is the main cause of early mortality after heart transplantation. Mechanical circulatory support has been used to treat this syndrome.

Objective:

Describe the experience with extracorporeal membrane oxygenation to treat post-transplant primary cardiac graft dysfunction.

Methods:

Between January 2007 and December 2013, a total of 71 orthotopic heart transplantations were performed in patients with advanced heart failure. Eleven (15.5%) of these patients who presented primary graft dysfunction constituted the population of this study. Primary graft dysfunction manifested in our population as failure to wean from cardiopulmonary bypass in six (54.5%) patients, severe hemodynamic instability in the immediate postoperative period with severe cardiac dysfunction in three (27.3%), and cardiac arrest (18.2%). The average ischemia time was 151 ± 82 minutes. Once the diagnosis of primary graft dysfunction was established, we installed a mechanical circulatory support to stabilize the severe hemodynamic condition of the patients and followed their progression longitudinally.

Results:

The average duration of extracorporeal membrane oxygenation support was 76 ± 47.4 hours (range 32 to 144 hours). Weaning with cardiac recovery was successful in nine (81.8%) patients. However, two patients who presented cardiac recovery did not survive to hospital discharge.

Conclusion:

Mechanical circulatory support with central extracorporeal membrane oxygenation promoted cardiac recovery within a few days in most patients.

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Original Article

Reverse Auction: A Potential Strategy for Reduction of Pharmacological Therapy Cost

Sara Michelly Gonçalves Brandão et al. Victor Sarli Issa Silvia Moreira Ayub-Ferreira Samantha Storer … Bianca Gigliotti Gonçalves Valter Garcia Santos Nelson Carvas Junior Guilherme Veiga Guimarães Edimar Alcides Bocchi

Background:

Polypharmacy is a significant economic burden.

Objective:

We tested whether using reverse auction (RA) as compared with commercial pharmacy (CP) to purchase medicine results in lower pharmaceutical costs for heart failure (HF) and heart transplantation (HT) outpatients.

Methods:

We compared the costs via RA versus CP in 808 HF and 147 HT patients followed from 2009 through 2011, and evaluated the influence of clinical and demographic variables on cost.

Results:

The monthly cost per patient for HF drugs acquired via RA was $10.15 (IQ 3.51-40.22) versus $161.76 (IQ 86.05‑340.15) via CP; for HT, those costs were $393.08 (IQ 124.74-774.76) and $1,207.70 (IQ 604.48-2,499.97), respectively.

Conclusion:

RA may reduce the cost of prescription drugs for HF and HT, potentially making HF treatment more accessible. Clinical characteristics can influence the cost and benefits of RA. RA may be a new health policy strategy to reduce costs of prescribed medications for HF and HT patients, reducing the economic burden of treatment.

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Original Article

Testosterone Deficiency Increases Hospital Readmission and Mortality Rates in Male Patients with Heart Failure

Marcelo Rodrigues dos Santos et al. Ana Luiza Carrari Sayegh Raphaela Vilar Ramalho Groehs Guilherme Fonseca … Ivani Credidio Trombetta Antônio Carlos Pereira Barretto Marco Antônio Arap Carlos Eduardo Negrão Holly R. Middlekauff Maria-Janieire de Nazaré Nunes Alves

Background:

Testosterone deficiency in patients with heart failure (HF) is associated with decreased exercise capacity and mortality; however, its impact on hospital readmission rate is uncertain. Furthermore, the relationship between testosterone deficiency and sympathetic activation is unknown.

Objective:

We investigated the role of testosterone level on hospital readmission and mortality rates as well as sympathetic nerve activity in patients with HF.

Methods:

Total testosterone (TT) and free testosterone (FT) were measured in 110 hospitalized male patients with a left ventricular ejection fraction < 45% and New York Heart Association classification IV. The patients were placed into low testosterone (LT; n = 66) and normal testosterone (NT; n = 44) groups. Hypogonadism was defined as TT < 300 ng/dL and FT < 131 pmol/L. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography in a subpopulation of 27 patients.

Results:

Length of hospital stay was longer in the LT group compared to in the NT group (37 ± 4 vs. 25 ± 4 days; p = 0.008). Similarly, the cumulative hazard of readmission within 1 year was greater in the LT group compared to in the NT group (44% vs. 22%, p = 0.001). In the single-predictor analysis, TT (hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.58–4.85; p = 0.02) predicted hospital readmission within 90 days. In addition, TT (HR, 4.65; 95% CI, 2.67–8.10; p = 0.009) and readmission within 90 days (HR, 3.27; 95% CI, 1.23–8.69; p = 0.02) predicted increased mortality. Neurohumoral activation, as estimated by MSNA, was significantly higher in the LT group compared to in the NT group (65 ± 3 vs. 51 ± 4 bursts/100 heart beats; p < 0.001).

Conclusion:

These results support the concept that LT is an independent risk factor for hospital readmission within 90 days and increased mortality in patients with HF. Furthermore, increased MSNA was observed in patients with LT.

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Original Article

Cardiac Sympathetic Hyperactivity after Chemotherapy: Early Sign of Cardiotoxicity?

Sarita Lígia Pessoa de Melo Machado Guimarães et al. Simone Cristina Soares Brandão Luciana Raposo Andrade Rafael José Coelho Maia Brivaldo Markman Filho

Background:

Chemotherapy with anthracyclines and trastuzumab can cause cardiotoxicity. Alteration of cardiac adrenergic function assessed by metaiodobenzylguanidine labeled with iodine-123 (¹²³I-mIBG) seems to precede the drop in left ventricular ejection fraction.

Objective:

To evaluate and to compare the presence of cardiovascular abnormalities among patients with breast cancer undergoing chemotherapy with anthracyclines and trastuzumab, and only with anthracycline.

Methods:

Patients with breast cancer were analyzed clinical, laboratory, electrocardiographic and echocardiographic and cardiac sympathetic activity. In scintigraphic images, the ratio of ¹²³I-mIBG uptake between the heart and mediastinum, and the washout rate were calculated. The variables were compared between patients who received anthracyclines and trastuzumab (Group 1) and only anthracyclines (Group 2).

Results:

Twenty patients, with mean age 57 ± 14 years, were studied. The mean left ventricular ejection fraction by echocardiography was 67.8 ± 4.0%. Mean washout rate was 28.39 ± 9.23% and the ratio of ¹²³I-mIBG uptake between the heart and mediastinum was 2.07 ± 0.28. Of the patients, 82% showed an increased in washout rate, and the ratio of ¹²³I-mIBG uptake between the heart and mediastinum decreased in 25%. Concerning the groups, the mean washout rate of Group 1 was 32.68 ± 9.30% and of Group 2 was 24.56 ± 7.72% (p = 0,06). The ratio of ¹²³I-mIBG uptake between the heart and mediastinum was normal in all patients in Group 2, however, the Group 1, showed 50% the ratio of ¹²³I-mIBG uptake between the heart and mediastinum ≤ 1.8 (p = 0.02).

Conclusion:

In women with breast cancer undergoing chemotherapy, assessment of cardiac sympathetic activity with ¹²³I-mIBG appears to be an early marker of cardiotoxicity. The combination of chemotherapy showed higher risk of cardiac adrenergic hyperactivity.

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Artigo Original

Heart Rate and Systolic Blood Pressure Variability on Recently Diagnosed Diabetics

Anaclara Michel-Chávez et al. Bruno Estañol José Antonio Gien-López Adriana Robles-Cabrera … María Elena Huitrado-Duarte René Moreno-Morales Brayans Becerra-Luna

Background:

Diabetes affects approximately 250 million people in the world. Cardiovascular autonomic neuropathy is a common complication of diabetes that leads to severe postural hypotension, exercise intolerance, and increased incidence of silent myocardial infarction.

Objective:

To determine the variability of heart rate (HR) and systolic blood pressure (SBP) in recently diagnosed diabetic patients.

Methods:

The study included 30 patients with a diagnosis of type 2 diabetes of less than 2 years and 30 healthy controls. We used a Finapres® device to measure during five minutes beat-to-beat HR and blood pressure in three experimental conditions: supine position, standing position, and rhythmic breathing at 0.1 Hz. The results were analyzed in the time and frequency domains.

Results:

In the HR analysis, statistically significant differences were found in the time domain, specifically on short-term values such as standard deviation of NN intervals (SDNN), root mean square of successive differences (RMSSD), and number of pairs of successive NNs that differ by more than 50 ms (pNN50). In the BP analysis, there were no significant differences, but there was a sympathetic dominance in all three conditions. The baroreflex sensitivity (BRS) decreased in patients with early diabetes compared with healthy subjects during the standing maneuver.

Conclusions:

There is a decrease in HR variability in patients with early type 2 diabetes. No changes were observed in the BP analysis in the supine position, but there were changes in BRS with the standing maneuver, probably due to sympathetic hyperactivity.

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Review Article

Impact of Physical Activity Interventions on Blood Pressure in Brazilian Populations

Vivian Freitas Rezende Bento et al. Flávia Barbizan Albino Karen Fernandes de Moura Gustavo Jorge Maftum … Mauro de Castro dos Santos Luiz César Guarita-Souza José Rocha Faria Neto Cristina Pellegrino Baena

Background:

High blood pressure is associated with cardiovascular disease, which is the leading cause of mortality in the Brazilian population. Lifestyle changes, including physical activity, are important for lowering blood pressure levels and decreasing the costs associated with outcomes.

Objective:

Assess the impact of physical activity interventions on blood pressure in Brazilian individuals.

Methods:

Meta-analysis and systematic review of studies published until May 2014, retrieved from several health sciences databases. Seven studies with 493 participants were included. The analysis included parallel studies of physical activity interventions in adult populations in Brazil with a description of blood pressure (mmHg) before and after the intervention in the control and intervention groups.

Results:

Of 390 retrieved studies, eight matched the proposed inclusion criteria for the systematic review and seven randomized clinical trials were included in the meta-analysis. Physical activity interventions included aerobic and resistance exercises. There was a reduction of -10.09 (95% CI: -18.76 to -1.43 mmHg) in the systolic and -7.47 (95% CI: -11.30 to -3.63 mmHg) in the diastolic blood pressure.

Conclusions:

Available evidence on the effects of physical activity on blood pressure in the Brazilian population shows a homogeneous and significant effect at both systolic and diastolic blood pressures. However, the strength of the included studies was low and the methodological quality was also low and/or regular. Larger studies with more rigorous methodology are necessary to build robust evidence.

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