2016;106(6) – ABC CARDIOL

Clinicoradiological Session

Case 4/2016: 32-Year-Old Female, with Critical Pulmonary Valve Stenosis. Operated at 4 Months of Age, in Normal Healing Evolution

Supplementary Exams

Electrochardiogram showed junctional rhythm and discreet end disorder of conduction through the right branch with complex rSr in V1 with normal duration of QRS of 0.094 seconds. AP = -30º; AQRS = -10º; AT = +10º (). ECG, done before the surgery at 4 months old, highlighted the significant right ventricular and atrial overload with electrical signals of systolic pressure of the right ventricle greater than systemic pressure with depression of ST segment in the right precordials and QR waves from V1 to V5, largely negative T waves from V1 to V6 and peaked P wave with 5 to 6 mm amplitude from V2 to V4; AP = +50°, AQRS = + 170°, AT = -60°. ().

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Editorial

Primordial Prevention and Wearable Health Devices: The Wearables in Cardiology

Eduardo Campos Pellanda et al. Lucia Campos Pellanda

Epidemiology has shown the growing importance of prevention as a way of dealing with the cardiovascular risk epidemic. One of the fundamental changes in concepts in recent decades was the shift in the prevention paradigm to ever earlier stages, both in the disease development, affecting an increasing number of individuals that have yet to develop a pathological condition or those who are in the early and treatable stages, as of the life line itself, looking for the origin of chronic diseases in intrauterine life. Thus, the concept of primordial prevention arose, that is, the prevention of the actual risk factors.

Ideally, preventing the establishment of risk factors in a population would keep it disease-free. Although utopian, the scenario described is useful to guide prevention strategies. One of the main current objectives is to reach the greatest possible number of individuals before they develop a risk profile.

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Letter to the Editor

Predictors of Atrial Fibrillation Recurrence in Hyperthyroid and Euthyroid Patients

Levent Cerit

To the Editor,

I have read with great interest the article entitled “Predictors of Atrial Fibrillation Recurrence in Hyperthyroid and Euthyroid Patients” by Gürdogan et al., recently published in Arquivos Brasileiros de Cardiologia. The investigators reported that rates of atrial fibrillation (AF) recurrence were similar in hyperthyroid and euthyroid patients and that the duration of AF was the only predictor of AF recurrence in both.

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Case Report

Drug-Coated Balloon Treatment of Very Late Stent Thrombosis Due to Complicated Neoatherosclerosis

Fernando Alfonso et al. Teresa Bastante Javier Cuesta Amparo Benedicto Fernando Rivero

Abstract

We describe the treatment of a patient presenting with very-late stent thrombosis with the use of a drug-coated balloon. In this patient, optical coherence tomography disclosed that ruptured and complicated neoatherosclerosis was the underlying substrate responsible for the episode of very-late stent thrombosis. The potential use of drug-coated balloons in this unique scenario is discussed.

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Image

Left Ventricular Rigid Body Rotation in Ebstein's Anomaly from the MAGYAR-Path Study

Attila Nemes et al. Kálmán Havasi Péter Domsik Anita Kalapos Tamás Forster

A 70-year-old female patient with Ebstein’s anomaly (EA) that had never undergone palliation was assessed (the case originates from the MAGYAR-Path Study). Complete two-dimensional (2D) Doppler and three-dimensional (3D) speckle-tracking echocardiography were carried out with commercially available Toshiba Artida^™ echocardiography equipment. During 2D echocardiography, the septal leaflet-tricuspid annulus distance showed to be 25 mm, confirming EA. While the right ventricle (RV) was enlarged with tricuspid annular plane systolic excursion > 23 mm and mitral regurgitation grade III, left ventricular (LV) size and function showed to be normal with an ejection fraction of 56% without wall motion abnormalities. However, all LV regions moved in almost the same counterclockwise direction, confirming absence of LV twist, called “rigid body rotation” (RBR) (). The mean global LV radial, circumferential, longitudinal, 3D and area strain parameters showed to be 11.5 ± 10.0%, -25.5 ± 15.4%, -18.6 ± 10.2%, 15.2 ± 10.8% and -34.7 ± 20.8%, respectively. EA is a congenital heart defect in which septal and posterior leaflets of the tricuspid valve are displaced towards the RV apex, leading to RV partial atrialization, although the anatomic annulus of the valve is in the normal position. Malformation and displacement of the anterior leaflet can also be present. To the best of our knowledge, this is the first report to demonstrate LV-RBR, a known feature in LV myocardial mechanics, in a single patient with unrepaired EA. LV-RBR could be partially explained by the impaired ventricle-to-ventricle interactions due to displaced tricuspid valve leaflet attachments, alterations in the anatomic myocardial fiber orientation, but other reasons could also not be excluded.

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Original Article

Mortality from Circulatory System Diseases and Malformations in Children in the State of Rio de Janeiro

Thais Rocha Salim et al. Gabriel Porto Soares Carlos Henrique Klein Glaucia Maria Moraes de Oliveira

Abstract

Background:

The epidemiological profile of mortality in a population is important for the institution of measures to improve health care and reduce mortality

Objective:

To estimate mortality rates and the proportional mortality from cardiovascular diseases and malformations of the circulatory system in children and adolescents.

Methods:

This is a descriptive study of mortality from cardiovascular diseases, malformations of the circulatory system, from all causes, ill-defined causes and external causes in children and adolescents in the state of Rio de Janeiro from 1996 to 2012. Populations were obtained from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE) and deaths obtained from the Department of Informatics of the Unified Health System (DATASUS)/Ministry of Health.

Results:

There were 115,728 deaths from all causes, 69,757 in males. The annual mortality from cardiovascular diseases was 2.7/100,000 in men and 2.6/100,000 in women. The annual mortality from malformations of the circulatory system was 7.5/100,000 in men and 6.6/100,000 in women. Among the specific causes of circulatory diseases, cardiomyopathies had the highest rates of annual proportional mortality, and from malformations of the circulatory system, it occurred due to unspecified malformations of the circulatory system, at all ages and in both genders.

Conclusion:

Mortality from malformations of the circulatory system was most striking in the first years of life, while cardiovascular diseases were more relevant in adolescents. Low access to prenatal diagnosis or at birth probably prevented the proper treatment of malformations of the circulatory system.

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Original Article

Transcatheter Aortic Valve Implantation and Morbidity and Mortality-Related Factors: a 5-Year Experience in Brazil

André Luiz Silveira Souza et al. Constantino González Salgado Ricardo Mourilhe-Rocha Evandro Tinoco Mesquita … Luciana Cristina Lima Correia Lima Nelson Durval Ferreira Gomes de Mattos Arnaldo Rabischoffsky Francisco Eduardo Sampaio Fagundes Alexandre Siciliano Colafranceschi Luiz Antonio Ferreira Carvalho

Abstract

Background:

Transcatheter aortic valve implantation has become an option for high-surgical-risk patients with aortic valve disease.

Objective:

To evaluate the in-hospital and one-year follow-up outcomes of transcatheter aortic valve implantation.

Methods:

Prospective cohort study of transcatheter aortic valve implantation cases from July 2009 to February 2015. Analysis of clinical and procedural variables, correlating them with in-hospital and one-year mortality.

Results:

A total of 136 patients with a mean age of 83 years (80-87) underwent heart valve implantation; of these, 49% were women, 131 (96.3%) had aortic stenosis, one (0.7%) had aortic regurgitation and four (2.9%) had prosthetic valve dysfunction. NYHA functional class was III or IV in 129 cases (94.8%). The baseline orifice area was 0.67 ± 0.17 cm² and the mean left ventricular-aortic pressure gradient was 47.3±18.2 mmHg, with an STS score of 9.3% (4.8%-22.3%). The prostheses implanted were self-expanding in 97% of cases. Perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and one-year mortality, 15.5%. Blood transfusion (relative risk of 54; p = 0.0003) and pulmonary arterial hypertension (relative risk of 5.3; p = 0.036) were predictive of in-hospital mortality. Peak C-reactive protein (relative risk of 1.8; p = 0.013) and blood transfusion (relative risk of 8.3; p = 0.0009) were predictive of 1-year mortality. At 30 days, 97% of patients were in NYHA functional class I/II; at one year, this figure reached 96%.

Conclusion:

Transcatheter aortic valve implantation was performed with a high success rate and low mortality. Blood transfusion was associated with higher in-hospital and one-year mortality. Peak C-reactive protein was associated with one-year mortality.

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Original Article

Association between Spirituality and Adherence to Management in Outpatients with Heart Failure

Juglans Souto Alvarez et al. Livia Adams Goldraich Alice Hoefel Nunes Mônica Cristina Brugalli Zandavalli … Rafaela Brugalli Zandavalli Karlyse Claudino Belli Neusa Sica da Rocha Marcelo Pio de Almeida Fleck Nadine Clausell

Abstract

Background:

Spirituality may influence how patients cope with their illness.

Objectives:

We assessed whether spirituality may influence adherence to management of outpatients with heart failure.

Methods:

Cross sectional study enrolling consecutive ambulatory heart failure patients in whom adherence to multidisciplinary treatment was evaluated. Patients were assessed for quality of life, depression, religiosity and spirituality utilizing validated questionnaires. Correlations between adherence and psychosocial variables of interest were obtained. Logistic regression models explored independent predictors of adherence.

Results:

One hundred and thirty patients (age 60 ± 13 years; 67% male) were interviewed. Adequate adherence score was observed in 38.5% of the patients. Neither depression nor religiosity was correlated to adherence, when assessed separately. Interestingly, spirituality, when assessed by both total score sum (r = 0.26; p = 0.003) and by all specific domains, was positively correlated to adherence. Finally, the combination of spirituality, religiosity and personal beliefs was an independent predictor of adherence when adjusted for demographics, clinical characteristics and psychosocial instruments.

Conclusion:

Spirituality, religiosity and personal beliefs were the only variables consistently associated with compliance to medication in a cohort of outpatients with heart failure. Our data suggest that adequately addressing these aspects on patient’s care may lead to an improvement in adherence patterns in the complex heart failure management.

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Review Article

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows

Fernando Nobre et al. Décio Mion Junior

Abstract

Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring – ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

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Original Article

Functional Class in Children with Idiopathic Dilated Cardiomyopathy. A pilot Study

Aline Cristina Tavares et al. Edimar Alcides Bocchi Guilherme Veiga Guimarães

Abstract

Background:

Idiopathic dilated cardiomyopathy (IDCM), most common cardiac cause of pediatric deaths, mortality descriptor: a low left ventricular ejection fraction (LVEF) and low functional capacity (FC). FC is never self reported by children.

Objective:

The aims of this study were (i) To evaluate whether functional classifications according to the children, parents and medical staff were associated. (iv) To evaluate whether there was correlation between VO₂ max and Weber’s classification.

Method:

Prepubertal children with IDCM and HF (by previous IDCM and preserved LVEF) were selected, evaluated and compared. All children were assessed by testing, CPET and functional class classification.

Results:

Chi-square test showed association between a CFm and CFp (1, n = 31) = 20.6; p = 0.002. There was no significant association between CFp and CFc (1, n = 31) = 6.7; p = 0.4. CFm and CFc were not associated as well (1, n = 31) = 1.7; p = 0.8. Weber’s classification was associated to CFm (1, n = 19) = 11.8; p = 0.003, to CFp (1, n = 19) = 20.4; p = 0.0001and CFc (1, n = 19) = 6.4; p = 0.04).

Conclusion:

Drawing were helpful for children’s self NYHA classification, which were associated to Weber’s stratification.

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Original Article

Influence of Smoking Consumption and Nicotine Dependence Degree in Cardiac Autonomic Modulation

Ana Paula Soares dos Santos et al. Dionei Ramos Gabriela Martins de Oliveira Ana Alice Soares dos Santos … Ana Paula Coelho Figueira Freire Juliana Tiyaki Ito Renato Peretti Prieto Fernandes Luiz Carlos Marques Vanderlei Ercy Mara Cipulo Ramos

Abstract

Background:

Smoking consumption alters cardiac autonomic function.

Objective:

Assess the influence of the intensity of smoking and the nicotine dependence degree in cardiac autonomic modulation evaluated through index of heart rate variability (HRV).

Methods:

83 smokers, of both genders, between 50 and 70 years of age and with normal lung function were divided according to the intensity of smoking consumption (moderate and severe) and the nicotine dependency degree (mild, moderate and severe). The indexes of HRV were analyzed in rest condition, in linear methods in the time domain (TD), the frequency domain (FD) and through the Poincaré plot. For the comparison of smoking consumption, unpaired t test or Mann-Whitney was employed. For the analysis between the nicotine dependency degrees, we used the One-way ANOVA test, followed by Tukey’s post test or Kruskal-Wallis followed by Dunn’s test. The significance level was p < 0,05.

Results:

Differences were only found when compared to the different intensities of smoking consumption in the indexes in the FD. LFun (62.89 ± 15.24 vs 75.45 ± 10.28), which corresponds to low frequency spectrum component in normalized units; HFun (37.11 ± 15.24 vs 24.55 ± 10.28), which corresponds to high frequency spectrum component in normalized units and in the LF/HF ratio (2.21 ± 1.47 vs 4.07 ± 2.94). However, in the evaluation of nicotine dependency, significant differences were not observed (p > 0.05).

Conclusion:

Only the intensity of smoking consumption had an influence over the cardiac autonomic modulation of the assessed tobacco smokers. Tobacco smokers with severe intensity of smoking consumption presented a lower autonomic modulation than those with moderate intensity.

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Original Article

Early Markers of Atherosclerotic Disease in Individuals with Excess Weight and Dyslipidemia

Eduardo Menti et al. Denise Zaffari Thais Galarraga João Regis da Conceição e Lessa … Bruna Pontin Lucia Campos Pellanda Vera Lúcia Portal

Abstract

Background:

Excessive weight is a cardiovascular risk factor since it generates a chronic inflammatory process that aggravates the endothelial function.

Objective:

To evaluate the endothelial function in individuals with excess weight and mild dyslipidemia using brachial artery flow-mediated dilation (BAFMD), and the association of endothelial function with anthropometric and biochemical variables.

Methods:

Cross-sectional study that included 74 individuals and evaluated anthropometric variables (body mass index [BMI], waist-hip ratio [WHR], waist circumference [AC], and percentage of body fat [PBF]), biochemical (blood glucose, insulinemia, ultrasensitive C-reactive protein, fibrinogen, total cholesterol, HDL-cholesterol, triglycerides, and LDL-cholesterol) and endothelial function (BAFMD, evaluated by ultrasound). The statistical analysis was performed with SPSS, version 16.0. To study the association between the variables, we used chi-square, Student’s t and Mann-Whitney tests, and Pearson’s correlation. Logistic regression analyzed the independent influence of the factors. Values of p < 0.05 were considered significant.

Results:

The participants had a mean age of 50.8 years, and 57% were female. BMI, WC, WHR, and PBF showed no significant association with BAFMD. The male gender (p = 0.02) and higher serum levels of fibrinogen (p = 0.02) were significantly and independently associated with a BAFMD below 8%.

Conclusions:

In individuals with excess weight and mild untreated dyslipidemia, male gender and higher levels of fibrinogen were independently associated with worse BAFMD.

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Original Article

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care

Kenia Vieira da Silva et al. Maria Luiza Garcia Rosa Antônio José Lagoeiro Jorge Adson Renato Leite … Dayse Mary Silva Correia Davi de Sá Silva Diego Bragatto Cetto Andreia da Paz Brum Pedro Silveira Netto Gustavo Domingos Rodrigues

Abstract

Background:

Obstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women.

Objective:

To study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied.

Methods:

Observational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05).

Results:

Of the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III.

Conclusion:

BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.

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Original Article

The Labdane Ent-3-Acetoxy-Labda-8(17), 13-Dien-15-Oic Decreases Blood Pressure In Hypertensive Rats

Janaina A. Simplicio et al. Marilia R. Simão Sergio R. Ambrosio Carlos R. Tirapelli

Abstract

Background:

Labdane-type diterpenes induce lower blood pressure via relaxation of vascular smooth muscle; however, there are no studies describing the effects of labdanes in hypertensive rats.

Objective:

The present study was designed to investigate the cardiovascular actions of the labdane-type diterpene ent-3-acetoxy-labda-8(17), 13-dien-15-oic acid (labda-15-oic acid) in two-kidney 1 clip (2K-1C) renal hypertension.

Methods:

Vascular reactivity experiments were performed in aortic rings isolated from 2K-1C and normotensive (2K) male Wistar rats. Nitrate/nitrite (NOx) measurement was performed in aortas by colorimetric assay. Blood pressure measurements were performed in conscious rats.

Results:

Labda-15-oic acid (0.1-300 µmol/l) and forskolin (0.1 nmol/l – 1 µmol/l) relaxed endothelium-intact and endothelium-denuded aortas from both 2K-1C and 2K rats. Labda-15-oic acid was more effective at inducing relaxation in endothelium-intact aortas from 2K pre-contracted with phenylephrine when compared to the endothelium-denuded ones. Forskolin was more potent than labda-15-oic acid at inducing vascular relaxation in arteries from both 2K and 2K-1C rats. Labda-15-oic acid-induced increase in NOx levels was lower in arteries from 2K-1C rats when compared to 2K rats. Intravenous administration of labda-15-oic acid (0.3-3 mg/kg) or forskolin (0.1-1 mg/kg) induced hypotension in conscious 2K-1C and 2K rats.

Conclusion:

The present findings show that labda-15-oic acid induces vascular relaxation and hypotension in hypertensive rats.

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