2017;108(1) – ABC CARDIOL

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Original Article

Multiprofessional Treatment of High Blood Pressure in Very Elderly Patients

Luciana Muniz Sanches Siqueira Veiga Jardim et al. Thiago Veiga Jardim Weimar Kunz Sebba Barroso de Souza Camila Dutra Pimenta … Ana Luiza Lima Sousa Paulo César Brandão Veiga Jardim

Abstract

Background:

As the world population ages, patients older than 80 years, known as very elderly, are more frequently found. There are no studies in this age group aimed at analyzing the multidisciplinary intervention in the treatment of systemic arterial hypertension (SAH) and some comorbidities.

Objectives:

To assess the effect of a multidisciplinary approach in very elderly hypertensives cared for at a specialized service.

Methods:

Longitudinal retrospective cohort study in a multidisciplinary service specialized in the SAH treatment in the Brazilian West-Central region. Patients aged 80 years and older by June 2015 were included. Data from the first (V1) and last visit (Vf) were assessed. Anthropometric variables, blood pressure (BP), renal function, pharmacological treatment, lifestyle, comorbidities and cardiovascular events were studied, comparing data from V1 and Vf. Controlled BP was defined as systolic blood pressure (SBP) lower than 140 mm Hg and diastolic blood pressure (DBP) lower than 90 mm Hg. Statistical analyses were performed with SPSSR software, version 21.0. Values of p<0,05 were considered significant.

Results:

Data of 71 patients were assessed with a mean follow-up time of 15,22 years. Their mean age at V1 was 69.2 years, and, at Vf, 84.53 years, and 26.8% of them were males. There was a significant reduction in mean SBP (157.3 x 142.1 mm Hg; p<0.001) and DBP (95.1 x 77.8 mm Hg; p<0.001), with an increase in BP control rates from V1 to Vf (36.6 x 83.1%; p<0.001). The number of antihypertensive drugs used increased (1.49 x 2.85; p<0.001), with an increase in the use of angiotensin-converting enzyme inhibitors (22.5 x 46.5%; p=0.004), angiotensin II receptor blockers (4.2 x 35.2%; p<0.001) and calcium-channel blockers (18.3 x 67.6%; p<0.001). There was a reduction in total cholesterol (217.9 x 191 mg/dL; p<0.001) and LDL-cholesterol (139.6 x 119.0 mg/dL; p<0.001), but worsening of the glomerular filtration rate (62.5 x 45.4 mL/min; p<0.001).

Conclusion:

The multidisciplinary intervention in very elderly hypertensives increased BP control rate, with optimization of the pharmacological treatment.

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Original Article

Intima-Media Thickness in the Carotid and Femoral Arteries for Detection of Arteriosclerosis in Human Immunodeficiency Virus-Positive Individuals

Emmanuelle Tenório Albuquerque Madruga Godoi et al. Carlos Teixeira Brandt Heloisa Ramos Lacerda Jocelene Tenório Albuquerque Madruga Godoi … Dinaldo Cavalcanti de Oliveira Gabriela Farias Araujo Sousa Costa Gerson Gomes dos Santos Junior Kaliene Maria Estevão Leite Juannicelle Tenório Albuquerque Madruga Godoi Adriana Ferraz de Vasconcelos

Abstract

Background:

The prevalence of atherosclerosis is higher in HIV-positive people, who also experience it earlier than the general population.

Objectives:

To assess and compare the prevalence of atherosclerosis evaluated by the intima-media thickness of carotid and femoral arteries, and by the ankle-brachial pressure index (ABPI) in HIV patients treated or not treated with protease inhibitors (PIs) and controls.

Methods:

Eighty HIV+ subjects (40 using PIs and 40 not using PIs) and 65 controls were included in the study. Atherosclerosis was diagnosed by (carotid and femoral) ITM measurement and ABPI. Classical risk factors for atherosclerosis and HIV were compared between the groups by statistical tests. A p ≤ 0.05 was considered significant.

Results:

An IMT > P₇₅ or the presence of plaque was higher in the HIV+ than in the control group (37.5% vs 19%, p = 0.04). Comparative analysis showed a significant difference (p=0.014) in carotid IMT between HIV+ with PIs (0.71 ± 0.28 mm), without PIs 0.63 ± 0.11 mm and, and controls (0.59 ± 0.11 mm). There was no significant difference in femoral IMT between the groups or in ABPI between HIV+ subjects and controls. However, a significant difference (p=0.015) was found between HIV+ patients not treated with PIs (1.17 [1.08 – 1.23]), and controls 1.08 [1.07 – 1.17]).

Conclusion:

In HIV patients, atherosclerosis is more prevalent and seems to occur earlier with particular characteristics compared with HIV-negative subjects.

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Letter to the Editor

Recommendation of Early Surgery in Primary Mitral Regurgitation: Pros and Cons

To the Editor,

I have read the article entitled “Recommendation of Early Surgery in Primary Mitral Regurgitation: Pros and Cons” by Rosa et al. with great interest, recently published in Arquivos Brasileiros de Cardiologia 2016; 107: 173-5. The investigators reported that currently, the recommendation of mitral surgery for asymptomatic patients is very controversial, since the indication of valvular intervention for symptoms, left ventricular dysfunction and dilatation, recent onset atrial fibrillation or pulmonary arterial hypertension is well consolidated in literature.

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Viewpoint

The CRISPR/Cas9 System and the Possibility of Genomic Edition for Cardiology

Marcela Corso Arend et al. Jessica Olivaes Pereira Melissa Medeiros Markoski

Introduction

Cardiovascular diseases (CVD) and their associated pathologies are among the greatest causes of morbidity and mortality, entailing approximately 17.3 deaths a year. This class of pathology as a whole has a multi-factor etiology. Its possible prognoses lead to public health issues, with its incidence being related to behavioral, metabolic and genetic risk factors. In spite of the fact that the treatments established for the CVDs and their possible prognoses decrease the rhythm of progression of the illness, the need to develop therapeutic approaches able to reverse the pathology and its complications is growing.

The progresses in the fields of molecular and cellular biology have allowed the elucidation of molecular pathways and genetic causes involved in the establishment and progression of the CVDs, outlining a new viewpoint with regard to the prevention, treatment and possible outcomes of this pathological class. Recent discoveries, both experimental and those obtained by means of bioinformatics tools, regarding the molecular bases of cardiovascular dysfunctions, have been pointing to considerable therapeutic targets. However, most of these targets cannot be pharmacologically manipulated, which makes them potential candidates for genic therapy, such as the factors involved, for example, in angiogenesis, apoptosis and endothelial dysfunction. Within such context, gene manipulation may help suppress genetic factors connected to the incidence of the CVDs, as well as to mitigate the clinical complications caused by ischemic and occlusive events. Thus, the development and improvement of genome edition tools allow the creation of therapies focused in the genetic risk factors to cardiovascular damage and fundamental morphophysiological issues caused by the CVDs. In such context, the system formed by clustered regularly interspaced short palindromic repeats (CRISPR), and its CRISPR associated protein-9 (Cas9), stands out due to how easy it is to use it, its high specificity, easy in vitro and in vivo manipulation, in addition to the possibility of simultaneously editing multiple targets. Given the genomic complexity that intervenes in the CVDs, we shall indicate herein certain possibilities of applying the CRISPR/Cas9 tool in Cardiology.

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Editorial

Impact of Brazilian papers in cardiology and cardiovascular sciences in the last decade

Luiz Felipe P. Moreira

During the last decade, there has been a significant increase in the number of Brazilian publications in cardiology and cardiovascular sciences in important international citation indexing platforms. This occurred in Brazil and in most Latin American countries at approximately 13% per year between 1999 and 2008 according to the study by Colantionio et al. This represents nearly 3% of all articles published in international journals indexed in the Web of Science platform, maintained by Thompson-Reuters, and Scopus-Scimago, provided by Elsevier.

Although most of our indexed articles have been published in international journals, the citation indexes achieved by Brazilian and Latin American authors are usually lower than those from countries with higher income or higher Human Development Index. This is even more evident for studies conducted in national institutions in comparison with those developed with some degree of international cooperation.

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Clinicoradiological Session

Case 1/2017 – Percutaneous Repair of Right Atrioventricular Valve Insufficiency and Blalock-Taussig Shunt after Fontan Operation in Single Ventricle

Edmar Atik et al. Renata Sá Cassar Raul Arrieta

Clinical data

Twenty-seven-year old male patient reporting tiredness during exercise for three years, after total cavopulmonary connection with extracardiac conduit fenestration and closure with stiches of the free end of right atrioventricular valve (AV) for severe failure in double inlet left ventricle, pulmonary atresia, and aorta arising from rudimentary right ventricle. The patient had undergone right and left Blalock-Taussig shunts at 17 days and 9 months, respectively, and bidirectional Glenn shunt at 19 years old. The patient had arterial oxygen saturation of 84-88% during exercise and 93% at rest.

Physical exam: eupneic, cyanotic, normal pulse rate, with no jugular vein dilation. Weight: 61 Kg, Height: 163 cm, BP: 110/70 mm Hg, HR: 97 bpm, oxygen saturation = 87%. The aorta was palpable in the supra-sternal notch (grade 2).

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Case Report

Case Report: Multivessel Coronary Disease Assessment with SPECT 99mTc-Sestamibi and Rubidium-82 PET/CT

Bruno Gomes Padilha et al. Daniela Sabino Maria Clementina Giorgi José Soares Jr. … Marisa Izaki José Claudio Meneghetti

Introduction

Coronary angiography (CAG) is the standard diagnostic method for detection of coronary artery disease (CAD). However, it is often necessary to evaluate the expression of a coronary obstruction in relation to myocardial perfusion, before defining the best patient management.

Myocardial perfusion scintigraphy with technetium-99m-Sestamibi (^99mTc-sestamibi) allows early detection and evaluation of disease extension and cardiovascular risk in patients with suspected or established CAD, helping in decision-making regarding the start and type of therapy to be implemented. This method has been widely used, but shows difficulties in some situations such as balanced multivessel disease, in which the proportional flow distribution in the myocardial regions can hinder ischemia detection. In such cases, additional assessment data, such as evaluation of contractility, decrease in left ventricular ejection fraction (LVEF) under stress, electrocardiographic alterations or symptoms during stress, dilation of the left ventricle (LV) cavity under stress can provide evidence of ischemia, indicating further diagnostic investigation.

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Original Article

Impact of High Risk for Obstructive Sleep Apnea on Survival after Acute Coronary Syndrome: Insights from the ERICO Registry

Flavia C Maia et al. Alessandra C. Goulart Luciano F. Drager Henrique L. Staniak … Itamar de Souza Santos Paulo Andrade Lotufo Isabela M. Bensenor

Abstract

Background:

Obstructive sleep apnea (OSA) is a very often clinical condition that can be associated with high mortality risk, particularly in coronary heart disease (CHD). The diagnosis of OSA is not always accessible via the gold-standard method polysomnography.

Objective:

To evaluate long-term influence of the high risk for OSA on fatal and non-fatal outcomes after acute coronary syndrome (ACS) in the Acute Coronary Syndrome Registry Strategy (ERICO) Study using the Berlin questionnaire as a surrogate.

Methods:

Berlin questionnaire, a screening questionnaire for OSA, was applied in 639 cases of ACS 30 days after the index event. Cox regression proportional-hazards model was used to calculate the hazard ratio (HR) of all-cause, cardiovascular and CHD (myocardial infarction) mortality, as well as, the combined endpoint of fatal or recurrent non-fatal CHD.

Results:

The high-risk group for OSA had higher frequencies of previous personal/family history of CHD and diabetes, in addition to a poorer event-free survival, as compared to the low-risk group (p-log-rank=0.03). The HR for fatal or recurrent non-fatal CHD was 4.26 (95% confidence interval, 1.18 – 15.36) in patients at high risk for OSA compared to those at low risk for OSA after a 2.6-year mean follow-up.

Conclusions:

Using Berlin questionnaire, we were able to identify high risk for OSA as an independent predictor of non-fatal reinfarction or CHD mortality in post-ACS individuals in a long-term follow-up.

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Brief Communication

Compound Heterozygous SCN5A Mutations in a Toddler – Are they Associated with a More Severe Phenotype?

Luciana Sacilotto et al. Hindalis Ballesteros Epifanio Francisco Carlos da Costa Darrieux Fanny Wulkan … Theo Gremen Mimary Oliveira Denise Tessariol Hachul Alexandre da Costa Pereira Mauricio Ibrahim Scanavacca

Abstract

Compound heterozygosity has been described in inherited arrhythmias, and usually associated with a more severe phenotype. Reports of this occurrence in Brugada syndrome patients are still rare. We report a study of genotype-phenotype correlation after the identification of new variants by genetic testing. We describe the case of an affected child with a combination of two different likely pathogenic SCN5A variants, presenting sinus node dysfunction, flutter and atrial fibrillation, prolonged HV interval, spontaneous type 1 Brugada pattern in the prepubescent age and familiar history of sudden death.

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Original Article

Comparison between Radionuclide Ventriculography and Echocardiography for Quantification of Left Ventricular Systolic Function in Rats Exposed to Doxorubicin

Luciano Fonseca Lemos de Oliveira et al. João Lucas O'Connell Eduardo Elias Vieira de Carvalho Érica Carolina Campos Pulici … Minna Moreira Dias Romano Benedito Carlos Maciel Marcus Vinicius Simões

Abstract

Background:

Radionuclide ventriculography (RV) is a validated method to evaluate the left ventricular systolic function (LVSF) in small rodents. However, no prior study has compared the results of RV with those obtained by other imaging methods in this context.

Objectives:

To compare the results of LVSF obtained by RV and echocardiography (ECHO) in an experimental model of cardiotoxicity due to doxorubicin (DXR) in rats.

Methods:

Adult male Wistar rats serving as controls (n = 7) or receiving DXR (n = 22) in accumulated doses of 8, 12, and 16 mg/kg were evaluated with ECHO performed with a Sonos 5500 Philips equipment (12-MHz transducer) and RV obtained with an Orbiter-Siemens gamma camera using a pinhole collimator with a 4-mm aperture. Histopathological quantification of myocardial fibrosis was performed after euthanasia.

Results:

The control animals showed comparable results in the LVSF analysis obtained with ECHO and RV (83.5 ± 5% and 82.8 ± 2.8%, respectively, p > 0.05). The animals that received DXR presented lower LVSF values when compared with controls (p < 0.05); however, the LVSF values obtained by RV (60.6 ± 12.5%) were lower than those obtained by ECHO (71.8 ± 10.1%, p = 0.0004) in this group. An analysis of the correlation between the LVSF and myocardial fibrosis showed a moderate correlation when the LVSF was assessed by ECHO (r = -0.69, p = 0.0002) and a stronger correlation when it was assessed by RV (r = -0.79, p < 0.0001). On multiple regression analysis, only RV correlated independently with myocardial fibrosis.

Conclusion:

RV is an alternative method to assess the left ventricular function in small rodents in vivo. When compared with ECHO, RV showed a better correlation with the degree of myocardial injury in a model of DXR-induced cardiotoxicity.

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Image

Fatty Left Ventricular Cardiomyopathy: An Under-Diagnosed Disease

Abdalla Elagha et al. Anthon Fuisz

During a preoperative cardiac assessment, a 57-year-old asymptomatic female, without known cardiac risk-factors, was found to have LBBB on ECG. Echocardiography revealed dilated cardiomyopathy. To rule-out coronary artery disease, coronary CT-angiography was performed and showed no significant coronary obstruction.

For further evaluation, a cardiac magnetic resonance (CMR) study was performed. A focal area of fatty infiltration was seen in the left ventricular (LV) apex extending from the subendocardial to the subepicardial surfaces ( and ). This area was suppressed with fat saturation pulse-sequences (), and did not show enhanced signal on delayed-hyperenhancement images (DHE) (). Both LV and LA were dilated; LV systolic function was reduced globally. Additionally, the CMR showed normal RV dimensions, function, and wall-thickness. The fatty area was also seen retrospectively on the cardiac CT ().

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Original Article

Electrocardiogram Performance in the Diagnosis of Left Ventricular Hypertrophy in Hypertensive Patients With Left Bundle Branch Block

Paula Freitas Martins Burgos et al. Bráulio Luna Filho Francisco de Assis Costa Maria Teresa Nogueira Bombig … Dilma de Souza Henrique Tria Bianco Japy Angelini Oliveira Filho Maria Cristina de Oliveira Izar Francisco Antonio Helfenstein Fonseca Rui Póvoa

Abstract

Background:

Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular events, and its detection usually begins with an electrocardiogram (ECG).

Objective:

To evaluate the impact of complete left bundle branch block (CLBBB) in hypertensive patients in the diagnostic performance of LVH by ECG.

Methods:

A total of 2,240 hypertensive patients were studied. All of them were submitted to an ECG and an echocardiogram (ECHO). We evaluated the most frequently used electrocardiographic criteria for LVH diagnosis: Cornell voltage, Cornell voltage product, Sokolow-Lyon voltage, Sokolow-Lyon product, RaVL, RaVL+SV₃, RV₆/RV₅ ratio, strain pattern, left atrial enlargement, and QT interval. LVH identification pattern was the left ventricular mass index (LVMI) obtained by ECHO in all participants.

Results:

Mean age was 11.3 years ± 58.7 years, 684 (30.5%) were male and 1,556 (69.5%) were female. In patients without CLBBB, ECG sensitivity to the presence of LVH varied between 7.6 and 40.9%, and specificity varied between 70.2% and 99.2%. In participants with CLBBB, sensitivity to LVH varied between 11.9 and 95.2%, and specificity between 6.6 and 96.6%. Among the criteria with the best performance for LVH with CLBBB, Sokolow-Lyon, for a voltage of ≥ 3,0mV, stood out with a sensitivity of 22.2% (CI 95% 15.8 – 30.8) and specificity of 88.3% (CI 95% 77.8 – 94.2).

Conclusion:

In hypertensive patients with CLBBB, the most often used criteria for the detection of LVH with ECG showed significant decrease in performance with regards to sensitivity and specificity. In this scenario, Sokolow-Lyon criteria with voltage ≥3,0mV presented the best performance.

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Original Article

Speckle Tracking and Transthyretin Amyloid Cardiomyopathy

Alexandre Marins Rocha et al. Suzane Garcia Ferreira Marcelo Souto Nacif Mario Luiz Ribeiro … Marcos Raimundo Gomes de Freitas Cláudio Tinoco Mesquita

Abstract

Background:

Amyloidosis is a disease caused by deposits of insoluble fibrils in extracellular spaces. The most common type of familial amyloidosis is mediated by mutation of transthyretin, especially Val30Met. Symptoms and ejection fraction decrease may occur in cardiac amyloidosis only in case of poor prognosis. Myocardial strain detected by two-dimensional speckle tracking echocardiography can indicate changes in myocardial function at early stages of the disease.

Objective:

To determine the accuracy of left ventricular longitudinal strain by two-dimensional speckle tracking echocardiography in patients with familial amyloidosis caused by Val30Met transthyretin mutation.

Methods:

Eighteen consecutive patients, carriers of transthyretin mutation, were evaluated by two-dimensional speckle tracking echocardiography, by which myocardial strain curves were obtained, following the American Society of Echocardiography recommendations.

Results:

Patients were divided into three groups: 1- Val30Met with cardiac amyloidosis; 2-Val30Met with extracardiac amyloidosis; 3 – Val30Met without evidence of disease. As the three groups were compared by the Mann-Whitney test, we found a statistically significant difference between groups 1 and 2 in the mean longitudinal tension (p=0.01), mean basal longitudinal strain (p=0.014); in mean longitudinal tension and mean longitudinal strain between groups 1 and 3 (p=0.005); and in the ratio of longitudinal strain of apical septum segment to longitudinal strain of basal septum (p=0.041) between groups 2 and 3.

Conclusion:

Left ventricular longitudinal strain detected by two-dimensional speckle tracking echocardiography is able to diagnose left ventricular dysfunction in early stages of familial amyloidosis caused by transthyretin Val30Met mutation.

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Research Article

Lifestyle Intervention on Metabolic Syndrome and its Impact on Quality of Life: A Randomized Controlled Trial

Patrícia Pozas Saboya et al. Luiz Carlos Bodanese Paulo Roberto Zimmermann Andreia da Silva Gustavo … Fabricio Edler Macagnan Ana Pandolfo Feoli Margareth da Silva Oliveira

Abstract

Background:

Lifestyle intervention programs can reduce the prevalence of metabolic syndrome (MetS) and, therefore, reduce the risk for cardiac disease, one of the main public health problems nowadays.

Objective:

The aim of this study was to compare the effects of three types of approach for lifestyle change programs in the reduction of metabolic parameters, and to identify its impact on the quality of life (QOL) of individuals with MetS.

Methods:

A randomized controlled trial included 72 individuals with MetS aged 30-59 years. Individuals were randomized into three groups of multidisciplinary intervention [Standard Intervention (SI) – control group; Group Intervention (GI); and Individual Intervention (II)] during 12 weeks. The primary outcome was change in the metabolic parameters, and secondarily, the improvement in QOL measures at three moments: baseline, 3 and 9 months.

Results:

Group and individual interventions resulted in a significant reduction in body mass index, waist circumference, systolic blood pressure at 3 months and the improvement of QOL, although it was significantly associated with the physical functioning domain. However, these changes did not remain 6 months after the end of intervention. Depression and anxiety were significantly associated with worse QOL, although they showed no effect on the response to intervention.

Conclusion:

Multidisciplinary intervention, especially in a group, might be an effective and economically feasible strategy in the control of metabolic parameters of MetS and improvement of QOL compared to SI, even in a dose-effect relationship.

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Original Article

Comparative Study between Perfusion Changes and Positive Findings on Coronary Flow Reserve

Costantino Roberto Frack Costantini et al. Jose Antonio Ramires Costantino Ortiz Costantini Marcos Antonio Denk … Sergio Gustavo Tarbine Marcelo de Freitas Santos Daniel Aníbal Zanuttini Carmen Weigert Silveira Admar Moraes de Souza Rafael Michel de Macedo

Abstract

Background:

Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used.

Objective:

To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction.

Methods:

Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies.

Results:

All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed.

Conclusion:

Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS.

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Review Article

Cardiac Cachexia: Perspectives for Prevention and Treatment

Marina Politi Okoshi et al. Rafael Verardino Capalbo Fernando G Romeiro Katashi Okoshi

Abstract

Cachexia is a prevalent pathological condition associated with chronic heart failure. Its occurrence predicts increased morbidity and mortality independent of important clinical variables such as age, ventricular function, or heart failure functional class. The clinical consequences of cachexia are dependent on both weight loss and systemic inflammation, which accompany cachexia development. Skeletal muscle wasting is an important component of cachexia; it often precedes cachexia development and predicts poor outcome in heart failure. Cachexia clinically affects several organs and systems. It is a multifactorial condition where underlying pathophysiological mechanisms are not completely understood making it difficult to develop specific prevention and treatment therapies. Preventive strategies have largely focused on muscle mass preservation. Different treatment options have been described, mostly in small clinical studies or experimental settings. These include nutritional support, neurohormonal blockade, reducing intestinal bacterial translocation, anemia and iron deficiency treatment, appetite stimulants, immunomodulatory agents, anabolic hormones, and physical exercise regimens. Currently, nonpharmacological therapy such as nutritional support and physical exercise are considered central to cachexia prevention and treatment.

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