2017;108(5) – ABC CARDIOL

ABC

ABC Family | ABC

Original Article

Factors Associated With Coronary Artery Disease Progression Assessed By Serial Coronary Computed Tomography Angiography

Gabriel Cordeiro Camargo et al. Tamara Rothstein Maria Eduarda Derenne Leticia Sabioni … João A. C. Lima Ronaldo de Souza Leão Lima Ilan Gottlieb

Abstract

Background:

Coronary computed tomography angiography (CCTA) allows for noninvasive coronary artery disease (CAD) phenotyping. Factors related to CAD progression are epidemiologically valuable.

Objective:

To identify factors associated with CAD progression in patients undergoing sequential CCTA testing.

Methods:

We retrospectively analyzed 384 consecutive patients who had at least two CCTA studies between December 2005 and March 2013. Due to limitations in the quantification of CAD progression, we excluded patients who had undergone surgical revascularization previously or percutaneous coronary intervention (PCI) between studies. CAD progression was defined as any increase in the adapted segment stenosis score (calculated using the number of diseased segments and stenosis severity) in all coronary segments without stent (in-stent restenosis was excluded from the analysis). Stepwise logistic regression was used to assess variables associated with CAD progression.

Results:

From a final population of 234 patients, a total of 117 (50%) had CAD progression. In a model accounting for major CAD risk factors and other baseline characteristics, only age (odds ratio [OR] 1.04, 95% confidence interval [95%CI] 1.01-1.07), interstudy interval (OR 1.03, 95%CI 1.01-1.04), and past PCI (OR 3.66, 95%CI 1.77-7.55) showed an independent relationship with CAD progression.

Conclusions:

A history of PCI with stent placement was independently associated with a 3.7-fold increase in the odds of CAD progression, excluding in-stent restenosis. Age and interstudy interval were also independent predictors of progression.

Read Full Article

Original Article

Relationship between Resting Heart Rate, Blood Pressure and Pulse Pressure in Adolescents

Diego Giulliano Destro Christofaro et al. Juliano Casonatto Luiz Carlos Marques Vanderlei Gabriel Grizzo Cucato Raphael Mendes Ritti Dias

Abstract

Background:

High resting heart rate is considered an important factor for increasing mortality chance in adults. However, it remains unclear whether the observed associations would remain after adjustment for confounders in adolescents.

Objectives:

To analyze the relationship between resting heart rate, blood pressure and pulse pressure in adolescents of both sexes.

Methods:

A cross-sectional study with 1231 adolescents (716 girls and 515 boys) aged 14-17 years. Heart rate, blood pressure and pulse pressure were evaluated using an oscillometric blood pressure device, validated for this population. Weight and height were measured with an electronic scale and a stadiometer, respectively, and waist circumference with a non-elastic tape. Multivariate analysis using linear regression investigated the relationship between resting heart rate and blood pressure and pulse pressure in boys and girls, controlling for general and abdominal obesity.

Results:

Higher resting heart rate values were observed in girls (80.1 ± 11.0 beats/min) compared to boys (75.9 ± 12.7 beats/min) (p ≤ 0.001). Resting heart rate was associated with systolic blood pressure in boys (Beta = 0.15 [0.04; 0.26]) and girls (Beta = 0.24 [0.16; 0.33]), with diastolic blood pressure in boys (Beta = 0.50 [0.37; 0.64]) and girls (Beta = 0.41 [0.30; 0.53]), and with pulse pressure in boys (Beta = -0.16 [-0.27; -0.04]).

Conclusions:

This study demonstrated a relationship between elevated resting heart rate and increased systolic and diastolic blood pressure in both sexes and pulse pressure in boys even after controlling for potential confounders, such as general and abdominal obesity.

Read Full Article

Original Article

Degree of Agreement between Cardiovascular Risk Stratification Tools

Guilherme Thomé Garcia et al. Ana Maria Nunes de Faria Stamm Ariel Córdova Rosa Antônio Carlos Marasciulo … Rodrigo Conill Marasciulo Cristian Battistella Alexandre Augusto de Costa Remor

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in Brazil, and primary prevention care may be guided by risk stratification tools. The Framingham (FRS) and QRISK-2 (QRS) risk scores estimate 10-year overall cardiovascular risk in asymptomatic individuals, but the instrument of choice may lead to different therapeutic strategies.

Objective:

To evaluate the degree of agreement between FRS and QRS in 10-year overall cardiovascular risk stratification in disease-free individuals.

Methods:

Cross-sectional, observational, descriptive and analytical study in a convenience sample of 74 individuals attending the outpatient care service of a university hospital in Brazil between January 2014 and January 2015. After application of FRS and QRS, patients were classified in low/moderate risk (< 20%) or high risk (≥ 20%).

Results:

The proportion of individuals classified as at high risk was higher in FRS than in QRS (33.7% vs 21.6%). A synergic effect of male gender with systemic arterial hypertension was observed in both tools, and with for geriatric age group in QRS (p < 0.05) in high-risk stratum. The Kappa index was 0.519 (95%CI = 0.386-0.652; p < 0.001) between both instruments.

Conclusion:

There was a moderate agreement between FRS and QRS in estimating 10-year overall cardiovascular risk. The risk scores used in this study can identify synergism between variables, and their behavior is influenced by the population in which it was derived. It is important to recognize the need for calibrating risk scores for the Brazilian population.

Read Full Article

Anatomopathological Session

Case 2/2017 – 56-Year-Old Male with Refractory Heart Failure, Systemic Arterial Hypertension and Aortic Valve Stenosis That Led to Heart Transplantation

Desidério Favarato et al. Paulo Sampaio Gutierrez

Clinical aspects

The 56-year-old male patient, who smoked and had arterial hypertension and hypertriglyceridemia, developed heart failure with dilatation of heart chambers and severe systolic dysfunction. His echocardiography showed low-gradient aortic stenosis.

According to the Brazilian Society of Cardiology III Guideline on Heart Failure, a patient with signs and symptoms of heart failure should undergo some tests to characterize the heart failure, such as resting electrocardiography, chest X ray, echocardiography and BNP measurement. Then, laboratory and invasive tests, such as coronary cineangiography and cardiac biopsy, should be performed for etiological diagnosis.

[…]

Read Full Article

Special Article

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors´ Network

Fernando Alfonso et al. Karlen Adamyan Jean-Yves Artigou Michael Aschermann … Michael Boehm Alfonso Buendia Pao-Hsien Chu Ariel Cohen Livio Dei Cas Mirza Dilic Anton Doubell Dario Echeverri Nuray Enç Ignacio Ferreira-González Krzysztof J. Filipiak Andreas Flammer Eckart Fleck Plamen Gatzov Carmen Ginghina Lino Goncalves Habib Haouala Mahmoud Hassanein Gerd Heusch Kurt Huber Ivan Hulín Mario Ivanusa Rungroj Krittayaphong Chu-Pak Lau Germanas Marinskis François Mach Luiz Felipe Moreira Tuomo Nieminen Latifa Oukerraj Stefan Perings Luc Pierard Tatjana Potpara Walter Reyes-Caorsi Se-Joong Rim Olaf Rødevand Georges Saade Mikael Sander Evgeny Shlyakhto Bilgin Timuralp Dimitris Tousoulis Dilek Ural J. J. Piek Albert Varga Thomas F. Lüscher

Abstract

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship – emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology.

Read Full Article

Review Article

Myocardial Viability on Cardiac Magnetic Resonance

Ana Luiza Mansur Souto et al. Rafael Mansur Souto Isabella Cristina Resende Teixeira Marcelo Souto Nacif

Abstract

The study of myocardial viability is of great importance in the orientation and management of patients requiring myocardial revascularization or angioplasty. The technique of delayed enhancement (DE) is accurate and has transformed the study of viability into an easy test, not only for the detection of fibrosis but also as a binary test detecting what is viable or not. On DE, fibrosis equal to or greater than 50% of the segmental area is considered as non-viable, whereas that below 50% is considered viable. During the same evaluation, cardiac magnetic resonance (CMR) may also use other techniques for functional and perfusion studies to obtain a global evaluation of ischemic heart disease. This study aims to highlight the current concepts and broadly emphasize the use of CMR as a method that over the last 20 years has become a reference in the detection of infarction and assessment of myocardial viability.

Read Full Article

Editorial

Challenges of Translational Science

Leonardo R. Garcia et al. Bertha F. Polegato Leonardo A. M. Zornoff

The introduction of standardized therapies for the treatment of major cardiovascular diseases, such as heart failure and myocardial infarction, significantly reduced mortality. However, cardiovascular diseases are still one of the main causes of morbidity and mortality worldwide. Consequently, a large number of experimental studies are published regarding this subject. These studies investigate, in addition to the mechanisms involved in the genesis of cardiovascular disease, potential therapeutic targets, as well as interventions that are beneficial in reducing the size of the ischemic lesion and the progression of cardiac dysfunction and, consequently, decrease mortality.

In some situations, the results of preclinical research are reproducible in clinical studies. As an example, we could cite the influence of obesity on the process of cardiac remodeling. It is accepted that the remodeling process plays a critical role in the onset and progression of cardiac dysfunction secondary to different stimuli. Experimental studies have shown that obesity induces ventricular remodeling, since it has been confirmed in clinical studies.^,

[…]

Read Full Article

Original Article

Self-Reported High-Cholesterol Prevalence in the Brazilian Population: Analysis of the 2013 National Health Survey

Paulo A. Lotufo et al. Raul D. Santos Andrei C. Sposito Marcelo Bertolami … Jose Rocha-Faria Neto M. Cristina Izar Celia Szwarcwald Rogério R. Prado Sheila R. Stoppa Deborah C. Malta Isabela M. Bensenor

Abstract

Background:

Data on the prevalence of dyslipidemia in Brazil are scarce, with surveys available only for some towns.

Objective:

To evaluate the prevalence of the self-reported medical diagnosis of high cholesterol in the Brazilian adult population by use of the 2013 National Health Survey data.

Methods:

Descriptive study assessing the 2013 National Health Survey data, a household-based epidemiological survey with a nationally representative sample and self-reported information. The sample consisted of 60,202 individuals who reported a medical diagnosis of dyslipidemia. The point prevalence and 95% confidence interval (95%CI) for the medical diagnosis of high cholesterol/triglyceride by gender, age, race/ethnicity, geographic region and educational level were calculated. Adjusted odds ratio was calculated.

Results:

Of the 60,202 participants, 14.3% (95%CI=13.7-14.8) never had their cholesterol or triglyceride levels tested, but a higher frequency of women, white individuals, elderly and those with higher educational level had their cholesterol levels tested within the last year. The prevalence of the medical diagnosis of high cholesterol was 12.5% (9.7% in men and 15.1% in women), and women had 60% higher probability of a diagnosis of high cholesterol than men. The frequency of the medical diagnosis of high cholesterol increased up to the age of 59 years, being higher in white individuals or those of Asian heritage, in those with higher educational level and in residents of the Southern and Southeastern regions.

Conclusion:

The importance of dyslipidemia awareness in the present Brazilian epidemiological context must be emphasized to guide actions to control and prevent coronary heart disease, the leading cause of death in Brazil and worldwide.

Read Full Article

Image

Three-Dimensional Printing Model-Guided Percutaneous Closure of Atrial Septal Defect

Hongxing Luo et al. Yu Xu Zhongmin Wang Yuhao Liu Chuanyu Gao

A 32-year-old female with a 2-year history of chest distress was admitted to our department due to exacerbation for 3 days. On physical examination, we found fixed splitting second heart sounds on the patient’s pulmonic area. An echocardiography was performed and showed a 15-mm atrial septal defect of the inferior vena cava type. After obtaining the patient’s consent, a three-dimensional printing cardiac model was printed out. We tried various sizes of ASD occluders on the model to completely cover the defect, which indicated that a 28-mm occluder was appropriate. Thus, we placed a 28-mm ASD occluder during the operation and succeeded after only one attempt. The patient was re-assessed by echocardiography, which showed a favorable position of the ASD occluder without any left-to-right shunt.

Three-dimensional printing (3D printing) is a new technology that converts two-dimensional medical images into a tangible object, allowing not only a comprehensive view of the cardiac anatomical structures but also preoperative simulation to choose the optimal size of ASD occluder. Although it has been applied to orthopedics, general surgery and so on, the use of 3D printing in cardiology is still at its infancy. Our case showed the feasibility of using a 3D printing cardiac model to guide the percutaneous closure of ASD. It is likely to increase the success rate and reduce the operation time for interventional cardiology, especially the complex ASD cases, and more studies should be carried out to extend its fields of application.

[…]

Read Full Article

Viewpoint

Prediction Models for Decision-Making on Chagas Disease

Fernanda de Souza Nogueira Sardinha Mendes et al. Pedro Emmanuel Alvarenga Americano do Brasil

To investigate the relationship between future or unknown outcomes and baseline health states among people with specific conditions, prediction models are an interesting strategy used to assist diagnosis, prognosis and treatment. They estimate the likelihood of clinical events taking into account clinical relevant measures and complementary tests. These predictors and their importance vary between the different events of interest and their prediction ability varies when considered singly or in combination with other predictors. They may facilitate simple and direct comparisons of risks, individualize treatment regimens, and may refine prognosis stratification of patients, especially when many prognostic factors are known. Models have to be simple, easy to use and lead the clinician to make decisions which are more likely to bring benefit to the patients.

The World Health Organization estimates that 7-8 million people worldwide are infected with T.cruzi. Chagas disease is endemic in Latin America and the immigration pattern in the past years has made this disease an important health issue in many countries. In United States, more than 300,000 individuals might be infected and one study estimated that 3.5% of immigrants to Canada from Latin America were infected. Physicians should be able to recognize signs and symptoms of Chagas disease as globalization increase the burden of this disease in non-Latin American countries, where vector transmission is unlikely to occur.

[…]

Read Full Article

Case Report

Myocardial Deformation by Echocardiogram after Transcatheter Aortic Valve Implantation

Carolina Stangenhaus et al. Marcelo Luiz Campos Vieira Claudio Henrique Fischer Antonio Carlos Bacelar Nunes Filho … Marco Antonio Perin Adriano Mendes Caixeta

Introduction

Myocardial deformation (strain) analysis may be done through echocardiography from data obtained by tissue doppler technique or two-dimensional images from speckle tracking, allowing the calculation of longitudinal, circumferential and radial deformations of myocardial fibers.^, Myocardial strain analysis has recently been used in the evaluation of regional myocardial movement and function and in the systolic time-to-peak calculation which studies cardiac synchronicity and myocardial electromechanical coupling. In clinical practice, conventional echocardiographic investigation is helpful in detecting global myocardial dysfunction and alterations in ventricular segmental contractility. In cardiotoxicity from the use of chemotherapeutics, we may find alterations in cardiac mechanics with no modification of the left ventricle ejection fraction (LVEF). Thus, the analysis of myocardial deformation brings relevant information in the analysis of regional ventricular systolic dysfunction in subclinical conditions.

Similarly, previous investigations have shown that the study of myocardial deformation is able to detect sudden and early alterations in systolic function of valve disease patients, even before they present LVEF modifications.^,^, This phenomenon is due to a significant decrease in myocardial deformation in three different spatial planes, triggering deformation modifications in the longitudinal, circumferential and radial axes. In patients who present reduced longitudinal myocardial deformation, we can observe radial deformation that is superior to normality parameters, which may result in preserved ventricular function, when estimated by LVEF. Other applications of myocardial deformation include amyloidosis, hypertrophic cardiomyopathy, right ventricular dysfunction, athlete’s heart, cardiac dyssynchrony and valve diseases (mitral insufficiency and aortic stenosis).

[…]

Read Full Article

Original Article

Effects of a Single Bout of Resistance Exercise in Different Volumes on Endothelium Adaptations in Healthy Animals

Marcelo Mendonça Mota et al. Tharciano Luiz Teixeira Braga da Silva Fabricio Nunes Macedo Thássio Ricardo Ribeiro Mesquita … Lucindo José Quintans Júnior Valter Joviniano de Santana-Filho Sandra Lauton-Santos Márcio Roberto Viana Santos

Abstract

Background:

Resistance exercise (RE) has been recommended for patients with cardiovascular diseases. Recently, a few studies have demonstrated that the intensity of a single bout of RE has an effect on endothelial adaptations to exercise. However, there is no data about the effects of different volumes of RE on endothelium function.

Objective:

The aim of the study was to evaluate the effects of different volumes of RE in a single bout on endothelium-dependent vasodilatation and nitric oxide (NO) synthesis in the mesenteric artery of healthy animals.

Methods:

Male Wistar rats were divided into three groups: Control (Ct); low-volume RE (LV, 5 sets x 10 repetitions) and high-volume RE (HV, 15 sets x 10 repetitions). The established intensity was 70% of the maximal repetition test. After the exercise protocol, rings of mesenteric artery were used for assessment of vascular reactivity, and other mesenteric arteries were prepared for detection of measure NO production by DAF-FM fluorescence. Insulin responsiveness on NO synthesis was evaluated by stimulating the vascular rings with insulin (10 nM).

Results:

The maximal relaxation response to insulin increased in the HV group only as compared with the Ct group. Moreover, the inhibition of nitric oxide synthesis (L-NAME) completely abolished the insulin-induced vasorelaxation in exercised rats. NO production showed a volume-dependent increase in the endothelial and smooth muscle layer. In endothelial layer, only Ct and LV groups showed a significant increase in NO synthesis when compared to their respective group under basal condition. On the other hand, in smooth muscle layer, NO fluorescence increased in all groups when compared to their respective group under basal condition.

Conclusions:

Our results suggest that a single bout of RE promotes vascular endothelium changes in a volume-dependent manner. The 15 sets x 10 repetitions exercise plan induced the greatest levels of NO synthesis.

Read Full Article

Original Article

Effect of Lactation on myocardial vulnerability to ischemic insult in rats

Sahar Askari et al. Alireza Imani Hamidreza Sadeghipour Mahdieh Faghihi … Zohreh Edalatyzadeh Samira Choopani Nasser Karimi Sulail Fatima

Abstract

Background:

Cardiovascular diseases are the leading cause of mortality and long-term disability worldwide. Various studies have suggested a protective effect of lactation in reducing the risk of cardiovascular diseases.

Objective:

This study was designed to assess the effects of pregnancy and lactation on the vulnerability of the myocardium to an ischemic insult.

Methods:

Eighteen female rats were randomly divided into three groups: ischemia-reperfusion (IR), in which the hearts of virgin rats underwent IR (n = 6); lactating, in which the rats nursed their pups for 3 weeks and the maternal hearts were then submitted to IR (n = 6); and non-lactating, in which the pups were separated after birth and the maternal hearts were submitted to IR (n = 6). Outcome measures included heart rate (HR), left ventricular developed pressure (LVDP), rate pressure product (RPP), ratio of the infarct size to the area at risk (IS/AAR %), and ventricular arrhythmias – premature ventricular contraction (PVC) and ventricular tachycardia (VT).

Results:

The IS/AAR was markedly decreased in the lactating group when compared with the non-lactating group (13.2 ± 2.5 versus 39.7 ± 3.5, p < 0.001) and the IR group (13.2 ± 2.5 versus 34.0 ± 4.7, p < 0.05). The evaluation of IR-induced ventricular arrhythmias indicated that the number of compound PVCs during ischemia, and the number and duration of VTs during ischemia and in the first 5 minutes of reperfusion in the non-lactating group were significantly (p < 0.05) higher than those in the lactating and IR groups.

Conclusion:

Lactation induced early-onset cardioprotective effects, while rats that were not allowed to nurse their pups were more susceptible to myocardial IR injury.

Read Full Article

Original Article

Prognostic Value of Coronary Flow Reserve Obtained on Dobutamine Stress Echocardiography and its Correlation with Target Heart Rate

José Sebastião de Abreu et al. Eduardo Arrais Rocha Isadora Sucupira Machado Isabelle Oliveira Parahyba … Thaís de Brito Rocha Fernando José Villar Nogueira Paes Tereza Cristina Pinheiro Diogenes Marília Esther Benevides de Abreu Ana Gardenia Liberato Ponte Farias Marcia Maria Carneiro José Nogueira Paes Junior

Abstract

Background:

Normal coronary flow velocity reserve (CFVR) (≥ 2) obtained in the left anterior descending coronary artery (LAD) from transthoracic echocardiography is associated with a good prognosis, but there is no study correlating CFVR with submaximal target heart rate (HR).

Objective:

To evaluate the prognostic value of CFVR obtained in the LAD of patients with preserved (>50%) left ventricular ejection fraction (LVEF) who completed a dobutamine stress echocardiography (DSE), considering target HR.

Methods:

Prospective study of patients with preserved LVEF and CFVR obtained in the LAD who completed DSE. In Group I (GI = 31), normal CFVR was obtained before achieving target HR, and, in Group II (GII = 28), after that. Group III (G III=24) reached target HR, but CFVR was abnormal. Death, acute coronary insufficiency, coronary intervention, coronary angiography without further intervention, and hospitalization were considered events.

Results:

In 28 ± 4 months, there were 18 (21.6%) events: 6% (2/31) in GI, 18% (5/28) in GII, and 46% (11/24) in GIII. There were 4 (4.8%) deaths, 6 (7.2%) coronary interventions and 8 (9.6%) coronary angiographies without further intervention. In event-free survival by regression analysis, GIII had more events than GI (p < 0.001) and GII (p < 0.045), with no difference between GI and GII (p = 0.160). After adjustment, the only difference was between GIII and GI (p = 0.012).

Conclusion:

In patients with preserved LVEF and who completed their DSE, normal CFVR obtained before achieving target HR was associated with better prognosis.

Read Full Article

Original Article

Assessment of Carotid Intima-Media Thickness as an Early Marker Of Vascular Damage In Hypertensive Children

Liz Andréa Villela Baroncini et al. Lucimary de Castro Sylvestre Camila Varotto Baroncini Roberto Pecoits Filho

Abstract

Background:

The increased carotid intima-media thickness (CIMT) correlates with the presence of atherosclerosis in adults and describes vascular abnormalities in both hypertensive children and adolescents.

Objective:

To assess CIMT as an early marker of atherosclerosis and vascular damage in hypertensive children and adolescents compared with non-hypertensive controls and to evaluate the influence of gender, age, and body mass index (BMI) on CIMT on each group.

Methods:

Observational cohort study. A total of 133 hypertensive subjects (male, n = 69; mean age, 10.5 ± 4 years) underwent carotid ultrasound exam for assessment of CIMT. One hundred and twenty-one non-hypertensive subjects (male, n = 64; mean age, 9.8 ± 4.1 years) were selected as controls for gender, age (± 1 year), and BMI (± 10%).

Results:

There were no significant difference regarding gender (p = 0.954) and age (p = 0.067) between groups. Hypertensive subjects had higher BMI when compared to control group (p = 0.004), although within the established range of 10%. Subjects in the hypertensive group had higher CIMT values when compared to control group (0.46 ± 0.05 versus 0.42 ± 0.05 mm, respectively, p < 0.001; one-way ANOVA). Carotid IMT values were not significantly influenced by gender, age, and BMI when analyzed in both groups separately (Student's t-test for independent samples). According to the adjusted determination coefficient (R²) only 11.7% of CIMT variations were accounted for by group variations, including age, gender, and BMI.

Conclusions:

Carotid intima-media thickness was higher in hypertensive children and adolescents when compared to the control group. The presence of hypertension increased CIMT regardless of age, gender, and BMI.

Read Full Article