2017;108(6) – ABC CARDIOL

ABC

ABC Family | ABC

Clinicoradiological Session

Case 4/2017 – Double-Chambered Right Ventricle with Dextrocardia and Hypoxemia Due to Atrial Shunt in a 4-Year-Old Girl

Edmar Atik et al. José Fernando Cavalini

Clinical data

A premature female twin (33-week gestation), weighing at birth 1935 g, remained hospitalized for one month due to the diagnosis of atrial septal defect (ASD) + ventricular septal defect (VSD) + persistence of ductus arteriosus (PDA). The patient gained less weight than the average children, but maintained full and similar activity, receiving furosemide and captopril, up to the age of 3 years, when her mother noticed cyanosis.

[…]

Read Full Article

Original Article

Cardiovascular Risk Stratification and Statin Eligibility Based on the Brazilian vs. North American Guidelines on Blood Cholesterol Management

Fernando Henpin Yue Cesena et al. Antonio Gabriele Laurinavicius Viviane A. Valente Raquel D. Conceição … Raul D. Santos Marcio S. Bittencourt

Abstract

Background:

The best way to select individuals for lipid-lowering treatment in the population is controversial.

Objective:

In healthy individuals in primary prevention:

Methods:

In individuals aged 40-75 years consecutively submitted to routine health assessment at one single center, four criteria of eligibility for statin were defined: BR-1, BR-2 (LDL-c above or at least 30 mg/dL above the goal recommended by the Brazilian Guideline, respectively), USA-1 and USA-2 (10-year risk estimated by the PCE ≥ 5.0% or ≥ 7.5%, respectively).

Results:

The final sample consisted of 13,947 individuals (48 ± 6 years, 71% men). Most individuals at intermediate or high risk based on the V Brazilian Guideline had a low risk calculated by the PCE, and more than 70% of those who were considered at high risk had this categorization because of the presence of aggravating factors. Among women, 24%, 17%, 4% and 2% were eligible for statin use according to the BR-1, BR-2, USA-1 and USA-2 criteria, respectively (p < 0.01). The respective figures for men were 75%, 58%, 31% and 17% (p < 0.01). Eighty-five percent of women and 60% of men who were eligible for statin based on the BR-1 criterion would not be candidates for statin based on the USA-1 criterion.

Conclusions:

As compared to the North American Guideline, the V Brazilian Guideline considers a substantially higher proportion of the population as eligible for statin use in primary prevention. This results from discrepancies between the risk stratified by the Brazilian Guideline and that calculated by the PCE, particularly because of the risk reclassification based on aggravating factors.

Read Full Article

Original Article

Discordant Lipid Pattern and Carotid Atherosclerotic Plaque. Importance of Remnant Cholesterol

Walter Masson et al. Martín Lobo Graciela Molinero Daniel Siniawski

Abstract

Background:

Subjects with levels of non-HDL-C 30 mg/dL above those of LDL-C (lipid discordance) or with high remnant cholesterol levels could have a greater residual cardiovascular risk.

Objectives:

Methods:

Primary prevention patients without diabetes or lipid-lowering therapy were included. Regardless of the LDL-C level, we define “lipid discordance” if the non-HDL-C value exceeded 30 mg/dL that of LDL-C. Remnant cholesterol was calculated as total cholesterol minus HDL-C minus LDL-C when triglycerides were < 4.0 mmol/L. Ultrasound was used to assess carotid plaque occurrence. Multiple regression logistic models were performed.

Results:

The study included 772 patients (mean age 52 ± 11 years, 66% women). The prevalence of lipid discordance was 34%. Male sex and body mass index were independently associated with discordant lipid pattern. The prevalence of carotid plaque was higher in subjects with lipid discordance (40.2% vs. 29.2, p = 0.002). The multivariate analysis showed that the discordant lipid pattern was associated with the greater probability of carotid plaque (OR 1.58, 95% CI 1.08-2.34, p = 0.02). Similarly, a significant association between calculated remnant cholesterol and carotid plaque was found.

Conclusion:

Lipid discordance and presence of a higher level of calculated remnant cholesterol are associated with subclinical atherosclerosis. Our findings could be used to improve the residual cardiovascular risk evaluation.

Read Full Article

Editorial

The Concept of Clinical Economics and its Relation with Effectiveness

Franz Porzsolt et al. Luis C. L. Correia

Efficacy versus Effectiveness

We underlined that efficacy and effectiveness describe two different types of information: efficacy is the demonstration that a new principle can theoretically work, which comes from studies under ideal controlled conditions; effectiveness is how the concept proven by efficacy studies works under real world conditions (RWC).^, For demonstration of efficacy, one should select the optimal scenario for the proof of principle. It requires an experimental study design, with random allocation of treatments, to eliminate confounding bias and proper assessment of causality, it means the trial is explanatory.

The demonstration of effectiveness is pragmatic and takes place in the scenario in which the new principle will be used (RWC). The design is observational and treatment allocation is under the discretion and preferences of physician and patient. It allows assessment of the two main determinants of effectiveness: practical issues regarding adequate applicability of treatment and the impact of individualized choices. The interaction of these two forces determines whether the effectiveness of a treatment will be smaller than its proven efficacy (loss of beneficial effect in the real world) or whether the treatment will be even more effective than efficacious. The first situation should be a concern when logistic issues impair the treatment to be ideally applied (a not well trained doctor, a patient not educated enough to properly take an anticoagulant, a system not able to provide adequate door-to-balloon time in primary angioplasty for acute myocardial infarction), what tends to happen when the treatment is somewhat complex. The second situation takes place when physicians and patients provide a better solution than a simple randomization can do allocation.

[…]

Read Full Article

Original Article

Pacemaker Implants in Children and Adolescents with Chagas Disease in Brazil: 18-Year Incidence

Carolina Christianini Mizzaci et al. Thiago Gonçalves Schroder e Souza Gabriel Pelegrineti Targueta Ana Paula Frederico Tótora … Juan Carlos Pachón Mateos José Carlos Pachon Mateos

Abstract

Background:

Chagas disease continues to be a serious public health problem, and accounts for 25-30% of the indications for cardiac stimulation in Brazil.

Objective:

To assess clinical and epidemiological characteristics of patients with Chagas disease, younger than 18 years, who had undergone pacemaker implantation in Brazil between 1994 and 2011, and its temporal trend.

Methods:

This was a cross-sectional analysis of data from the Brazilian Pacemaker Registry database. The following variables were analyzed: year when pacemaker was implanted, location, age, sex, ethnic group, functional class and the main electrocardiographic findings at baseline.

Results:

In a total of 183,123 implants performed between 1994 and 2011, 214 implants of cardiac stimulation device in Chagas disease patients aged younger than 18 years were identified. Mean age at implantation was 5.6 ± 6.2 years. Second- and third-degree atrioventricular blocks corresponded to 71% of indications for pacemaker implantation. Fifty-six percent of the procedures were performed in the southeast region. Regarding the total number of pacemaker implants per year, there was a remarkable increase in the implants for all causes. However, time series analysis of the implants in Chagas disease patients younger than 18 years revealed a significant reduction in the annual number of implants.

Conclusion:

There has been an important reduction in the number of pacemaker implantations among children and adolescents with Chagas disease, suggesting a reduction in the vertical transmission of the parasite.

Read Full Article

Erratum

Erratum

August issue of 2012, vol. 99 (2), Suppl. 2, pages 1-28

In “First Brazilian Guidelines for Familial Hypercholesterolemia”, consider Lottenberg AM as the correct form for the name of the author Ana Maria Lottenberg.

[…]

Read Full Article

Case Report

Myocardial Bridge and Angiotomography of the Coronary Arteries: Perfusion under Pharmacological Stress

Wilter dos Santos Ker et al. Daniel Gama Neves Alair Sarmet A. A. Damas Cláudio Tinoco Mesquita Marcelo Souto Nacif

Introduction

The myocardial bridge is one of the most prevalent congenital anomalies that involve the coronary circulation, and its incidence in the general population is high, affecting from 23 to 55% in necropsy studies.The impairment of the anterior descending artery is more frequent, on its proximal 2/3.In most patients, the myocardial bridges do not cause symptoms, because in order to have ischemia, there must be an imbalance between supply and consumption of oxygen. The superficial bridges, with small or slender muscle band, are the most common ones, and they may account for 75% of the cases, with average length of 1.5 cm and usually without causing symptoms. In approximately 24% of the cases, we observed deep myocardial bridges, with thicker muscle band.^,

Atherosclerosis is the most common cause of ischemic heart disease. However, other causes for ischemia are frequent, and among them, we highlight the myocardial bridge, which may provoke typical or atypicalchest angina,acute myocardial infarction and sudden death.^–

[…]

Read Full Article

Original Article

Healthy School, Happy School: Design and Protocol for a Randomized Clinical Trial Designed to Prevent Weight Gain in Children

Daniela Schneid Schuh et al. Maíra Ribas Goulart Sandra Mari Barbiero Caroline D’Azevedo Sica … Raphael Borges David William Moraes Lucia Campos Pellanda

Abstract

Background:

Schools have become a key figure for the promotion of health and obesity interventions, bringing the development of critical awareness to the construction and promotion of a healthy diet, physical activity, and the monitoring of the nutritional status in childhood and adolescence.

Objectives:

To describe a study protocol to evaluate the effectiveness of an intervention designed to improve knowledge of food choices in the school environment.

Methods:

This is a cluster-randomized, parallel, two-arm study conducted in public elementary and middle schools in Brazil. Participants will be children and adolescents between the ages of 5 and 15 years, from both genders. The interventions will be focusing on changes in lifestyle, physical activities and nutritional education. Intervention activities will occur monthly in the school’s multimedia room or sports court. The control group arm will receive usual recommendations by the school. The primary outcome variable will be anthropometric measures, such as body mass index percentiles and levels of physical activity by the International Physical Activity Questionnaire.

Results:

We expect that after the study children will increase the ingestion of fresh food, reduce excessive consumption of sugary and processed foods, and reduce the hours of sedentary activities.

Conclusion:

The purpose of starting the dietary intervention at this stage of life is to develop a knowledge that will enable for healthy choices, providing opportunities for a better future for this population.

Read Full Article

Special Article

Long-term Results of a Cardiology Postgraduate Program

Edimar Alcides Bocchi et al. Danielle Pazzotti Borges Vagner Oliveira-Carvalho Rigaud

Introduction

Research and innovation help to drive economic growth and address socioeconomic challenges like poverty and health. Many developed and developing countries have introduced policies and systems to increase research and innovation.

In Brazil, a system was created on 1951 with the objectives of improving technology and innovation and strengthening scientific research.^, Similar to postgraduate doctorate programs in developed countries, postgraduate programs with broader and more in-depth scientific research objectives have been developed in Brazil. In fact, a linear relationship has been demonstrated between the number of students graduating from these programs and the number of scientific publications produced by them. Beyond scientific output, publishing a high-impact paper or in a journal with a high-impact factor seems to be an important requirement for innovation and technology growth. Considering that postgraduate students play an important role in scientific production in Brazil, a study including the characteristics of the scientific production of these students is justifiable.

[…]

Read Full Article

Review Article

Cirrhotic Cardiomyopathy: A New Clinical Phenotype

Luis Otávio Cardoso Mocarzel et al. Mariana Macedo Rossi Bruna de Mello Miliosse Pedro Gemal Lanzieri Ronaldo Altenburg Gismondi

Introduction

Hepatic cirrhosis is the final spectrum of several aggressions to the liver, with great relevance to public healthcare. National data estimate a prevalence of 0.14% to 0.35%, mortality of 3 to 35 per 100,000 individuals and an annual average of 30,000 hospital admissions in Brazil.^, With the ageing population, the prevalence of chronic liver diseases, in particular steatohepatitis associated to obesity and metabolic syndrome, results in an increase in the number of hepatic cirrhosis cases.

Cardiac manifestations of hepatic cirrhosis were first reported in the 20^th century, with alterations on cardiac output. With new information on the extra-hepatic repercussions of cirrhosis, cirrhotic cardiomyopathy (CCM) has been described as a spectrum of chronic morphofunctional alterations in the heart of cirrhotic patients with no previous cardiac diseases.^– The cardiomyocyte lesion is provoked by an imbalance in hemeostasis that occurs in the progression of cirrhosis, with exhaustion of beta-adrenergic receptors, cytoplasmic impregnation by endocannabinoids, and imbalance of nitric oxide and endothelin. CCM is asymptomatic; however, systolic and diastolic structural alterations are described in the electrocardiogram (ECG) and Doppler echocardiogram (ECHO).

[…]

Read Full Article

Image

Exuberant Vasospastic Angina Simulating Severe Three-Vessel Disease

Bruno Marmelo et al. Luís Abreu Júlio Gil Pedro Ferreira José Cabral

A 56-year-old Caucasian male, came to our hospital complaining of thoracic oppression at exertion and sometimes occurring at rest, lasting for a few minutes. The patient was an active smoker, with a moderate alcohol consumption habit and had had an episode of unstable angina two months earlier. At that episode, two drug-eluting stents were implanted, one in the distal anterior descending artery and the other in the proximal first diagonal artery. The ECG showed mild ST-elevation in V1-V3 and a T-wave inversion in V3-V5. There was a slight increase in Troponin I up to 0.24 ng/mL but the blood tests were otherwise unremarkable. The patient was admitted at the coronary unit and was scheduled for urgent coronary angiogram. The exam revealed severe and diffuse stenosis in the territories of the right and left coronary arteries with slow flow (TIMI 1-2), sparing only the stented segments (picture/). The administration of 2 mg of intracoronary isosorbite dinitrate reverted all the stenosis but slow flow (TIMI 2) was still observed in the left coronary artery. Hence, the diagnosis of vasospastic angina was made. The patient was successfully controlled with calcium antagonists and has remained asymptomatic.

Vasospastic angina is commonly misinterpreted as acute coronary syndrome. Although its pathophysiology is not fully understood, it usually has a favorable long-term prognosis, although coronary artery spasms may have an important role in arrhythmia generation and subsequent cardiac arrest.

[…]

Read Full Article

Original Article

The Expected Cardiovascular Benefit of Plasma Cholesterol Lowering with or Without LDL-C Targets in Healthy Individuals at Higher Cardiovascular Risk

Fernando Henpin Yue Cesena et al. Antonio Gabriele Laurinavicius Viviane A. Valente Raquel D. Conceição … Raul D. Santos Marcio S. Bittencourt

Abstract

Background:

There is controversy whether management of blood cholesterol should be based or not on LDL-cholesterol (LDL-c) target concentrations.

Objectives:

To compare the estimated impact of different lipid-lowering strategies, based or not on LDL-c targets, on the risk of major cardiovascular events in a population with higher cardiovascular risk.

Methods:

We included consecutive individuals undergoing a routine health screening in a single center who had a 10-year risk for atherosclerotic cardiovascular disease (ASCVD) ≥ 7.5% (pooled cohort equations, ACC/AHA, 2013). For each individual, we simulated two strategies based on LDL-c target (≤ 100 mg/dL [S_target-100] or ≤ 70 mg/dL [S_target-70]) and two strategies based on percent LDL-c reduction (30% [S_30%] or 50% [S_50%]).

Results:

In 1,897 subjects (57 ± 7 years, 96% men, 10-year ASCVD risk 13.7 ± 7.1%), LDL-c would be lowered from 141 ± 33 mg/dL to 99 ± 23 mg/dL in S_30%, 71 ± 16 mg/dL in S_50%, 98 ± 9 mg/dL in S_target-100, and 70 ± 2 mg/dL in S_target-70. Ten-year ASCVD risk would be reduced to 8.8 ± 4.8% in S_50% and 8.9 ± 5.2 in S_target-70. The number of major cardiovascular events prevented in 10 years per 1,000 individuals would be 32 in S_30%, 31 in S_target-100, 49 in S_50%, and 48 in S_target-70. Compared with S_target-70, S_50% would prevent more events in the lower LDL-c tertile and fewer events in the higher LDL-c tertile.

Conclusions:

The more aggressive lipid-lowering approaches simulated in this study, based on LDL-c target or percent reduction, may potentially prevent approximately 50% more hard cardiovascular events in the population compared with the less intensive treatments. Baseline LDL-c determines which strategy (based or not on LDL-c target) is more appropriate at the individual level.

Read Full Article

Original Article

Three-Dimensional Volumetric Assessment of Diastolic Function by Cardiac Magnetic Resonance Imaging: The Multi-Ethnic Study of Atherosclerosis (MESA)

Marcelo S Nacif et al. Andre L. C. Almeida Alistair A Young Brett R Cowan … Anderson C Armstrong Eunice Yang Christopher T Sibley W. Gregory Hundley Songtao Liu Joao AC Lima David A Bluemke

Abstract

Background:

Cardiac Magnetic Resonance is in need of a simple and robust method for diastolic function assessment that can be done with routine protocol sequences.

Objective:

To develop and validate a three-dimensional (3D) model-based volumetric assessment of diastolic function using cardiac magnetic resonance (CMR) imaging and compare the results obtained with the model with those obtained by echocardiography.

Methods:

The study participants provided written informed consent and were included if having undergone both echocardiography and cine steady-state free precession (SSFP) CMR on the same day. Guide points at the septal and lateral mitral annulus were used to define the early longitudinal relaxation rate (E’), while a time-volume curve from the 3D model was used to assess diastolic filling parameters. We determined the correlation between 3D CMR and echocardiography and the accuracy of CMR in classifying the diastolic function grade.

Results:

The study included 102 subjects. The E/A ratio by CMR was positively associated with the E/A ratio by echocardiography (r = 0.71, p < 0.0001). The early diastolic relaxation velocity by tissue Doppler and longitudinal relaxation rate for the lateral mitral annulus displacement were positively associated (p = 0.007), as were the ratio between Doppler E/e' and CMR E/E' (p = 0.01). CMR-determined normalized peak E (NE) and deceleration time (DT) were able to predict diastolic dysfunction (areas under the curve [AUCs] = 0.70 and 0.72, respectively). In addition, the lateral E/E' ratio showed good utility in identifying diastolic dysfunction (AUC = 0.80). Overall, echocardiography and CMR interobserver and intraobserver agreements were excellent (intraclass correlation coefficient range 0.72 – 0.97).

Conclusion:

3D modeling of standard cine CMR images was able to identify study subjects with reduced diastolic function and showed good reproducibility, suggesting a potential for a routine diastolic function assessment by CMR.

Read Full Article

Original Article

The Effect of Physical Resistance Training on Baroreflex Sensitivity of Hypertensive Rats

Moisés Felipe Pereira Gomes et al. Mariana Eiras Borges Vitor de Almeida Rossi Elizabeth de Orleans C. de Moura Alessandra Medeiros

Abstract

Background:

Baroreceptors act as regulators of blood pressure (BP); however, its sensitivity is impaired in hypertensive patients. Among the recommendations for BP reduction, exercise training has become an important adjuvant therapy in this population. However, there are many doubts about the effects of resistance exercise training in this population.

Objective:

To evaluate the effect of resistance exercise training on BP and baroreceptor sensitivity in spontaneously hypertensive rats (SHR).

Method:

Rats SHR (n = 16) and Wistar (n = 16) at 8 weeks of age, at the beginning of the experiment, were randomly divided into 4 groups: sedentary control (CS, n = 8); trained control (CT, n = 8); sedentary SHR (HS, n = 8) and trained SHR (HT, n = 8). Resistance exercise training was performed in a stairmaster-type equipment (1.1 × 0.18 m, 2 cm between the steps, 80° incline) with weights attached to their tails, (5 days/week, 8 weeks). Baroreceptor reflex control of heart rate (HR) was tested by loading/unloading of baroreceptors with phenylephrine and sodium nitroprusside.

Results:

Resistance exercise training increased the soleus muscle mass in SHR when compared to HS (HS 0.027 ± 0.002 g/mm and HT 0.056 ± 0.003 g/mm). Resistance exercise training did not alter BP. On the other hand, in relation to baroreflex sensitivity, bradycardic response was improved in the TH group when compared to HS (HS -1.3 ± 0.1 bpm/mmHg and HT -2.6 ± 0.2 bpm/mmHg) although tachycardia response was not altered by resistance exercise (CS -3.3 ± 0.2 bpm/mmHg, CT -3.3 ± 0.1 bpm/mmHg, HS -1.47 ± 0.06 bpm/mmHg and HT -1.6 ± 0.1 bpm/mmHg).

Conclusion:

Resistance exercise training was able to promote improvements on baroreflex sensitivity of SHR rats, through the improvement of bradycardic response, despite not having reduced BP.

Read Full Article

Original Article

Systemic Arterial Hypertension in Patients Exposed to Cesium-137 in Goiânia-GO: Prevalence Study

José Victor Rabelo Rodrigues et al. Murillo Macêdo Pinto Roberto Miller Pires Figueredo Helen de Lima … Rafael Souto Sylvana de Castro Sacchetim

Abstract

Background:

Systemic Arterial Hypertension (SAH) in the Brazilian population, in populations not exposed to Césio-137, presents a prevalence of 28% nationwide. However, in the group of radioactivity victims, these values are unknown.

Objective:

To analyze the prevalence of hypertension in patients exposed to Cesium-137 in Goiânia, enrolled in the Sistema de Monitoramento dos Radioacidentados (SISRAD) (Radioactivtity Victims Monitoring System) of the Centro de Assistência aos Radioacidentados (C.A.R.A) (Assistence Center for Radioactivity Victims).

Methods:

This is a descriptive, observational cross-sectional epidemiological study carried out in Goiânia-Goiás, from August 2013 to October 2014, with a group of patients enrolled in the Sistema de Monitoramento dos Radioacidentados (SISRAD) of the Centro de Assistência a Radioacidentados (C.A.R.A.). A total of 102 radioactive patients were divided into two groups: group 1 with 40 and group 2 with 62 participants. A field survey was conducted with a closed and semi-structured questionnaire in which the following contexts were addressed: sociodemographic profile, life habits and personal background. A database was created using the Google Forms application from the Google Web technologies company. The duly collected and stored data were imported and analyzed in the statistical software SPSS, version 21.

Results:

The prevalence of SAH reached a total of 25% (12 individuals) of the 48 interviewees, 50% of women (24) and 50% of men (24), of which 22.9% (11) of the radioactivity victims revealed to be smokers.

Conclusion:

The prevalence of SAH in the radioactivity victims population is similar to that of the population in general.

Read Full Article