2017;109(2) – ABC CARDIOL

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Erratum

Erratum

Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0

Consider correct authors’ affiliations Fábio Gazelato de Mello Franco,¹ Antonio Gabriele Laurinavicius,² Paulo A. Lotufo,³ Raquel D. Conceição,² Fernando Morita,¹ Marcelo Katz,¹ Maurício Wajngarten,¹ José Antonio Maluf Carvalho,¹ Hayden B. Bosworth,⁵ Raul Dias Santos^2,4 to the institutions: Hospital Israelita Albert Einstein;¹ Centro de Medicina Preventiva e Programa de Cardiologia do Hospital Israelita Albert Einstein;² Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP);³ Unidade Clínica de Lípides Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da USP;⁴ São Paulo, SP – Brasil; Duke University Medical Center⁵ – EUA to the article “Persistent Depressive Symptoms are Independent Predictors of Low-Grade Inflammation Onset Among Healthy Individuals”, published ahead of print.

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Image

Crescent Moon Image as a Peculiar Complication During Percutaneous Coronary Intervention of an In-Stent Chronic Total Occlusion

Mohsen Mohandes et al. Jordi Guarinos Cristina Moreno Sergio Rojas Alfredo Bardají

Case

55-year-old male with history of ischemic cardiomyopathy with previous percutaneous coronary intervention (PCI) in the anterior descending coronary artery (LAD) middle segment was admitted to our hospital for chest pains. A new coronary angiogram showed in-stent chronic total occlusion (ISCTO) of LAD receiving collaterals from right coronary artery (RCA). Left circumflex (LCX) was totally occluded and RCA presented a significant mid-segment lesion. Complete percutaneous revascularization was planned. First attempt to recanalize the LAD failed because the lesion obstructed the passage of the balloon, so a second dedicated attempt was planned. Bilateral injection using radial and femoral arteries was used, and a Confianza Pro 9 (Asahi Intecc, Japan) guidewire was progressively advanced through the ISCTO () and the wire’s position in true lumen was verified by contralateral injection. Considering the lesion, which impeded the balloon’s passage, a microcatheter Tornus (Asahi Intecc, Japan) was utilized to penetrate and advance through and past the occlusion (). After balloon predilatation, intravascular ultrasound sonography (IVUS) verified the position of the wire in a very short segment into true lumen, but outside the previously implanted stent (). Several drug eluting stents (DES) were implanted and the artery was successfully recanalized, although a very distal embolization was detected (). A new IVUS examination showed partial crush of the previous stent in the shape of a crescent moon ().

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Case Report

Asymptomatic Coronary Spasm Due to Polytraumatism

Maria Cruz Aguilera et al. Jorge Restrepo Fernando Rivero Teresa Bastante … Rio Aguilar Fernando Alfonso

Introduction

Variant angina is a form of angina pectoris caused by vasospasm of an epicardic coronary artery that results in myocardial ischemia that might be manifested by transient ST segment elevation on the electrocardiogram. Although it usually presents with chest pain, asymptomatic episodes are not rare.^, We report a case of an incidental diagnosis of asymptomatic coronary vasospam in a patient with polytrauma.

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Original Article

Assessment of Subclinical Doxorubicin-induced Cardiotoxicity in a Rat Model by Speckle-Tracking Imaging

Yu Kang et al. Wei Wang Hang Zhao Zhiqing Qiao … Xuedong Shen Ben He

Abstract

Backgrounds:

Despite their clear therapeutic benefits, anthracycline-induced cardiotoxicity is a major concern limiting the ability to reduce morbidity and mortality associated with cancers. The early identification of anthracycline-induced cardiotoxicity is of vital importance to assess the cardiac risk against the potential cancer treatment.

Objective:

To investigate whether speckle-tracking analysis can provide a sensitive and accurate measurement when detecting doxorubicin-induced left ventricular injury.

Methods:

Wistar rats were divided into 4 groups with 8 rats each, given doxorubicin intraperitoneally at weekly intervals for up to 4 weeks. Group 1: 2.5 mg/kg/week; group 2: 3 mg/kg/week; group 3: 3.5mg/kg/week; group 4: 4mg/kg/week. An additional 5 rats were used as controls. Echocardiographic images were obtained at baseline and 1 week after the last dose of treatment. Radial (Srad) and circumferential (Scirc) strains, radial (SRrad) and circumferential (SRcirc) strain rates were analyzed. After the experiment, cardiac troponin I (cTnI) was analyzed and the heart samples were histologically evaluated.

Results:

After doxorubicin exposure, LVEF was significantly reduced in group 4 (p = 0.006), but remained stable in the other groups. However, after treatment, Srads were reduced in groups 2, 3 and 4 (p all < 0.05). The decrease in Srads was correlated with cTnI (rho = -0.736, p = 0.000) and cardiomyopathy scores (rho = -0.797, p = 0.000).

Conclusion:

Radial strain could provide a sensitive and noninvasive index in early detection of doxorubicin-induced myocardial injury. The changes in radial strain had a significant correlation with myocardial lesions and serum cardiac troponin I levels, indicating that this parameter could accurately evaluate cardiotoxicity severity.

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Original Article

Plasma Total Antioxidant Capacity and Cardiometabolic Risk in Non-Obese and Clinically Healthy Young Adults

Jamille Oliveira Costa et al. Cecília M. Passos Vásquez Gleiciane de Jesus Santana Natanael de Jesus Silva … Juciene de Matos Braz Amélia M. Ribeiro de Jesus Danielle Góes da Silva Luana Celina Seraphim Cunha Kiriaque Barra Ferreira Barbosa

Abstract

Background:

The oxidative biomarkers play an important role in the genesis of cardiometabolic risk-related processes.

Objective:

To investigate the total antioxidant capacity of plasma and its association with cardiometabolic risk in non-obese and clinically healthy young adults.

Methods:

University students of the state of Sergipe, Brazil, aged between 18 and 25 years, were recruited for this study from May of 2013 and October of 2014. Anthropometric, clinical and biochemical parameters were measured and analyzed using protocols which were previously standardized and described in the literature. The measurement of plasma total antioxidant capacity was based on the ability that all the antioxidants present in the sample (plasma) have to inhibit the oxidation of the oxidizable substrate ABTS (2,2`- Azino-di-[3-ethylbenzthiazoline sulphonate]) to ABTS•+ by metmyoglobin.

Results:

Approximately 25% of the sample presented more than one component of cardiometabolic risk. Low HDL-cholesterol was the most prevalent component. Compared to absence of components, the subjects with at least one component presented greater body weight and waist circumference, higher levels of diastolic blood pressure and fasting glucose, greater total cholesterol/HDL-c ratio, and lower levels of HDL-c (p < 0.05). Fasting glycemia was the only parameter which was associated with total antioxidant capacity (R² = 0.10; β = 0.17; p = 0.001).

Conclusions:

The plasma total antioxidant capacity was not able to predict the cardiometabolic risk components due possibly to the establishment of compensatory mechanisms that become activated in physiological conditions.

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Original Article

Primary Mitral Valve Regurgitation Outcome in Patients With Severe Aortic Stenosis 1 Year After Transcatheter Aortic Valve Implantation: Echocardiographic Evaluation

Thiago Marinho Florentino et al. David Le Bihan Alexandre Antonio Cunha Abizaid Alexandre Vianna Cedro … Amably Pessoa Corrêa Alexandre Roginski Mendes dos Santos Alexandre Costa Souza Tiago Costa Bignoto José Eduardo Moraes Rego Sousa Amanda Guerra de Moraes Rego Sousa

Abstract

Background:

Mitral valve regurgitation (MR), present in up to 74% of the patients with severe aortic stenosis (AS), can be a negative prognostic factor when moderate or severe. The outcome of MR after percutaneous transcatheter aortic valve implantation (TAVI) and predictors associated with that outcome have not been well established in the literature.

Objective:

To assess the outcome of primary MR in patients submitted to TAVI and to identify associated factors.

Methods:

Observational study of patients with symptomatic severe AS submitted to TAVI from January 2009 to April 2015 at two specialized centers. Echocardiographic outcome was assessed with data collected before and 1 year after TAVI.

Results:

Of the 91 patients with MR submitted to TAVI and followed up for at least 12 months, 67 (73.6%) had minimum/mild MR before the procedure and 24 (26.4%) had moderate/severe MR. Of those with minimum/mild MR, 62 (92.5%) had no change in the MR grade (p < 0.001), while 5 (7.5%) showed worsening. Of those with moderate/severe MR, 8 (33.3%) maintained the same grade and 16 (66.7%) improved it (p = 0.076). Patients with moderate/severe MR who improved MR grade had lower EuroSCORE II (p = 0.023) and STS morbidity (p = 0.027) scores, as compared to those who maintained the MR grade.

Conclusion:

MR grades change after TAVI. This study suggests a trend towards improvement in moderate/severe MR after TAVI, which was associated with lower preoperative risk scores.

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Original Article

Peripheral Vascular Resistance Impairment during Isometric Physical Exercise in Normotensive Offspring of Hypertensive Parents

Natália Portela et al. Josária Ferraz Amaral Pedro Augusto de Carvalho Mira Livia Victorino de Souza … Daniel Godoy Martinez Mateus Camaroti Laterza

Abstract

Background:

A family history of hypertension is associated with vascular and autonomic abnormalities, as well as an impaired neurohemodynamic response to exercise.

Objective:

To test the hypothesis that normotensive individuals with a family history of hypertension present an impaired peripheral vascular resistance response to exercise.

Methods:

The study included 37 normotensive volunteers of both sexes who were sedentary, eutrophic, and nonsmokers, comprising 23 with (FH+; 24 ± 3 years) and 14 without (FH-; 27 ± 5 years) a family history of hypertension. Blood pressure, heart rate (DIXTAL®), forearm blood flow (Hokanson®), and peripheral vascular resistance were simultaneously measured for 3 minutes during rest and, subsequently, for 3 minutes during an isometric exercise at 30% of maximal voluntary contraction (Jamar^®).

Results:

At rest, the FH+ and FH- groups present similar mean blood pressure (83 ± 7 versus 83 ± 5 mmHg, p = 0.96), heart rate (69 ± 8 bpm versus 66 ± 7 bpm, p = 0.18), forearm blood flow (3 ± 1 mL/min/100 mL versus 2.7 ± 1 mL/min/100 mL, p = 0.16), and peripheral vascular resistance (30 ± 9 units versus 34±9 units, p = 0.21), respectively. Both groups showed a significant and similar increase in mean blood pressure (∆ = 15 ± 7 mmHg versus 14 ± 7 mmHg, p = 0.86), heart rate (∆ = 12 ± 8 bpm versus 13 ± 7 bpm, p = 0.86), and forearm blood flow (∆ = 0.8 ± 1.2 mL/min/100 mL versus 1.4 ± 1.1 mL/min/100 mL, p = 0.25), respectively, during exercise. However, individuals in the FH+ group showed no reduction in peripheral vascular resistance during exercise, which was observed in the FH- group (∆ = -0.4 ± 8.6 units versus -7.2 ± 6.3 units, p = 0.03).

Conclusion:

Normotensive individuals with a family history of hypertension present an impaired peripheral vascular resistance response to exercise.

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Review Article

A Meta-Analysis of Circulating Microvesicles in Patients with Myocardial Infarction

Zhida Wang et al. Wang Cai Shaolan Hu Yufei Xia … Yao Wang Qi Zhang Liming Chen

Abstract

Background:

Cell-derived microvesicles (MVs) are vesicles released from activated or apoptotic cells. However, the levels of MVs in myocardial infarction have been found inconsistent in researches.

Objective:

To assess the association between MVs and myocardial infarction by conducting a meta-analysis.

Methods:

A systematic literature search on PubMed, Embase, Cochran, Google Scholar electronic database was conducted. Comparison of the MVs levels between myocardial infarction patients and healthy persons were included in our study. Standard Mean Difference (SMD) and 95% confidence interval (CI) in groups were calculated and meta-analyzed.

Results:

11 studies with a total of 436 participants were included. Compared with the health persons, AMVs [SMD = 3.65, 95% CI (1.03, 6.27)], PMVs [SMD = 2.88, 95% CI (1.82, 3.93),] and EMVs [SMD = 2.73, 95% CI (1.13, 4.34)], levels were higher in patients with myocardial infarction. However, LMVs levels [SMD = 0.73, 95% CI (-0.57, 2.03)] were not changed significantly in patients with myocardial infarction.

Conclusions:

AMVs, PMVs and EMVs might be potential biomarkers for myocardial infarction.

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Original Article

The Diterpene Sclareol Vascular Effect in Normotensive and Hypertensive Rats

Debora Ribeiro Campos et al. Andrea Carla Celotto Agnes Afrodite S. Albuquerque Luciana Garros Ferreira … Ariadne Santana e Neves Monteiro Eduardo Barbosa Coelho Paulo Roberto Barbosa Evora

Abstract

Background:

The diterpene Sclareol has antimicrobial action, cytotoxic and cytostatic effects and anti-tumor activities. However, researches on the cardiovascular system are scarce.

Objective:

This study was designed to investigate the mechanisms involved in the Sclareol cardiovascular effect in normotensive and hypertensive rats.

Methods:

The arterial hypertension was promoted using 2-kidneys 1-clip model in rats. The effect of sclareol on blood pressure was performed by using three dose (10, 20 and 40 mg/kg). Cumulative dose-response curves for Sclareol were determined for endothelium-intact and endothelium-denuded aortic rings in presence or absence of L-NAME and ODQ. The NOx levels were measure in the plasma sample.

Results:

The Sclareol administration in vivo caused a significant reduction in blood pressure in both groups. In vitro the sclareol promoted relaxation in aorta, with endothelium, pre-contracted to Phe. The inhibitors of the nitric oxide synthase and soluble guanylate cyclase were as efficient as the removal of endothelium, in inhibiting the Sclareol-induced relaxation. Otherwise, it was no change of NOx. Also, for unknown reasons, the Sclareol is not selective for hypertensive animals.

Conclusion:

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Original Article

Persistent Depressive Symptoms are Independent Predictors of Low-Grade Inflammation Onset Among Healthy Individuals

Fábio Gazelato de Mello Franco et al. Antonio Gabriele Laurinavicius Paulo A. Lotufo Raquel D. Conceição … Fernando Morita Marcelo Katz Maurício Wajngarten José Antonio Maluf Carvalho Hayden B. Bosworth Raul Dias Santos

Abstract

Background:

Depressive symptoms are independently associated with an increased risk of cardiovascular disease (CVD) among individuals with non-diagnosed CVD. The mechanisms underlying this association, however, remain unclear. Inflammation has been indicated as a possible mechanistic link between depression and CVD.

Objectives:

This study evaluated the association between persistent depressive symptoms and the onset of low-grade inflammation.

Methods:

From a database of 1,508 young (mean age: 41 years) individuals with no CVD diagnosis who underwent at least two routine health evaluations, 134 had persistent depressive symptoms (Beck Depression Inventory – BDI ≥ 10, BDI+) and 1,374 had negative symptoms at both time points (BDI-). All participants had been submitted to repeated clinical and laboratory evaluations at a regular follow-up with an average of 26 months from baseline. Low-grade inflammation was defined as plasma high-sensitivity C-Reactive Protein (CRP) concentrations > 3 mg/L. The outcome was the incidence of low-grade inflammation evaluated by the time of the second clinical evaluation.

Results:

The incidence of low-grade inflammation was more frequently observed in the BDI+ group compared to the BDI- group (20.9% vs. 11.4%; p = 0.001). After adjusting for sex, age, waist circumference, body mass index, levels of physical activity, smoking, and prevalence of metabolic syndrome, persistent depressive symptoms remained an independent predictor of low-grade inflammation onset (OR = 1.76; 95% CI: 1.03-3.02; p = 0.04).

Conclusions:

Persistent depressive symptoms were independently associated with low-grade inflammation onset among healthy individuals.

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Original Article

Ruthenium Complex Improves the Endothelial Function in Aortic Rings From Hypertensive Rats

Izabela Pereira Vatanabe et al. Carla Nascimento dos Santos Rodrigues Tereza Cristina Buzinari Thiago Francisco de Moraes … Roberto Santana da Silva Gerson Jhonatan Rodrigues

Abstract

Background:

The endothelium is a monolayer of cells that extends on the vascular inner surface, responsible for the modulation of vascular tone. By means of the release of nitric oxide (NO), the endothelium has an important protective function against cardiovascular diseases.

Objective:

Verify if cis- [Ru(bpy)₂(NO₂)(NO)](PF₆)₂ (BPY) improves endothelial function and the sensibility of conductance (aorta) and resistance (coronary) to vascular relaxation induced by BPY.

Methods:

Normotensive (2K) and hypertensive (2K-1C) Wistar rats were used. For vascular reactivity study, thoracic aortas were isolated, rings with intact endothelium were incubated with: BPY(0.01 to10 µM) and concentration effect curves to acetylcholine were performed. In addition, cumulative concentration curves were performed to BPY (1.0 nM to 0.1 µM) in aortic and coronary rings, with intact and denuded endothelium.

Results:

In aorta from 2K-1C animals, the treatment with BPY 0.1µM increased the potency of acetylcholine-induced relaxation and it was able to revert the endothelial dysfunction. The presence of the endothelium did not modify the effect of BPY in inducing the relaxation in aortas from 2K and 2K-1C rats. In coronary, the endothelium potentiated the vasodilator effect of BPY in vessels from 2K and 2K-1C rats.

Conclusion:

Our results suggest that 0.1 µM of BPY is able to normalize the relaxation endothelium dependent in hypertensive rats, and the compound BPY induces relaxation in aortic from normotensive and hypertensive rats with the same potency. The endothelium potentiate the relaxation effect induced by BPY in coronary from normotensive and hypertensive rats, with lower effect on coronary from hypertensive rats.

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Original Article

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain

Luis Cláudio Lemos Correia et al. Fábio P. Esteves Manuela Carvalhal Thiago Menezes Barbosa de Souza … Nicole de Sá Vitor Calixto de Almeida Correia Felipe Kalil Beirão Alexandre Fernanda Lopes Felipe Ferreira Márcia Noya-Rabelo

Abstract

Background:

The accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD).

Objective:

To test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations.

Methods:

Patients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography.

Results:

In 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability < 50%, zero calcium score had a negative predictive value of 95% (95%CI = 83%-99%), with a number needed to test of 2.1 for obtaining one additional discharge.

Conclusion:

Zero calcium score substantially reduces the pretest probability of obstructive CAD in patients admitted to the CCU with acute chest pain. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

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Viewpoint

Hypotension and Renal Dysfunction: The Ghosts of Heart Failure

Humberto Villacorta Junior et al. Aline Sterque Villacorta

Hypotension, bradycardia and renal dysfunction as obstacles to the treatment of heart failure

Heart failure (HF) is a chronic, high morbidity and high cost disease. The treatment of HF due to left ventricular (LV) systolic dysfunction is well determined and is listed in Medical Guidelines. However, innumerable situations may limit treatment, causing the physician to fail to implement the guidelines. Some serious patients may not tolerate medications or recommended doses; others may have side effects. In some cases, however, there is an excess of caution, failing to prescribe the recommended treatment, fearing complications. The purpose of this article is to demystify, based on the literature, some situations that may prevent the optimized drug treatment from being offered to the HF patient.

The two major side effects that may act as barriers to the treatment of HF are hypotension and worsening renal function. Besides these, we will comment on bradycardia and hyperkalemia.

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Anatomopathological Session

Case 4/2017 – Young Male Marathoner with Heart Failure Due to Dilated Cardiomyopathy

Hilda Sara Montero Ramirez et al. Rafael Amorim Belo Nunes Vera Demarchi Aiello

Clinical aspects

The patient was a 22-year-old male marathoner with fatal heart failure for 1 year. The clinical data reported were dyspnea and precordial discomfort on exertion. The patient maintained his trainings and running practice less intensely due to lower limb pain and weakness in the last months, until he was hospitalized due to chest pain, dyspnea, hemoptysis, mental confusion and syncope. During hospitalization, his clinical findings rapidly and progressively deteriorated. His electrocardiogram on admission revealed signs of right atrial overload, left ventricular overload and secondary ventricular repolarization changes. The left ventricle was diffusely hypokinetic and the diastolic function pattern was restrictive. There was moderate mitral and tricuspid valve regurgitation. These findings suggest cardiomyopathy with important hemodynamic repercussion.

The causes of cardiomyopathy in young individuals are: idiopathic cardiomyopathy, infectious myocarditis and autoimmune myocarditis. Cardiotoxicity can also be observed in exposure to certain agents, such as alcohol, cocaine, heavy metals and antineoplastic drugs, such as anthracyclines and cyclophosphamide.

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Editorial

Calcium Score Use in Isolation in Acute Chest Pain Setting – Is it Sufficient?

Tiago Augusto Magalhães et al. Marcio Sommer Bittencourt Carlos Eduardo Rochitte

The clinical usefulness of any test in Medicine depends on the population studied, because even an accurate test will yield no benefit if applied to the wrong population. While sensitivity and specificity are characteristics inherent in the diagnostic method, the individual probability of having a disease when the test is positive (positive predictive value, PPV) and the probability of not having the disease when the test is negative (negative predictive value, NPV) depend on the disease prevalence in the population and the individual probability of having the disease before undergoing the test, the pretest probability.

The PPV and NPV are the information that matters for clinicians. In the presence of a positive test, clinicians are interested in the patient’s real probability of having the disease. However, in the presence of a negative test, Clinicians want to know the true probability of the disease even with the negative result. Thus, PPV and NPV should be considered before requesting a test, because some cases a positive test might not sufficient to confirm the presence of disease, while a negative test might not be able to exclude it safely.

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