2018;111(3) – ABC CARDIOL

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Original Article

Anger and Coronary Artery Disease in Women Submitted to Coronary Angiography: A 48-Month Follow-Up

Karine Elisa Schwarzer Schmidt et al. Alexandre Schaan de Quadros Mauro Regis Moura Carlos Antonio Mascia Gottschall Márcia Moura Schmidt

Abstract

Background:

Anger control was significantly lower in patients with coronary artery disease (CAD), regardless of traditionally known risk factors, occurrence of prior events or other anger aspects in a previous study of our research group.

Objective:

To assess the association between anger and CAD, its clinical course and predictors of low anger control in women submitted to coronary angiography.

Methods:

This is a cohort prospective study. Anger was assessed by use of Spielberger’s State-Trait Anger Expression Inventory (STAXI). Women were consecutively scheduled to undergo coronary angiography, considering CAD definition as ≥ 50% stenosis of one epicardial coronary artery.

Results:

During the study, 255 women were included, being divided into two groups according to their anger control average (26.99). Those with anger control below average were younger and had a family history of CAD. Patients were followed up for 48 months to verify the occurrence of major cardiovascular events.

Conclusion:

Women with CAD undergoing coronary angiography had lower anger control, which was associated with age and CAD family history. On clinical follow-up, event-free survival did not significantly differ between patients with anger control above or below average.

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Editorial

Obstructive Sleep Apnea: A Marker of Cardiac Remodeling in Patients with Chronic Chagas Disease

Reinaldo B. Bestetti

Chronic Chagas disease (CCD) continues to be a major scourge for people living in South America and an emergent medical problem outside the American Continent because of world globalization. Chronic Chagas heart disease (CCHD) affects about 30% of patients with CCD, appearing 20-30 years after infection with Trypanosoma cruzi. Prognosis of CCD patients is relentless, with a 5-year mortality approaching 35%. CCHD patients have an outcome even worse, particularly those with ventricular and atrial remodeling, which manifests by chronic systolic heart failure and atrial fibrillation.^,

It is, therefore, important to recognize predictors of ventricular and atrial remodeling in patients with CCHD to offer the proper available treatment for patients with this condition. Systolic blood pressure, male sex, and New York Heart Association Functional Class appear to predict ventricular remodeling in patients with CCD. Conversely, as far as I know, predictors of atrial remodeling have not yet been established for patients with this condition.

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Editorial

Secondary Dyslipidemia In Obese Children – Is There Evidence For Pharmacological Treatment?

Ana Cristina Sayuri Tanaka

Obesity is a condition that has progressively increased throughout the world, also affecting children and adolescents, leading to high costs for health systems. Pediatric obesity is associated with dyslipidemia, oxidative stress, insulin resistance, and endothelial dysfunction, cardiovascular risk factors and components of the metabolic syndrome, and leads to adverse consequences such as early mortality and physical morbidity in adulthood in the short and long term.

Obesity-related dyslipidemia consists of increased triglycerides and free fatty acids, and decreased HDL-c (high-density cholesterol), normal or slightly increased LDL-c (low-density cholesterol), and increased VLDL-c (cholesterol of very low density). Plasma apolipoprotein B (apo B) concentrations are also frequently increased, in part due to increased hepatic production of apo B-containing lipoproteins.^,

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Viewpoint

For a Model of Self-Citation Governance in Arquivos Brasileiros de Cardiologia

Marcos Antonio Almeida-Santos et al. Deyse Mirelle Souza Santos Beatriz Santana Prado José Augusto Barreto-Filho

Arquivos Brasileiros de Cardiologia (ABC) has been the official scientific publication of Brazilian Society of Cardiology (Sociedade Brasileira de Cardiologia, SBC) since 1948. Since its beginning, ABC has continuously published articles on a wide range of topics in cardiology, becoming the main organ of dissemination of scientific work in Brazil and Portuguese-speaking countries. Since 1950, the articles have been indexed in the main international databases (Institute of Scientific Information – ISI Web of Science; Cumulated Index Medicus – MEDLINE; Pubmed Central; EMBASE; SCOPUS; SCIELO and LILACS), and are currently published in two languages (English and Portuguese). Thomson Reuters publishing company, owner of the Journal Citation Reports (JCR) statistical database, created the concept of impact factor in 1955, aiming to provide an instrument to evaluate the performance of scientific publications in a comparative and quantitative manner. Impact factor is calculated by dividing the number of citations of articles published in an academic or technical journal indexed in the ISI by the total number of articles published in that journal during the two preceding years. These estimates include approximately 3,300 journals, 200 subject areas and 100 countries.

Impact factor is a metric for journal assessment, widely used by researchers to choose the best journal to submit their papers. However, its validity as an indicator of scientific impact has been questioned due to, among others, self-promoting journal self-citation in attempt to increase their impact factor. Overuse of self-citation practices is punishable, and caused the exclusion of 5 Brazilian journals from the JCR for one year (2013). For this reason, efficient control measures of this practice should be developed and implemented by scientific journals that seek to adhere to ethical precepts recommended by the scientific community.

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Editorial

Right Ventricular Evaluation with Speckle Tracking Echocardiography in COPD after a Pulmonary Rehabilitation Program

Djair Brindeiro Filho

Chronic obstructive pulmonary disease (COPD) is a serious public health problem, and is often related to smoking. In advanced stages of COPD, the presence of PAH is a common development. PAH progression rate in COPD is usually slow (an increase of < 1 mmHg per year). However, the presence of even moderate PAH is a strong predictor of mortality. During stable periods of the disease, the increase in mean pulmonary artery pressure is usually mild to moderate. However, severe PAH may occasionally occur in COPD patients COPD.

Conventional two-dimensional (2D) echo parameters allow a reasonable assessment of RV Function. In the 1990s, the use of tissue Doppler (TD) to measure the intramyocardial velocity gradient allowed measuring the rate of myocardial strain and its percentage (strain rate and strain). About ten years ago, the speckle tracking technique, based on the tracking of the speckles which two-dimensional echo images, allowed assessing myocardial strain without limitation by the DT insonation angle. 2D-STE strain can not only quantify the overall RV function, but it can also identify discrete, localized contractile losses, providing information regarding the pathophysiological mechanisms that lead to right ventricular failure. In a heterogeneous group of patients, RV lateral wall longitudinal strain showed a strong correlation with RV ejection fraction calculated by cardiac magnetic resonance. Peak longitudinal strain is a significant prognostic determinant in PAH patients, with greater value compared to other known clinical and echocardiographic predictors of mortality.

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Image

Right Ventricular Wound And Complete Mammary Artery Transection

Gregorio Laguna et al. Miriam Blanco Cristina García-Rico Yolanda Carrascal

Many patients die immediately after suffering a heart wound; on the other hand, many others die before the surgery, during surgery or later, due to complications.

We admitted a 33-year-old man after a suicide attempt occurring one hour before, with eleven knife-wounds localized in the left-anterior chest wall (). Physical exam showed hypotension, dyspnea, high central venous pressure and mild external bleeding. Hemodynamic monitoring, tracheal intubation, vasopressor perfusion, fluid therapy and urgent echocardiogram and tomography were undertaken. ACT showed severe pericardial effusion and moderate left pleural effusion (, white arrows). Emergency cardiac surgery was performed through median sternotomy. Multiple pericardial tears were visualized. The pericardial clot was removed () and the right ventricular wound was closed using a monofilament suture (, black arrow). In the inner chest wall, a complete left mammary artery transection was observed with severe bleeding into the left pleural cavity (, white arrow). The mammary artery was repaired, and the bleeding was controlled. The postoperative course was uneventful.

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Case Report

Partial Papillary Muscle Rupture after Myocardial Infarction and Early Severe Obstructive Bioprosthetic Valve Thrombosis: an Unusual Combination

Inês Silveira et al. Marta Oliveira Catarina Gomes Sofia Cabral … André Luz Severo Torres

Introduction

Mechanical complications after myocardial infarction (MI) have become uncommon since the introduction of primary angioplasty. They can lead to a rapid clinical deterioration and a fatal outcome, with patient’s survival being dependent on their prompt recognition and intervention. We describe a case of two rare mechanical complications: a partial papillary muscle rupture after MI, followed by an early severe obstructive thrombosis of the implanted bioprosthetic valve.

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Brief Communication

Silent Cerebral Infarctions with Reduced, Mid-Range and Preserved Ejection Fraction in Patients with Heart Failure

Márcia Maria Carneiro Oliveira et al. Elieusa e Silva Sampaio Jun Ramos Kawaoka Maria Amélia Bulhões Hatem … Edmundo José Nassri Câmara André Maurício Souza Fernandes Jamary Oliveira-Filho Roque Aras

Abstract

Heart failure predisposes to an increased risk of silent cerebral infarction, and data related to left ventricular ejection fraction are still limited. Our objective was to describe the clinical and echocardiographic characteristics and factors associated with silent cerebral infarction in patients with heart failure, according to the left ventricular ejection fraction groups. A prospective cohort was performed at a referral hospital in Cardiology between December 2015 and July 2017. The left ventricular ejection fraction groups were: reduced (≤ 40%), mid-range (41-49%) and preserved (≥ 50%). All patients underwent cranial tomography, transthoracic and transesophageal echocardiography. Seventy-five patients were studied. Silent cerebral infarction was observed in 14.7% of the study population (45.5% lacunar and 54.5% territorial) and was more frequent in patients in the reduced left ventricular ejection fraction group (29%) compared with the mid-range one (15.4%, p = 0.005). There were no cases of silent cerebral infarction in the group of preserved left ventricular ejection fraction. In the univariate analysis, an association was identified between silent cerebral infarction and reduced (OR = 8.59; 95%CI: 1.71 – 43.27; p = 0.009) and preserved (OR = 0.05; 95%CI: 0.003-0.817, p = 0.003) left ventricular ejection fraction and diabetes mellitus (OR = 4.28, 95%CI: 1.14-16.15, p = 0.031). In patients with heart failure and without a clinical diagnosis of stroke, reduced and mid-range left ventricular ejection fractions contributed to the occurrence of territorial and lacunar silent cerebral infarction, respectively. The lower the left ventricular ejection fraction, the higher the prevalence of silent cerebral infarction.

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Editorial

The Brazilian Society of Cardiology and Hypertension: It's Time for Action

Paulo César B. Veiga Jardim

The year is 2018 and the level of scientific knowledge is unquestionable.

In medicine in general, and in cardiology, in particular, advances in diagnoses are impressive, just as the therapeutic arsenal is extraordinary, either in clinical or surgical, conventional or alternative treatment.

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Clinicoradiological Correlation

Case 5/2018 – Severe Pulmonary Valve Stenosis (PVS), Relieved by a Double-balloon Catheter, in a 68-year-old Woman

Edmar Atik et al. Alessandra Costa Barreto Maria Angélica Binotto Luiz Junya Kajita

Clinical data

During a recent clinical evaluation for cholecystectomy surgery, a heart murmur was auscultated and complaint of fatigue at great efforts lasting for some months was reported by the patient. The diagnosis of severe PVS was attained, with a maximum gradient of 160 mmHg obtained at the echocardiography. The patient denied other symptoms and was unaware of the existence of this cardiopathy. She had no history of other morbidities and took vitamin D.

Physical examination: The patient was in good overall condition, eupneic, acyanotic, normal pulses in the 4 limbs. Weight: 70 kg, height: 160 cm, right upper limb blood pressure: 140/80 mmHg, heart rate: 80 bpm, oxygen saturation, 89%. Aorta not palpable in the suprasternal notch.

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Editorial

Anger and Cardiovascular Disease: An Old and Complicated Relationship

Carlos Eduardo Lucena Montenegro et al. Sergio Tavares Montenegro

Negative feelings have long been related to health problems. Buddhism, for example, refers to anger as one of the three “poisons of the mind” (greed, anger and madness). In the first edition of Circulation, there was already an article suggesting the association between stress and cardiovascular disease.

In the last decades, several studies have tried to correlate psychosocial factors, such as anger, anxiety, depression and stress, with coronary artery disease (CAD), demonstrating the increase in the incidence of CAD in patients with a higher incidence of these psychic conditions, for example, with a marked increase in events of acute myocardial infarction (AMI) between 2008 and 2009, in the United States, when there was a stock market crash.^– This relationship tends to be significantly more important in women, since factors such as low socioeconomic status and double working hours (conciliation of employment with maternity), among other factors, are more common in the female population. More recently, a longitudinal study of cohort was able to demonstrate the association between the activity of the cerebral amygdala (area involved with the emotions) and the increased risk of cardiovascular events.

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Editorial

Adiponectin in Relation to Coronary Plaque Characteristics on Radiofrequency Intravascular Ultrasound and Cardiovascular Outcome

José Mariani Junior

Inflammation is a complex and necessary component of the response to biological, chemical, or physical stimuli, and the cellular and molecular events that initiate and regulate the interactions between the various players in the inflammatory process of the atherosclerotic lesions remain a source of ongoing investigation.

The European Collaborative Project on Inflammation and Vascular Wall Remodeling in Atherosclerosis – Intravascular Ultrasound (ATHEROREMO-IVUS) study aimed to investigate the relations of genetic profile and novel circulating and inflammatory biomarkers with coronary plaque phenotype and vulnerability as determined by intravascular ultrasound (IVUS). Results from this trial have been helping us to improve our knowledge on the role of genetic profile and circulating inflammatory biomarkers in relation to the development of atherosclerosis and vulnerable plaques.

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Editorial

Three-dimensional Speckle Tracking Echocardiography in Amyloidosis: A New Assessment Method for a Rare Disease

Brivaldo Markman Filho

Immunoglobulin deposition in the myocardium characterizes involvement of cardiac amyloidosis (CA). Fibrillary infiltration, which may happen in every heart cavity, leads to the restrictive cardiomyopathy phenotype, with complex pathophysiological mechanisms, which will result in the syndromic diagnosis of congestive heart failure. Diastolic dysfunction is dominant in most cases, and it may or may not, follow diverse levels of systolic dysfunction in the most advanced phases of the disease. Atrial remodeling by amyloid infiltration may contribute to cardiac output decrease by means of insufficient or nonexistent telediastolic atrial contraction. The onset of atrial electrical instability, ending in atrial fibrillation, highlights symptomatic worsening and these patients’ reserved prognosis.

Historically, the right cavities of the heart have been neglected in echocardiographic assessments. The complex morphology of the right ventricle (RV) has possibly contributed for the lack of reproducible data on echocardiographic cutting plans, diversely from the left ventricle (LV). The development of three-dimensional echocardiography (3DE) has allowed for a more accurate calculation of right ventricle volume and function in the diverse pathologies involving that chamber.

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Original Article

Adiponectin in Relation to Coronary Plaque Characteristics on Radiofrequency Intravascular Ultrasound and Cardiovascular Outcome

Bárbara Campos Abreu Marino et al. Nermina Buljubasic Martijn Akkerhuis Jin M. Cheng … Hector M. Garcia-Garcia Evelyn Regar Robert-Jan van Geuns Patrick W. Serruys Eric Boersma Isabella Kardys

Abstract

Background:

Prospective data on the associations of adiponectin with in-vivo measurements of degree, phenotype and vulnerability of coronary atherosclerosis are currently lacking.

Objective:

To investigate the association of plasma adiponectin with virtual histology intravascular ultrasound (VH-IVUS)-derived measures of atherosclerosis and with major adverse cardiac events (MACE) in patients with established coronary artery disease.

Methods:

In 2008-2011, VH-IVUS of a non-culprit non-stenotic coronary segment was performed in 581 patients undergoing coronary angiography for acute coronary syndrome (ACS, n = 318) or stable angina pectoris (SAP, n = 263) from the atherosclerosis-intravascular ultrasound (ATHEROREMO-IVUS) study. Blood was sampled prior to coronary angiography. Coronary plaque burden, tissue composition, high-risk lesions, including VH-IVUS-derived thin-cap fibroatheroma (TCFA), were assessed. All-cause mortality, ACS, unplanned coronary revascularization were registered during a 1-year-follow-up. All statistical tests were two-tailed and p-values < 0.05 were considered statistically significant.

Results:

In the full cohort, adiponectin levels were not associated with plaque burden, nor with the various VH-tissue types. In SAP patients, adiponectin levels (median[IQR]: 2.9(1.9-3.9) µg/mL) were positively associated with VH-IVUS derived TCFA lesions, (OR[95%CI]: 1.78[1.06-3.00], p = 0.030), and inversely associated with lesions with minimal luminal area (MLA) ≤ 4.0 mm² (OR[95%CI]: 0.55[0.32-0.92], p = 0.025). In ACS patients, adiponectin levels (median[IQR]: 2.9 [1.8-4.1] µg/mL)were not associated with plaque burden, nor with tissue components. Positive association of adiponectin with death was present in the full cohort (HR[95%CI]: 2.52[1.02-6.23], p = 0.045) and (borderline) in SAP patients (HR[95%CI]: 8.48[0.92-78.0], p = 0.058). In ACS patients, this association lost statistical significance after multivariable adjustment (HR[95%CI]: 1.87[0.67-5.19], p = 0.23).

Conclusion:

In the full cohort, adiponectin levels were associated with death but not with VH-IVUS atherosclerosis measures. In SAP patients, adiponectin levels were associated with VH-IVUS-derived TCFA lesions. Altogether, substantial role for adiponectin in plaque vulnerability remains unconfirmed.

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Original Article

Secondary Dyslipidemia In Obese Children – Is There Evidence For Pharmacological Treatment?

Graciane Radaelli et al. Grasiele Sausen Claudia Ciceri Cesa Vera Lucia Portal Lucia Campos Pellanda

Abstract

Background:

Long-term safety, effectiveness and criteria for treatment with statins in children are still unclear in clinical practice. There is very limited evidence for the use of medication to treat children with dyslipidemia secondary to obesity who do not respond well to lifestyle modification.

Objective:

Systematic review of randomized clinical trials of statin use to treat children and adolescents with dyslipidemia secondary to obesity.

Methods:

We performed a search in PubMed, EMBASE, Bireme, Web of Science, Cochrane Library, SciELO, and LILACS for data to evaluate the effect of statins on: improvement of surrogate markers of coronary artery disease in clinical outcomes of adulthood; increased serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and apolipropotein B (APOB); and decreased serum levels of high-density lipoprotein cholesterol (HDL-C) from inception to February 2016. Participants were children and adolescents.

Results:

Of the 16793 potentially relevant citations recovered from the electronic databases, no randomized clinical trials fulfilled the inclusion criteria for children with dyslipidemia secondary to obesity.

Conclusions:

We found no specific evidence to consider statins in the treatment of hypercholesterolemia secondary to obesity in children. The usual practice of extrapolating findings from studies in genetic dyslipidemia ignores the differences in long-term cardiovascular risks and the long-term drug treatment risks, when compared to recommendation of lifestyle changes. Randomized clinical trials are needed to understand drug treatment in dyslipidemia secondary to obesity.

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Original Article

Right Atrial Deformation Analysis in Cardiac Amyloidosis – Results from the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Path Study

Attila Nemes et al. Dóra Földeák Péter Domsik Anita Kalapos … Árpád Kormányos Zita Borbényi Tamás Forster

Abstract

Background:

Light-chain (AL) cardiac amyloidosis (CA) is characterized by fibril deposits, which are composed of monoclonal immunoglobulin light chains. The right ventricle is mostly involved in AL-CA and impairment of its function is a predictor of worse prognosis.

Objectives:

To characterize the volumetric and functional properties of the right atrium (RA) in AL-CA by three-dimensional speckle-tracking echocardiography (3DSTE).

Methods:

A total of 16 patients (mean age: 64.5 ± 10.1 years, 11 males) with AL-CA were examined. Their results were compared to that of 15 age- and gender-matched healthy controls (mean age: 58.9 ± 6.9 years, 8 males). All cases have undergone complete two-dimensional Doppler and 3DSTE. A two-tailed p value of less than 0.05 was considered statistically significant.

Results:

Significant differences could be demonstrated in RA volumes respecting cardiac cycle. Total (19.2 ± 9.3% vs. 27.9 ± 10.7%, p = 0.02) and active atrial emptying fractions (12.1 ± 8.1 vs. 18.6 ± 9.8%, p = 0.05) were significantly decreased in AL-CA patients. Peak global (16.7 ± 10.3% vs. 31.2 ± 19.4%, p = 0.01) and mean segmental (24.3 ± 11.1% vs. 38.6 ± 17.6%, p =0.01) RA area strains, together with some circumferential, longitudinal and segmental area strain parameters, proved to be reduced in patients with AL-CA. Global longitudinal (4.0 ± 5.2% vs. 8.2 ± 5.5%, p = 0.02) and area (7.8 ± 8.1% vs. 15.9 ± 10.3%, p = 0.03) strains at atrial contraction and some circumferential and area strain parameters at atrial contraction were reduced in AL-CA patients.

Conclusion:

Significantly increased RA volumes and deteriorated RA functions could be demonstrated in AL-CA.

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Original Article

Fasting/Refeeding Cycles Prevent Myocardial Dysfunction and Morphology Damage in the Spontaneously Hypertensive Rats

Matheus Fécchio Pinotti et al. Amanda Martins Matias Mário Mateus Sugizaki André Ferreira do Nascimento … Maeli Dal Pai Ana Paula Lima Leopoldo Antônio Carlos Cicogna André Soares Leopoldo

Abstract

Background:

Caloric restriction is known to impair the cardiac function and morphology in hypertrophied hearts of spontaneously hypertensive rats (SHR); however, the influence of fasting/refeeding (RF) is unknown.

Objective:

To investigate the fasting/refeeding approach on myocardial remodeling and function. In addition, the current study was designed to bring information regarding the mechanisms underlying the participation of Ca²⁺ handling and b-adrenergic system.

Methods:

Sixty-day-old male SHR rats were submitted to food ad libitum (C), 50% food restriction (R₅₀) or RF cycles for 90 days. Cardiac remodeling was assessed by ultrastructure analysis and isolated papillary muscle function. The level of significance considered was 5% (a = 0.05).

Results:

The RF rats presented lower cardiac atrophy than R₅₀ in relation to C rats. The C rats increased weight gain, R₅₀ maintained their initial body weight and RF rats increased and decreased weight during RF. The RF did not cause functional impairment because the isotonic and isometric parameters showed similar behavior to those of C. The isotonic and isometric cardiac parameters were significantly elevated in RF rats compared to R₅₀ rats. In addition, the R₅₀ rats had cardiac damage in relation to C for isotonic and isometric variables. While the R₅₀ rats showed focal changes in many muscle fibers, the RF rats displayed mild alterations, such as loss or disorganization of myofibrils.

Conclusion:

Fasting/refeeding promotes cardiac beneficial effects and attenuates myocardial injury caused by caloric restriction in SHR rats, contributing to reduce the cardiovascular risk profile and morphological injuries. Furthermore, RF promotes mild improvement in Ca²⁺ handling and b-adrenergic system.

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Original Article

Obstructive Sleep Apnea is Common and Associated with Heart Remodeling in Patients with Chagas Disease

Carolina de Araújo Medeiros et al. Isaac Vieira Secundo Carlos Antônio da Mota Silveira José Maria del Castilho … Afonso Luiz Tavares de Albuquerque Sílvia Marinho Martins Wilson de Oliveira Júnior Geraldo Lorenzi-Filho Luciano F. Drager Rodrigo Pinto Pedrosa

Abstract

Background:

Chagas Disease (CD) is an important cause of morbimortality due to heart failure and malignant arrhythmias worldwide, especially in Latin America.

Objective:

To investigate the association of obstructive sleep apnea (OSA) with heart remodeling and cardiac arrhythmias in patients CD.

Methods:

Consecutive patients with CD, aged between 30 to 65 years old were enrolled. Participants underwent clinical evaluation, sleep study, 24-hour Holter monitoring, echocardiogram and ambulatory blood pressure monitoring.

Results:

We evaluated 135 patients [age: 56 (45-62) years; 30% men; BMI: 26 ± 4 kg/m², Chagas cardiomyopathy: 70%]. Moderate to severe OSA (apnea-hypopnea index, AHI, ≥ 15 events/h) was present in 21% of the patients. OSA was not associated with arrhythmias in this population. As compared to patients with mild or no OSA, patients with moderate to severe OSA had higher frequency of hypertension (79% vs. 72% vs. 44%, p < 0.01) higher nocturnal systolic blood pressure: 119 ± 17 vs. 113 ± 13 vs. 110 ± 11 mmHg, p = 0.01; larger left atrial diameter [37 (33-42) vs. 35 (33-39) vs. 33 (30-36) mm, p < 0.01]; and a greater proportion of left ventricular dysfunction [LVEF < 50% (39% vs. 28% vs. 11%), p < 0.01], respectively. Predictor of left atrial dimension was Log₁₀ (AHI) (b = 3.86, 95% CI: 1.91 to 5.81; p 15 events/h (OR = 3.61, 95% CI: 1.31 – 9.98; p = 0.01), systolic blood pressure (OR = 1.06, 95% CI: 1.02 – 1.10; p < 0.01) and male gender (OR = 3.24, 95% CI: 1.31 – 8.01; p = 0.01).

Conclusions:

OSA is independently associated with atrial and ventricular remodeling in patients with CD.

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Original Article

Evaluation of the Bleeding Intensity of Patients Anticoagulated with Warfarin or Dabigatran Undergoing Dental Procedures

Marcus Vinicius Santos Andrade et al. Luciana Azevedo Prata Andrade Alan Freitas Bispo Luana de Alencar Freitas … Milena Quadros Sampaio Andrade Gilson Soares Feitosa Gilson Soares Feitosa-Filho

Abstract

Background:

Thrombotic disorders remain one of the leading causes of death in the Western world. Dabigatran appeared as an alternative to warfarin for anticoagulation in the treatment of atrial fibrillation (AF). The risk associated with bleeding due to its use has been documented in several randomized clinical trials, but no large study has examined in detail the risk of bleeding during dental extraction and other dental procedures involving bleeding.

Objective:

To compare the intensity of bleeding in individuals taking dabigatran or vitamin K antagonist (warfarin) and undergoing dental procedures.

Methods:

Prospective, single-center, controlled study with one single observer. Patients diagnosed with nonvalvular AF, on warfarin or dabigatran, cared for at a cardiology referral center, and requiring single or multiple dental extractions, were evaluated up to seven days post-extraction. The following outcomes were assessed: bleeding time between the beginning and the end of suture and complete hemostasis; bleeding before the procedure, after 24 hours, 48 hours, 7 days, during and after suture removal (late); p<0.05 was defined as of statistical relevance.

Results:

We evaluated 37 individuals, 25 in the warfarin group and 12 in the dabigatran group. Age, sex, weight, height, blood pressure, color, schooling, family income and comorbidities were similar between the two groups. Regarding bleeding after 24 hours of the procedure, no one in the dabigatran group had bleeding, whereas 32% in the warfarin group had documented bleeding (p = 0.028). The other variables analyzed did not differ between the groups.

Conclusions:

This study suggests that, regarding dental extraction, there is no statistically significant difference in the intensity of bleeding of patients taking dabigatran as compared to those taking warfarin. Bleeding 24 hours after the procedure was less frequent among patients on dabigatran.

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Original Article

Right Ventricular Functional Improvement after Pulmonary Rehabilitation Program in Patients with COPD Determined by Speckle Tracking Echocardiography

Batur Gonenc Kanar et al. Ipek Ozmen Elif Ozari Yildirim Murat Ozturk Murat Sunbul

Abstract

Background:

Although right ventricular (RV) dysfunction in pulmonary diseases has been associated with increased morbidity, tools for RV dysfunction identification are not well defined.

Objective:

The aim of this study was to evaluate the magnitude of RV dysfunction by means of speckle tracking echocardiography (STE) in patients with chronic obstructive pulmonary disease (COPD) and to investigate whether STE could be used as an index of RV improvement after a pulmonary rehabilitation (PR) program.

Methods:

Forty-six patients with COPD undergoing PR program and 32 age-sex matched healthy subjects were enrolled. RV function was evaluated at admission and after PR program by conventional two-dimensional echocardiography (2DE) and STE. In addition, exercise tolerance of subjects was evaluated using the six-minute walk test (6MWT).

Results:

COPD patients had worse RV function according to STE and 2DE as well. STE was more sensitive than conventional 2DE in determining RV improvement after PR program – RV global longitudinal strain (LS): 20.4 ± 2.4% vs. 21.9 ± 2.9% p < 0.001 and RV free wall LS: 18.1 ± 3.4% vs. 22.9 ± 3.7%, p < 0.001). RV free wall LS was directly related to distance walked at baseline 6MWT (r = 0.58, p < 0.001) and to the change in the 6MWT distance (6MWTD ∆) (r = 0.41, p = 0.04).

Conclusions:

We conclude that STE might be as effective as 2DE for evaluation of global and regional RV functions. STE may become an important tool for assessment and follow-up of COPD patients undergoing PR program to determine the relationship between RV function and exercise tolerance.

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