2019;112(2) – ABC CARDIOL

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Viewpoint

Early Diagnosis and Treatment in Infective Endocarditis: Challenges for a Better Prognosis

Daniely Iadocico Sobreiro et al. Roney Orismar Sampaio Rinaldo Focaccia Siciliano Calila Vieira Andrade Brazil … Carlos Eduardo de Barros Branco Antônio Sergio de Santis Andrade Lopes Flávio Tarasoutchi Tânia Mara Varejão Strabelli

Infective endocarditis (IE), a microbial infection of the cardiac or adjacent vascular endothelium, remains a feared disease, although the modern diagnosis systematizations date back to 1885 by Osler. Although relatively uncommon, with approximately 3-10 cases per 100,000 individuals/year, the mortality remains high: more than one-third of patients die in the first year after the diagnosis.^, Only early diagnosis and treatment, whether exclusively clinical or associated with cardiac surgery, may interfere to reduce this high mortality rate.

IE used to be more frequent in young and middle-aged adults with rheumatic or congenital heart disease. However, recent studies have shown a significant reduction in the incidence of IE in these groups, especially in more developed countries.

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Anatomopathological Correlation

Case 1/2019 – A 51-year-old Man with Arterial Hypertension, Aortic Dissection and Aortic Valve Regurgitation, in Addition to Heart Failure with Unchanged Clinical Course After Surgical Intervention

Desiderio Favarato et al. Vera Demarchi Aiello

Clinical aspects

This was a male patient, who presented with ascending aortic dissection, and who, even after surgery for dissection repair, developed a picture of severe heart failure and died.

The International Registry of Acute Aortic Dissection (IRAD) showed that patients with aortic dissection were older than our patient, 61 years; and a majority of males (63%). Regarding the diseases related to the dissection, they were: Marfan syndrome (6.7%), hypertension (69.3%), atherosclerosis (24.4%), previously known aortic aneurysm (12.4%), previous aortic dissection 3.9%) and diabetes mellitus (4.3%). Also, 15.9% had a history of previous cardiac surgery and iatrogenic cause in 4.8% (1.7% coronary angiography and 3.1% after cardiac surgery). The 2015 update of the same registry, with a ten-fold higher number of patients, showed an increase in hypertension (75.5%) and a decrease in the presence of Marfan syndrome (4.5%), (75.5%), atherosclerosis (19.6%) and previous cardiac surgery (10.6%).

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Erratum

Erratum

January issue of 2019, vol. 112(1), pages 67-75

In “Sex-Related Effects of Prenatal Stress on Region-Specific Expression of Monoamine Oxidase A and B Adrenergic Receptors in Rat Hearts”, consider Tanja Jevdjovic as the correct form for the name of the author Tanja Jevjdovic.

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Brief Communication

Analysis of Iron Metabolism in Chronic Chagasic Cardiomyopathy

Carla Paixão Miranda et al. Fernando Antônio Botoni Maria do Carmo Pereira Nunes Manoel Otávio da Costa Rocha

Abstract

Changes in iron metabolism in heart failure (HF) have been described as an important prognostic marker.

To check if the markers of iron kinetics are related to the morbidity and etiology of chagasic cardiomyopathy.

Patients with Chronic Chagasic Cardiomyopathy (CCC, n = 40), with indeterminate form (IND, n = 40), besides non-chagasic cardiomyopathy (NCh, n = 40).

The mean age was 50.98 ± 5.88 in CCC, 50% were male, 49.68 ± 5.28 in IND, 52.2% were male, and 49.20 ± 10.09 in NCh, 12.5% were male. Lower levels of iron (FeSe) were observed in the CCC groups (93.15 ± 36.53), when compared to IND (125.30 ± 22.79) and NCh (114.77 ± 18.90) (p = 0.0004), lower IST transferrin saturation index in CCC (29.48 ± 6.59), when compared to IND (30.95 ± 7.06) and in the NCh group (39.70 ± 7.54) p = 0.0001), total binding capacity of the lower CTLF iron in the CCC group (297.30 ± 36.46), when compared to the IND group (196.52 ± 56.95) and the NCh group (275.18 ± 33, 48) (p = 0.0001), lower ferritin in the CCC group (134.55, 1.56-42.36), when compared to the IND group (156,25, 1,72-42,20) and the NCh group (112.95, 2.88-42.66) (p = 0.0004). It was also observed that FeSe (95% CI 1.00-1.04, p = 0.0014), IST (95% CI 1.02-1.22) (p = 0.0012) and gender (95% CI 1.07-14.43 p = 0.0038) were independently associated with the degree of ventricular dysfunction in chagasic cardiomyopathy.

CCC patients showed greater change in iron metabolism regarding the indeterminate form and other forms of cariomyopathies.

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Editorial

The Importance of Identifying Risk Factors in Childhood and Adolescence

Ana Paula Marte Chacra

The study “Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association” showed a high prevalence of obesity (53%) followed by overweight (25.2%) in adolescents. The obese group had a predominance of low HDL-c besides the positive association of body mass index (BMI) and abdominal circumference with triglyceride values. These date are fundamental and warn of the importance of early assessment of risk factors.

Elevated triglycerides and low HDL-c are strongly linked to obesity, especially in youth and early exposure to that unfavourable metabolic profile will contribute to a higher cardiovascular risk.

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Case Report

Large Bilateral Coronary Artery Fistula: 10-year Follow-up in Clinical Treatment

Rodrigo Melo Kulchetscki et al. Luka David Lechinewski Luciana Oliveira Cascaes Dourado Whady Armindo Hueb Luiz Antonio Machado César

Case Report

A 59-year-old asymptomatic female patient, with a diagnosis of a large bilateral coronary-pulmonary artery fistula made in 2007 was investigated after a cardiac murmur was identified on a routine examination. At the time, conservative treatment was chosen. Cardiac auscultation showed a more audible systolic-diastolic murmur in the upper left sternal border, with a more audible component in systole. There were no other findings in the cardiological physical examination or even the overall segmental examination. The patient had no comorbidities at the time, except for a prior history of smoking (10-pack-years). During the evolution, at the annual outpatient follow-up, she had diagnoses of dyslipidemia, glucose intolerance and depression. At the last consultation, in 2017, the patient was asymptomatic. She used atenolol 25 mg/ day, metformin 850 mg/day, atorvastatin 20 mg/day and sertraline 50 mg/day.

The examinations performed after 10 years of follow-up were compared with those at the time of diagnosis. The current echocardiogram showed right coronary (RC) with 4 mm of diameter at the origin and 7 mm in the middle third; the left main coronary artery (LMCA) with 8 mm. The patient had a fistulous trajectory with tortuous flow communicating both coronaries with the pulmonary trunk, without the presence of pulmonary hyperflow. Additionally, the evolution of mitral regurgitation showed to be of an important degree. shows the echocardiographic parameters during follow-up.

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Original Article

The Effect of Garlic and Voluntary Exercise on Cardiac Angiogenesis in Diabetes: The Role of MiR-126 and MiR-210

Roya Naderi et al. Gisou Mohaddes Mustafa Mohammadi Alireza Alihemmati … Amirmahdi Khamaneh Rafighe Ghyasi Rana Ghaznavi

Abstract

Background:

Diabetes mellitus (DM) is one of the major risk factors for cardiovascular disease, leading to endothelial dysfunction and angiogenesis impairment . MiR-126 and miR-210 support angiogenic response in endothelial cells.

Objective:

The present study sought to explore the effect of garlic and voluntary exercise, alone or together, on miR-126 and miR-210 expressions and cardiac angiogenesis in rats with type 1 diabetes.

Methods:

Male Wistar rats were divided into five groups (n = 7): Control, Diabetes, Diabetes+Garlic, Diabetes+Exercise, and Diabetes+Garlic+Exercise. Diabetes was induced in the animals by streptozotocin (ip, 50 mg/kg). The rats were then fed raw fresh garlic homogenate (250 mg/kg) or were subjected to voluntary exercise, or to combined garlic and voluntary exercise for 6 weeks. MiR-126 and miR-210 expressions in the myocardium were determined by real time PCR, and the serum lipid profile was measured by enzymatic kits. Angiogenesis was evaluated by immunostaining for PECAM-1/ CD31 in the myocardium.

Results:

Diabetes reduced both cardiac miR-126 expression and angiogenesis (p < 0.05). On the other hand, there was a miR-210 expression increase in the myocardium of diabetic animals (p < 0.001). However, those effects reversed either with garlic or voluntary exercise (p < 0.01). Moreover, treating diabetic rats with garlic and voluntary exercise combined had an additional effect on the expressions of miR-126 and miR-210 (p < 0.001). Furthermore, both voluntary exercise and garlic significantly improved serum lipid profiles (p < 0.001).

Conclusion:

The induction of diabetes decreased angiogenesis in the myocardium, whereas our treatment using long-term voluntary exercise and garlic improved myocardial angiogenesis. These changes were possibly owing to the enhancement of myocardial miR-126 and miR-210 expressions.

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Review Article

The Year in Cardiology 2018: ABC Cardiol and RPC at a glance

Ricardo Fontes-Carvalho et al. Glaucia Maria Moraes de Oliveira Lino Gonçalves Carlos Eduardo Rochitte

Coronary artery disease

In 2018, Rev Port Cardiol reported the 15-year results of the Portuguese Registry of Acute Coronary Syndromes (PorACS). This is a multi-center, continuous, and ongoing registry which has already involved more than 45,000 events, from 45 centers. It is one of the largest national registries in this field, which is only exceeded by the SWEDEHEART and the MINAP registries. This article provides very important information about the epidemiology and evolution of ACS treatment. First, it demonstrates that the clinical profile of ACS patients changed little over the years, and the proportion of ST-elevation myocardial infarction (STEMI) remained stable (45%). More importantly, over the years, there has been a major improvement in the overall quality of ACS care. For example, more than 85% of STEMI patients in Portugal now receive reperfusion therapy, which is mainly performed by primary PCI (only 5.2% underwent thrombolysis). This improvement in ACS care led to a remarkable reduction of in-hospital mortality, which decreased from 6.7% in 2002 to 2.5% in 2016. Therefore, the cardiovascular community must be acknowledged for this striking achievement. Nevertheless, the work is not finished, and this study also shows important gaps in ACS care that should be addressed. Unfortunately, time-to-reperfusion has not improved sufficiently, and there is an urgent need to improve both the “patient-delay” and “system-delay” times.

In another interesting article published in 2018, Pereira H. et al. evaluated the determinants of this “patient-delay” time in the Portuguese health system in 994 patients with suspected STEMI. Although most healthcare systems focus their performance measures in the evaluation of “door-to-balloon times”, it is important to understand and address the reasons for this “patient-delay time”, which means the time from symptom onset to the first medical contact. The investigators observed that patient-delay time was too long (about 120 minutes) and identified five predictors of increased patient-delay: 1) age > 75 years; 2) symptom onset between 0:00 and 8:00 a.m.; 3) attending a primary care unit before first medical contact; 4) not calling the national medical emergency number; and 5) self-transport to the emergency department. Therefore, this article provides important information to plan more effective patient-directed campaigns that can decrease patient-delay time and improve STEMI management and prognosis.

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Editorial

Exercise and Garlic Modulate microRNAs Involved in Diabetic Cardiopathy

Aline Regina Ruiz Lima

Diabetes mellitus (DM) is a major risk factor for cardiovascular disorders and stroke development and is associated with increased morbidity and mortality. The prevalence of diabetes is increasing at an alarming rate worldwide. Indeed, according to estimates of the International Diabetes Federation, 552 million people are expected to be diabetic in 2030. Although a definitive cure is not on the horizon, with proper management, diabetic patients can attenuate the development of serious complications that reduce life quality and expectancy. Facing a considerable rate of occurrence and prognosis complications, studies focusing on high efficiency and low toxicity treatments are of great importance.

MicroRNAs are small non-coding RNAs controlling gene expression and participating in many physiopathological processes. These small molecules are getting a lot of attention nowadays since they are universally recognized as major regulators of gene expression and as key controllers of several biological and pathological processes. They are essential intracellular mediators in a variety of cellular processes, such as inflammation, mitochondrial metabolism, apoptosis, among others. Therefore, miRNAs could be potential targets to treat some chronic diseases. Besides, these molecules can also be used as early biomarkers, once they are released in urine and blood when in presence of tissue lesion. Recently, it was verified that miRNAs are also involved in cardiovascular disorders, especially those which impaired angiogenesis is observed.

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Editorial

Physical Inactivity in Brazil and Sweden – Different Countries, Similar Problem

Ricardo Stein et al. Mats Börjesson

Does Sweden and Brazil have the same problem?

Low or decreasing PA levels often correspond with a high or rising gross national product. In high-income countries, 26% of men and 35% of women were insufficiently physically active, as compared to 12% of men and 24% of women in low-income countries. This drop is partly due to inactivity during leisure time and sedentary behavior at home or during work. Also, an increase in car, bus and train use has contributed to insufficient PA. Besides, fear of violence and crime in outdoor areas, pollution, high-density traffic, lack of parks, sidewalks and sports/recreation facilities discourage people from becoming more active.

There is a known socioeconomic division regarding PA levels in Europe; the Eurobarometer (), a survey series based on self-reported activity levels and sports participation, shows that 91% of Swedes of all ages, but only 22% of Bulgarians report to exercise. Populations from highly industrialized countries from northern and western Europe tend to practice more exercise/sports activities, compared with southeastern European countries. This, somehow, illustrates the well-known socioeconomic difference, in which higher education is associated with more sitting time, but also more “gym-cards” and higher fitness, typical of northern Europe, in contrast with other European countries.

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Editorial

Fontan-Kreutzer Conversion to Total Cavopulmonary Surgery due to Failing Univentricular Circulation. A Feasible Therapeutic Option?

Isabel Cristina Britto Guimarães

Fontan surgery, a palliative operation for patients with “single-ventricle” heart physiology, has undergone several modifications since the first procedure was performed in 1971 for individuals with diagnosis of tricuspid atresia.

The Fontan-Kreutzer (FK) atrial-pulmonary anastomosis technique was widely used in the 1980s. Publications regarding the late follow-up of patients submitted to the technique before 1990 showed a higher frequency of complications such as heart failure, arrhythmias, thromboembolic events, protein-losing enteropathy, plastic bronchitis, sudden death and liver failure.^,

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Editorial

Cardiac Effects of Trimetazidine in Diabetic Rats

Alfredo J. Mansur

Diabetes mellitus may be associated with a specific form of cardiomyopathy independent of other comorbidities. Left ventricular hypertrophy is the main pathological change described in cardiomyopathy of patients with diabetes mellitus. Different mechanisms may be operative in the pathogenesis of the hypertrophy: metabolic derangements, inflammation and among other factors, oxidative stress. Oxidative stress may lead to cellular damage by free radical-induced oxidation of DNA, proteins and lipids.

Reactive oxygen species may lead to consequences in cardiomyocytes including hypertrophy, apoptosis and fibrosis; in this regard a cellular detoxification mechanism may be missing for attenuating severity of damage induced by some reactive oxygen species. Hence, interventions that might be protective would be worth to be investigated, including drug therapy.

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Original Article

Outcomes of the Conversion of the Fontan-Kreutzer Operation to a Total Cavopulmonary Connection for the Failing Univentricular Circulation

Gabriel Carmona Fernandes et al. Guilherme Viotto Rodrigues da Silva Luiz Fernando Caneo Carla Tanamati … Aida Luiza Ribeiro Turquetto Marcelo Biscegli Jatene

Abstract

Background:

The Fontan-Kreutzer procedure (FK) was widely performed in the past, but in the long-term generated many complications resulting in univentricular circulation failure. The conversion to total cavopulmonary connection (TCPC) is one of the options for treatment.

Objective:

To evaluate the results of conversion from FK to TCPC.

Methods:

A retrospective review of medical records for patients who underwent the conversion of FK to TCPC in the period of 1985 to 2016. Significance p < 0,05.

Results:

Fontan-type operations were performed in 420 patients during this period: TCPC was performed in 320, lateral tunnel technique in 82, and FK in 18. Ten cases from the FK group were elected to conversion to TCPC. All patients submitted to Fontan Conversion were included in this study. In nine patients the indication was due to uncontrolled arrhythmia and in one, due to protein-losing enteropathy. Death was observed in the first two cases. The average intensive care unit (ICU) length of stay (LOS) was 13 days, and the average hospital LOS was 37 days. A functional class by New York Heart Association (NYHA) improvement was observed in 80% of the patients in NYHA I or II. Fifty-seven percent of conversions due to arrhythmias had improvement of arrhythmias; four cases are cured.

Conclusions:

The conversion is a complex procedure and requires an experienced tertiary hospital to be performed. The conversion has improved the NYHA functional class despite an unsatisfactory resolution of the arrhythmia.

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Editorial

Evaluating Sodium Restriction in Heart Failure

Pedro Pimenta de Mello Spineti

Although salt and water retention plays a crucial role in heart failure (HF) pathophysiology, controversy still exists about dietary salt restriction in the treatment of HF patients. Small clinical studies have suggested that excessive sodium restriction (< 5 g of salt per day), as compared with normal-sodium diet (approximately 7 g of salt per day), may be associated with deleterious effects in patients with chronic HF, including increased neurohormonal activation, and higher hospitalization and mortality rates.^,

A recent meta-analysis of nine studies involving 479 HF patients undergoing dietary sodium restriction was inconclusive for the recommendation of this strategy in hospitalized patients. None of the studies analyzed in the meta-analysis included hard endpoints such as all-cause death or cardiovascular mortality. However, a modest tendency for improvement of functional class was observed in outpatients undergoing sodium restriction intake. The author reinforces the need for randomized, prospective studies including large sample sizes, evaluating the effect of different regimens of sodium intake on relevant outcomes to build evidence base for detailed recommendations.

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Original Article

Cut-Point for Satisfactory Adherence of the Dietary Sodium Restriction Questionnaire for Patients with Heart Failure

Karina Sanches Machado d’Almeida et al. Sofia Louise Santin Barilli Gabriela Corrêa Souza Eneida Rejane Rabelo-Silva

Abstract

Background:

The low or non-adherence to reduction of sodium intake has been identified as one of the main precipitating factors of heart failure (HF). The Dietary Sodium Restriction Questionnaire (DSRQ) identifies factors that can interfere with adherence to this recommendation. However, there is still no cut-point to define adherence for this questionnaire.

Objectives:

To identify the cut-point for satisfactory adherence to the Brazilian version of the DSRQ, (the Questionário de Restrição de Sódio na Dieta, QRSD).

Methods:

Multicenter study. Patients with HF in outpatient treatment (compensated) and those treated in emergency departments due to acute HF (decompensated) were included. For the cut-point definition, the DSRQ scores were compared between groups. A ROC curve was constructed for each subscale to determine the best point of sensitivity and specificity regarding adherence. A 5% significance level was adopted.

Results:

A total of 206 compensated patients and 225 decompensated were included. Compensated patients exhibited scores that showed higher adhesion in all subscales (all p <0.05). Scores ≥ 40 points of a total of 45 for the subscale of Attitude and Subjective Norm; scores ≤ eight of a total of 20 for Perceived Behavioral Control; and ≤ three of a total of 15 for Dependent Behavior Control were indicative of satisfactory adherence.

Conclusions:

Based on the evaluation of patients in these two scenarios, it was possible to determine the cut-point for satisfactory adherence to the reduction of sodium in the diet of patients with HF. Countries with similar culture could use this cut-point, as other researchers could also use the results as a reference for further studies.

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Editorial

Single Photon Computed Tomography-Myocardial Perfusion Scintigraphy. Diagnostic Tool Anticipating the Disease

Without making any value judgment, a large percentage of physicians who request tests to make diagnoses is observed in the contemporary clinical practice. On the other hand, a considerable percentage of physicians who make the diagnosis and possibly ask for tests to confirm the diagnosis is also observed. Both behaviors are considered valid when common good is achieved: The patients’ benefit. However, the request for tests without an appropriate criterion is not only harmful to the patient, but also to the system.

In present-day medicine, there is a large collection of tests considered normal throughout the medical knowledge area, including cardiology. In a publication by Dippe Jr et al. in this issue, the authors, in a retrospective analysis of a database, found this trend. Of 5,526 scans of myocardial perfusion scans performed on obese patients (grade 1), 77% were considered normal. Assuming that the exams were requested for investigation of myocardial ischemia, the authors related the presence of perfusion deficit with myocardial ischemia in only 23%. Based on these data, they found, after applying a “creative statistic”, a 245% risk-ratio for typical angina. It is known, in principle, that perfusion deficit is an expression of intrinsic myocardial abnormality.

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Original Article

Long Term Cardiovascular Outcome Based on Aspirin and Clopidogrel Responsiveness Status in Young ST-Elevated Myocardial Infarction Patients

Mustafa Umut Somuncu et al. Ali Riza Demir Seda Tukenmez Karakurt Huseyin Karakurt Turgut Karabag

Abstract

Background:

A subset of patients who take antiplatelet therapy continues to have recurrent cardiovascular events which may be due to antiplatelet resistance. The effect of low response to aspirin or clopidogrel on prognosis was examined in different patient populations.

Objective:

We aimed to investigate the prevalence of poor response to dual antiplatelet therapy and its relationship with major adverse cardiovascular events (MACE) in young patients with ST-elevation myocardial infarction (STEMI).

Methods:

In our study, we included 123 patients under the age of 45 with STEMI who underwent primary percutaneous intervention. A screening procedure to determine both aspirin and clopidogrel responsiveness was performed on the fifth day of admission. We followed a 2×2 factorial design and patients were allocated to one of four groups, according to the presence of aspirin and/or clopidogrel resistance. Patients were followed for a three-year period. A p-value less than 0.05 was considered statistically significant.

Results:

We identified 48% of resistance against one or more antiplatelet in young patients with STEMI. More MACE was observed in patients with poor response to dual platelet therapy or to clopidogrel compared those with adequate response to the dual therapy (OR: 1.875, 1.144-3.073, p < 0.001; OR: 1.198, 0.957-1.499, p = 0.036, respectively). After adjustment for potential confounders, we found that poor responders to dual therapy had 3.3 times increased odds for three-year MACE than those with adequate response to the dual therapy.

Conclusion:

Attention should be paid to dual antiplatelet therapy in terms of increased risk for cardiovascular adverse events especially in young patients with STEMI.

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Original Article

Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association

Nathalia Pereira Vizentin et al. Paula Mendonça Santos Cardoso Camila Aparecida Gomes Maia Isabela Perez Alves … Gabriel Lunardi Aranha Denise Tavares Giannini

Abstract

Background:

Early exposure to obesity favors greater risks of cardiovascular factors such as dyslipidemia.

Objectives:

To establish the prevalence of dyslipidemia, and to evaluate its association with nutritional status of the adolescents attended at the ambulatory of the Adolescent Health Studies Center of the University Hospital Pedro Ernesto.

Methods:

This is a cross-sectional, observational study, the sample of which was of convenience, consisting of adolescents from 12 to 18 years old of both genders. The lipid profile was evaluated, along with its association with the anthropometric indicators: body mass index and waist circumference. For statistical analysis, a significance level of 5% was used.

Results:

A total of 239 adolescents, 104 boys (43.5%) and 135 girls (56.5%) were evaluated and, of these, 52 (21.8%) were eutrophic, 60 (25.1%) overweight, and 127 (53.1%) obese. Obeseadolescents had significantly lower mean values of HDL-cholesterol (44.7 mg/dl vs 53.9 mg/dl; p < 0.001) and higher triglycerides (109.6 mg/dl vs 87.3 mg/dl; p = 0.01). The changes with higher prevalence were low HDL-cholesterol (50.6%), hypercholesterolemia (35.1%), and hypertriglyceridemia (18.4%). A negative association of HDL-cholesterol with body mass index and a positive association of triglycerides with body mass index could be observed, even after adjustment for gender and skin color.

Conclusion:

This study demonstrated high prevalence of dyslipidemia among adolescents. In view of the significant association between lower levels of HDL-cholesterol and increased triglycerides with overweight, the control of these factors should receive attention, with the precocious diagnosis of the dyslipidemia being important, mainly if it is associated with another cardiovascular risk, to develop effective intervention strategies.

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Original Article

Study of Myocardial Perfusion in Obese Individuals without Known Ischemic Heart Disease

Tufi Dippe Jr. et al. Cláudio Leinig Pereira da Cunha Rodrigo Julio Cerci Arnaldo Lafitte Stier Jr. João Vicente Vítola

Abstract

Background:

Obesity is associated with an increased risk of type 2 diabetes mellitus (DM), ischemic heart disease (IHD) and cardiovascular mortality. Several studies have demonstrated the diagnostic and prognostic value of single photon computed tomography-myocardial perfusion scintigraphy (SPECT-MPI) in the evaluation of patients with suspected IHD, including in obese population. Data on clinical risk factors and their association with abnormal myocardial perfusion in obese patients are scarce in the Brazilian population.

Objective:

To determine the factors associated with abnormal myocardial perfusion in obese individuals without known IHD.

Methods:

We studied obese patients without known IHD who were referred for evaluation through SPECT-MPI between January 2011 and December 2016. Clinical variables and results of SPECT-MPI were obtained systematically. The distribution of continuous variables was assessed using the Shapiro-Wilk and Shapiro-Francia tests. We used the unpaired Student t test to compare the means of continuous variables with normal distribution and the Chi Square test for binomial variables analysis. A p value < 0.05 was considered statistically significant. The association of the clinical variables for the presence of factors associated with abnormal myocardial perfusion was determined by univariate and multivariate logistic regression analysis, and respective odds ratios (OR) and 95% confidence intervals (CI).

Results:

The study sample consisted of 5,526 obese patients. Mean body mass index (BMI) of our patients was 33.9 ± 3.7 kg/m², 31% had DM, and myocardial perfusion abnormalities was observed in 23% of the total sample. The factors associated with abnormal myocardial perfusion on multivariate analysis were: age (OR: 1.02, 95% CI 1.01-1.03, p < 0.001), DM (OR: 1.57, 95% CI 1.31-1.88, p < 0.001), typical angina before the test (OR: 2.45, 95% CI: 1.82-3.31, p < 0.001), need for pharmacologic stress test (OR: 1.61, 95% CI: 1.26-2.07, p < 0.001), less physical effort evaluated in metabolic equivalents (METs) during the exercise treadmill test (OR: 0.89, 95% CI: 0.85-0.94, p < 0.001) and a lower post-stress left ventricular ejection fraction after stress (LVEF; OR: 0.989, 95% CI: 0.984-0.994, p < 0.001).

Conclusion:

The factors associated with abnormal myocardial perfusion in obese patients without known IHD were age, DM, presence of typical angina, ventricular dysfunction, and inability to undergo physical stress as clinical variables, in addition to functional capacity during physical stress.

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Original Article

The Effects of Trimetazidine on QT-interval Prolongation and Cardiac Hypertrophy in Diabetic Rats

Fatemeh Ramezani-Aliakbari et al. Mohammad Badavi Mahin Dianat Seyed Ali Mard Akram Ahangarpour

Abstract

Background:

Trimetazidine (TMZ) is an anti-ischemic drug. In spite of its protective effects on cardiovascular system, there is no scientific study on the usefulness of TMZ treatment for prolonged QT interval and cardiac hypertrophy induced by diabetes.

Objectives:

To evaluate the effects of TMZ on QT interval prolongation and cardiac hypertrophy in the diabetic rats.

Methods:

Twenty-four male Sprague-Dawley rats (200-250 g) were randomly assigned into three groups (n = 8) by simple random sampling method. Control (C), diabetic (D), and diabetic administrated with TMZ at 10 mg/kg (T10). TMZ was administrated for 8 weeks. The echocardiogram was recorded before isolating the hearts and transfer to a Langendorff apparatus. Hemodynamic parameters, QT and corrected QT interval (QTc) intervals, heart rate and antioxidant enzymes were measured. The hypertrophy index was calculated. The results were evaluated by one-way ANOVA and paired t-test using SPSS (version 16) and p < 0.05 was regarded as significant.

Results:

The diabetic rats significantly indicated increased hypertrophy, QT and QTc intervals and decreased Left ventricular systolic pressure (LVSP), Left ventricular developed pressure (LVDP), rate pressure product (RPP), Max dp/dt, and min dp/dt (±dp/dt max), heart rate, superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase in the heart. Treatment with TMZ in the diabetic animals was significantly improved these parameters in comparison to the untreated diabetic group.

Conclusions:

TMZ improves QTc interval prolongation and cardiac hypertrophy in diabetes.

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Original Article

Evaluation of Collagen Fibers, MMP2, MMP9, 8-OHdG and Apoptosis in the Aorta of Ovariectomized LDL Knockout Mice Submitted to Aerobic Exercise

Laura Beatriz M. Maifrino et al. Nathalia E. A. de Lima Mara R. Marques Clever G. Cardoso … Lidiane B. de Souza Tabata de Carvalho Tomé Hananiah Tardivo Quintana Flavia de Oliveira Beatriz da Costa Aguiar Alves Reis Fernando Luiz Affonso Fonseca

Abstract

Background:

In menopause, there is greater cellular exposure to oxidative stress, related to the decreased antioxidative effects of estrogen. These metabolic changes favor the progression of cardiovascular diseases, such as atherosclerosis. Abnormal function of the aorta – the most important artery – is associated with many cardiovascular diseases. Collagen, especially types I and III, is one of the most important aortic wall components and it can be affected by many factors, including menopause. The 8-OHdG is one of the main markers of DNA oxidative damage induced by reactive oxygen species (ROS).

Objective:

We aimed to investigate effects of moderate aerobic training on the ascending aorta of LDL-knockout (LDL-KO) and ovariectomized female mice.

Methods:

A total of 15 C57BL/6 mice and 15 LDL-KO mice were divided into experimental groups. The thickness and volume density of types I and III collagen fibers were performed by morphoquantitative analysis, whereas the MMP-2 and MMP-9 and 8-OHdG were detected by immunohistochemistry and apoptosis was detected by the TUNEL assay. The significance level for all tests was p < 0.05.

Results:

Exercise causes an increase in the thickness of the aorta in LDL-KO groups, particularly accentuated in the ovariectomized groups. The type I collagen fibers showed an increase in volume density influenced by training in both Control groups and in the LDL-KO group. Type III collagen density decreased in both groups. The MMP-2 showed moderade immunostaining in the tunica media in LDL-KO groups, which did not occur in the control groups and the MMP-9 stained irregularly in all tissues. The marker 8-OhdG was stronger in the exercise training groups. Additionally, the ovariectomy, the exercise training and the LDL-KO treatments increased apoptosis.

Conclusion:

These results suggest that moderate-intensity aerobic exercise in ovariectomized mice associated to an increase in LDL rate possibly increases oxidative stress and apoptosis induction.

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