2023;120(9) – ABC CARDIOL

ABC

ABC Family | ABC

Editorial

Morning Surge Blood Pressure and Obesity in Hypertensive Patients

Sayuri Inuzuka et al. Weimar Kunz Sebba Barroso

Obesity and hypertension are two of the most common diseases and they are usually interrelated. The five main modifiable risk factors – dyslipidemia, diabetes, hypertension, obesity and smoking are estimated to account for more than 50% of cardiovascular mortality. There are many hypertensive patients with subclinical lesions in the early stages of the disease that are not generally identified by the traditional assessment model.^, The presence of left ventricular hypertrophy (LVH) determines general risk stratification and is a major therapeutic target in hypertension. Both obesity and hypertension may have additive and interactive effects on LVH. In order to identify early cardiovascular system damage, more specific complementary exams for biomarker analysis have been recommended by hypertension guidelines.^–

Different methods to determine morning surge blood pressure (MSBP) elevation have been proposed,^– but there are still several gaps regarding the establishment of cutoffs and clinical meaningful recommendations. Some studies showed that MSBP have an adverse prognostic value, independently of 24h mean blood pressure. However, due to the difficulty in standardizing the calculation of this parameter, the incremental predictive value is still unclear and its low reproducibility indicate that, according to guidelines, it should not be used in clinical practice.^,

[…]

Read Full Article

Review Article

The Role of Echocardiography in the Assessment of the Interatrial Septum and Patent Foramen Ovale as an Emboligenic Source

Angele Azevedo Alves Mattoso et al. Joberto Pinheiro Sena Viviane Tiemi Hotta

Abstract

Atrial septal defects (ASD) account for approximately 6%-10% of congenital heart defects, with an incidence of 1 in 1,500 live births.¹ Patent foramen ovale (PFO) is more common and is present in more than 20%-25% of adults.² Clinical syndromes associated with ASD and PFO are variable, and their implications are targeted by pediatric and adult medicine, neurology, and surgery.

Additional interest in the anatomy of the interatrial septum (IAS) has increased substantially over the last two decades. Additionally, percutaneous procedures involving left-sided structural heart disease and electrophysiological procedures have evolved considerably. Ideally, these catheter-based interventions require a direct route to the left atrium (LA) through the IAS, with a full understanding of its anatomy. Also, sophisticated and noninvasive imaging technologies such as two-dimensional transesophageal echocardiography (2D-TEE) and three-dimensional transesophageal echocardiography (3D-TEE), cardiac magnetic resonance imaging (CMR), and computed tomography (CT) have evolved considerably, providing anatomical details of cardiac structures visualized in 2D and 3D format and being key for the diagnosis and treatment of patients with heart diseases.

Therefore, assessing the anatomy of the IAS and any abnormalities requires a standardized and systematic approach, integrating diagnostic modalities and enabling adequate and consistent evaluation for both surgical and transcatheter therapies.

Read Full Article

Editorial

The Right Way to Identify Bad Cardiorespiratory Fitness: Look to the Right

Willian R. Menegazzo et al. Anderson Donelli da Silveira

The right ventricle (RV), previously known as the forgotten ventricle, is progressively gaining attention as a strong indicator of poorer prognosis in heart disease.^, Besides prognostic implications, RV dysfunction is associated with worse cardiorespiratory fitness (CRF), independently of other anatomic and functional variables.^, Unfortunately, the current treatment strategies for RV failure do not confer the same clinical and prognostic benefits of the left ventricle (LV) failure,^, which limits its management and warrants new treatment strategies.

Ramirez et al. accessed this important topic by studying the RV function on 109 patients with ST-elevation myocardial (STEMI), its association with CRF, and its improvement after cardiac rehabilitation (CR) in a single center in Monterrey, Mexico. Their primary goal was to evaluate the association between RV function and CRF in this population, and the secondary objectives were to analyze the CRF before and after a program of CR in patients with or without RV dysfunction. They evaluated exercise tolerance through cardiopulmonary exercise testing and RV longitudinal function through echocardiographic measurement of the S’ Doppler wave of the tricuspid annulus and the tricuspid annular posterior systolic excursion and RV radial function through RV fractional area change. The population was mainly male gender (83%), with anterior STEMI (55%), median LV ejection fraction of 49%, and normal RV function (90%). They have shown an association and correlation between RV radial and longitudinal dysfunction and CRF before and after CR. The main finding is that RV dysfunction evaluated after STEMI and before CR, being radial or longitudinal, was associated with a lack of improvement of at least 1 Metabolic Equivalent Task after a program of CR (p = 0.028 for RV radial dysfunction and p = 0.008 for RV longitudinal dysfunction). The authors concluded that RV dysfunction in STEMI patients is associated and correlated with poorer exercise capacity and functional class before CR and that CR improved CRF. This helps to identify a subgroup of patients with a higher risk of being symptomatic, with a worse prognosis and possibly better candidates for CR.

[…]

Read Full Article

Editorial

Aerobic Exercise Prescription: The Talk Test Rises Over the 6-Minute Walk Test

Márcio Garcia Menezes et al. Vitor Augusto Fronza Leandro Franzoni

Cardiovascular diseases (CVDs) represent a concerning reality, leading to a high morbidity and mortality rate in many countries, with a global total of 18 million deaths. Moreover, these conditions pose substantial economic and social burdens.^–

Cardiovascular rehabilitation holds significant promise in benefiting patients with CVDs, with aerobic exercises (AE) as pivotal allies in improving cardiorespiratory fitness, muscular endurance, cardiovascular function, and overall quality of life.^– According to the Sociedade Brasileira de Cardiologia, the general recommendation for engaging in physical exercise is 150 minutes per week, distributed across three to five sessions. One of the foremost objectives in cardiovascular rehabilitation is to enhance cardiorespiratory fitness through the incorporation of AE.^, Furthermore, the judicious practice of physical activity aims to mitigate hypertension, the risk of cardiovascular events, and overall mortality in cardiovascular patients.^–

[…]

Read Full Article

Original Article

Associations between Normal-Weight Obesity and Disturbances in the Lipid Profile of Young Adults

Anna Flavia Ferreira Passos et al. Acsa de Castro Santos Alexandre Siqueira Guedes Coelho Cristiane Cominetti

Abstract

Background

Normal-weight obesity (NWO) is characterized by normal body mass index (BMI) but high body fat percentage (%BF) that increases the risks of cardiometabolic comorbidities. Accurate assessment and interpretation of body composition data are necessary to reduce these risks.

Objectives

To compare the cardiometabolic profile of individuals with NWO and normal %BF and evaluate the associated risk factors.

Methods

A cross-sectional study was conducted with 222 Brazilian adults from a university community, of whom 157 had NWO and 65 had normal BMI and %BF (non-NWO). All participants reported being asymptomatic and without underlying health conditions. Socioeconomic, lifestyle, food intake, anthropometry, body composition measures (using dual-energy radiological absorptiometry), and lipid and glycemic profiles were evaluated. A p < 0.05 was established as significant.

Results

The median age of the participants was 23 years (interquartile range: 21 to 25), and most were female (67.1%). No significant differences were found in blood pressure, age, or physical activity levels between the NWO and non-NWO groups. However, the frequency of lipid profile disturbances was higher in the NWO group (54%) compared to the non-NWO group (34%) (p < 0.006). Neck circumference, %BF, and lipid profile disturbances were positively associated with NWO.

Conclusion

Individuals with NWO have a worse cardiometabolic profile than those without NWO, and this condition is associated with important biomarkers. Addressing these outcomes is important for preventing long-term cardiometabolic complications. Accurate assessment and interpretation of body composition data, regardless of BMI, are crucial in this scenario.

Read Full Article

Research Letter

In the Cardiac Rehabilitation Era, is There a “No-Option” Refractory Angina Patient?: A Case Report

Luciana Oliveira Cascaes Dourado et al. Camila Paixão Jordão Camila Regina Alves Assumpção Luciana Diniz Nagem Janot de Matos

Abstract

Exercise-based cardiac rehabilitation, an effective and safe adjuvant treatment recommended to patients with coronary artery disease, is scarcely applied to patients with refractory angina (RA) due to difficulties related to safety, trainning prescription and their clinical management. This case report presents an instance of a “no-option” patient with RA, who was included in a 12-week exercise program, in sessions consisted of 40 minutes of treadmill aerobic exercise, three times a week, and intensity prescribed between ischemic/angina threshold and ventilatory threshold 1, obtained in the cardiopulmonary exercise test; mild to moderate angina was allowed during training. Furthermore, 15 minutes of moderate-intensity resistance training (large group muscle exercises, two sets of 8 to 12 repetitions) was performed. At the end of the protocol, the patient presented an important improvement in functional performance (VO ₂ peak 17.0 ml/kg/min to 27.3 ml/kg/min), angina threshold (HR 68 bpm to 95 bpm), and intensity chest pain (levels 7 to 5) with no clinical adverse events during the period. Exercise-based cardiac rehabilitation was safe, even in the occurrence of angina/ischemia during training, according to tolerability to symptoms and other warning clinical signs.

Read Full Article

Editorial

Physical Activity and Quality of Life in Children with Congenital Heart Diseases: A Public Health Issue

Silvana Vertematti

Physical activity is both a form of expression for children and a means for promoting their development. The fun derived from engaging in this activity is one of the main factors for promoting the social inclusion of children, in addition to ensuring their continued ability to perform movements. The physical, physiological, psychological, and social dividends physical activity brings to children and adolescents are unequivocal.

Physical activity is defined as any bodily movement produced by skeletal muscles and resulting in energy expenditure. Physical exercise is a planned physical activity. It is structured within a sports and social context, involves logical and organized repetitions, and is designed to maintain physical fitness. Fitness, in turn, is characterized by a set of physical attributes related to improving the child’s health and performance and can be measured by specific physical tests conducted by trained professionals.

[…]

Read Full Article

Editorial

Health-related Quality of Life and Long-term Outcomes after Mildly Symptomatic COVID-19: Exploring the Protocol

Lucas Borges Pereira et al. João Paulo Vilela Rodrigues Fabiana Rossi Varallo Leonardo Régis Leira Pereira

The post-COVID-19 condition has been defined by the World Health Organization as a “condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, typically after three months from the onset of COVID-19, with symptoms lasting at least two months and that an alternative diagnosis can not explain.” The primary symptoms associated with this condition include fatigue, muscle and joint pain, shortness of breath, sleep difficulties, mental and neurological symptoms such as depression and anxiety, loss of smell and taste, headache, and difficulty in thinking and concentrating. ^, The cytopathic effect of the virus on the endothelium, along with endothelial damage as a consequence of systemic inflammation, has been associated with cardiovascular events such as myocarditis, myocardial infarction, arrhythmias, and thromboembolic events.

Various studies conducted worldwide have also found evidence of other signs and symptoms. ^– However, the incidence of these symptoms has shown significant variation due to the heterogeneity of the studies. This variation may be associated with factors such as the post-COVID study period, the region where the study was conducted, and the severity of the disease.

[…]

Read Full Article

Research Letter

Viability and Safety of Early Hospital Discharge after Minimalist TAVI in the Brazilian Unified Health System

Marcos Almeida Meniconi et al. Fernanda Jacques Calçado Oliveira Alberto Colella Cervone Dorival Julio Della Togna … Fausto Feres Auristela Isabel de Oliveira Ramos Dimytri Alexandre de Alvim Siqueira

Introduction

Transcatheter aortic valve implantation (TAVI) has established itself as the treatment of choice for octogenarian patients with aortic stenosis. Broadly speaking, TAVI with a minimalist approach (M-TAVI) refers to the performance of the procedure under conscious sedation and local anesthesia, percutaneous femoral access, monitoring with transthoracic echocardiography, and early mobilization. Studies have indicated the safety of M-TAVI with hospital discharge within 24 hours after the procedure^, with reduced hospital costs,^,which is a relevant aspect from the perspective of national public health. Thus, the objective of this study was to evaluate the feasibility and safety of a multidisciplinary institutional M-TAVI protocol with the goal of hospital discharge within 48 hours, implemented in a tertiary hospital that is part of the Brazilian Unified Health System (SUS).

[…]

Read Full Article

Original Article

Real-Life Data on Hydroxychloroquine or Chloroquine with or Without Azithromycin in COVID-19 Patients: A Retrospective Analysis in Brazil

Maíra Viana Rego Souza-Silva et al. Daniella Nunes Pereira Magda Carvalho Pires Isabela Muzzi Vasconcelos … Alexandre Vargas Schwarzbold Diego Henrique de Vasconcelos Elayne Crestani Pereira Euler Roberto Fernandes Manenti Felício Roberto Costa Filipe Carrilho de Aguiar Fernando Anschau Frederico Bartolazzi Guilherme Fagundes Nascimento Heloisa Reniers Vianna Joanna d’Arc Lyra Batista Juliana Machado-Rugolo Karen Brasil Ruschel Maria Angélica Pires Ferreira Leonardo Seixas de Oliveira Luanna Silva Monteiro Menezes Patricia Klarmann Ziegelmann Marcela Gonçalves Trindade Tofani Maria Aparecida Camargos Bicalho Matheus Carvalho Alves Nogueira Milton Henriques Guimarães-Júnior Rúbia Laura Oliveira Aguiar Danyelle Romana Alves Rios Carisi Anne Polanczyk Milena Soriano Marcolino

Abstract

Background

Despite no evidence showing benefits of hydroxychloroquine and chloroquine with or without azithromycin for COVID-19 treatment, these medications have been largely prescribed in Brazil.

Objectives

To assess outcomes, including in-hospital mortality, electrocardiographic abnormalities, hospital length-of-stay, admission to the intensive care unit, and need for dialysis and mechanical ventilation, in hospitalized COVID-19 patients who received chloroquine or hydroxychloroquine, and to compare outcomes between those patients and their matched controls.

Methods

A retrospective multicenter cohort study that included consecutive laboratory-confirmed COVID-19 patients from 37 Brazilian hospitals from March to September 2020. Propensity score was used to select matching controls by age, sex, cardiovascular comorbidities, and in-hospital use of corticosteroid. A p-value <0.05 was considered statistically significant.

Results

From 7,850 COVID-19 patients, 673 (8.6%) received hydroxychloroquine and 67 (0.9%) chloroquine. The median age in the study group was 60 years (46 – 71) and 59.1% were women. During hospitalization, 3.2% of patients presented side effects and 2.2% required therapy discontinuation. Electrocardiographic abnormalities were more prevalent in the chloroquine/hydroxychloroquine group (13.2% vs. 8.2%, p=0.01), and the long corrected QT interval was the main difference (3.6% vs. 0.4%, p<0.001). The median hospital length of stay was longer in the HCQ/CQ + AZT group than in controls (9.0 [5.0, 18.0] vs. 8.0 [4.0, 14.0] days). There was no statistical differences between groups in intensive care unit admission (35.1% vs. 32.0%; p=0.282), invasive mechanical ventilation support (27.0% vs. 22.3%; p=0.074) or mortality (18.9% vs. 18.0%; p=0.682).

Conclusion

COVID-19 patients treated with chloroquine or hydroxychloroquine had a longer hospital length of stay, when compared to matched controls. Intensive care unit admission, invasive mechanical ventilation, dialysis and in-hospital mortality were similar.

Read Full Article

Editorial

Our Patients Deserve More

Roberto Muniz Ferreira

Clinical decision-making implies that multiple options are possible for any given medical situation. Fortunately, science is constantly evolving and will continue to do so incrementally. Thus, physicians should routinely analyze previous outcomes of similar circumstances to increase the probability of selecting the most appropriate alternative. Discerning data that may assist in decision-making from inconsistent scientific information is a fundamental requirement of evidence-based medicine (EBM).

For over 40 years, EBM has been the cornerstone of clinical practice, improving the efficacy and safety involved with medical decisions, according to the most current scientific knowledge. Nevertheless, publications do not always adhere to validated methodological concepts and may rely solely on non-scientific motivations. When personal beliefs overshadow medical science, it invariably occurs to the detriment of patient care. Conversely, EBM provides a systematic and organized method to appraise scientific information in various medical literature forms.

[…]

Read Full Article

Editorial

The Conception of the Selvester Score: Interface with the Development of Electro-Vectorcardiography

Carlos Alberto Pastore

At the Annual Conference of the International Society for Computerized Electrocardiology (ISCE) in 2015, in San José – Costa Rica, a session was organized to honor the extraordinary work and life of specialists in electrocardiology, among them Ron Selvester.

Ron Selvester was one of the best editors of the Journal of Electrocardiology. He recruited the best connoisseurs to be co-editors, leading the Journal to grow in content and improving its impact factor.

[…]

Read Full Article

Letter to the Editor

Suspension of Thiazide Diuretics in Advanced Chronic Kidney Disease. Time to Review an Old Concept

Rodrigo Bezerra et al. Flávio Teles de Farias Filho Audes Feitosa Wilson Nadruz … Andrea Araújo Brandão Weimar Kunz Sebba Barroso

The Hypertension Guidelines of the Sociedade Brasileira de Cardiologia (SBC), Brazilian Society of Hypertension (BSH), and Brazilian Society of Nephrology (BSN) recommend the use of loop diuretics to replace thiazides in patients with chronic kidney disease (CKD) stages 4 and 5, who have glomerular filtration rate (GFR) ≤ 30ml/min/1.73m².

These guidelines are in line with other guidelines, such as the European Hypertension Guideline (ESC/ESH 2018), which states that thiazide and thiazide-like diuretics are less effective in patients with GFR < 45ml/min/1.73m² and ineffective when GFR < 30ml/min/1.73m². However, the study that established this concept dates from 1961 and evaluated only 11 patients, among whom 5 had GFR < 37ml/min/1.73m². Despite this, this concept generated a dogma exported to textbooks, which has been propagated for decades as an incontestable truth.

[…]

Read Full Article

Original Article

Activities of Daily Living, Physical Activity, Physical Fitness and Quality of Life in Children with Congenital Heart Disease: A Case-Control Study

Berfin Kişin et al. Sema Savci Buse Ozcan Kahraman Aylin Tanriverdi … Hazer Erçan Bozyer Halise Zeynep Genç Mustafa Kir

Abstract

Background

Despite reports of reduced physical fitness in children with congenital heart disease (CHD), no specific performance evaluations for activities of daily living have been conducted.

Objectives

The aim was to compare the activities of daily living, quality of life, posture, physical fitness and physical activity levels of children with CHD with healthy controls (HC).

Methods

The study included 30 children aged 6-14 diagnosed with moderate or severe CHD and 30 age-sex-matched HC. The sociodemographic and clinical data of the participants were recorded. All participants went through several tests, namely the TGlittre-P test for activities of daily living, the 6-minute walk test (6MWT) for functional capacity, the Fitnessgram test battery for physical fitness, the hand dynamometer for measuring grip strength, the pedometer for measuring physical activity, and both the child and parents reported the Pediatric Quality of Life Inventory (PedsQL) for evaluating the quality of life, in addition to posture analyses. Values of p < 0.05 were considered statistically significant.

Results

Individuals with CHD had a longer TGlittre-P test completion time and a shorter 6MWT distance than HC (TGlittre-P: CHD 3.45 [3.24-4.02]min vs. HC 3.10 [2.57-3.23]min, 6MWT: CHD 514.00 [412.50-566.00]m vs. HC 591.50 [533.00-631.00]m). For the CHD group, sit-ups, push-ups, trunk lift, and sit-and-reach test scores within the Fitnessgram battery, grip strength, posture, and quality of life scores were lower than those for the HC group. Physical activity levels were similar in the groups.

Conclusions

The performance of activities of daily living, functional capacity, physical fitness, posture, and quality of life of children with moderate and severe CHD were affected compared to healthy peers.

Read Full Article

Original Article

Health-Related Quality of Life and Long-Term Outcomes after Mildly Symptomatic COVID-19: The Post-COVID Brazil Study 2 Protocol

Marciane Maria Rover et al. Geraldine Trott Fernando Luís Scolari Mariana Motta Dias da Silva … Denise de Souza Rosa da Rosa Minho dos Santos Ana Paula Aquistapase Dagnino Juliana de Mesquita Neto Gabriel Pozza Estivalete Amanda Christina Kozesinski-Nakatani Milena Soriano Marcolino Bruna Brandão Barreto Paulo Roberto Schvartzman Ana Carolina Peçanha Antonio Caroline Cabral Robinson Maicon Falavigna Andreia Biolo Carisi Anne Polanczyk Regis Goulart Rosa

Abstract

Background

The long-term effects of mild COVID-19 on physical, cognitive, and mental health are not yet well understood.

Objective

The purpose of this paper is to describe the protocol for the ongoing “Post-COVID Brazil” study 2, which aims to evaluate the factors associated with health-related quality of life and long-term cardiovascular and non-cardiovascular outcomes one year after a mild episode of symptomatic COVID-19.

Methods

The “Post-COVID Brazil” study 2 is a prospective multicenter study that plans to enroll 1047 patients (NCT05197647). Centralized, structured telephone interviews are conducted at 1, 3, 6, 9, and 12 months after COVID-19 diagnosis. The primary outcome is the health-related quality-of-life utility score, assessed using the EuroQol-5D-3L (EQ-5D-3L) questionnaire at 12 months. Secondary endpoints include the EQ-5D-3L at 3, 6, and 9 months, as well as all-cause mortality, major cardiovascular events, hospitalization, return to work or education, persistent symptoms, new disabilities in instrumental activities of daily living, cognitive impairment, anxiety, depression, and post-traumatic stress symptoms at 3, 6, 9, and 12 months after SARS-CoV-2 infection. A p-value < 0.05 will be considered statistically significant for all analyses.

Results

The primary endpoint will be presented as the overall frequency of the EQ-5D-3L domains 12 months after SARS-CoV-2 infection. Main analysis will explore the association of independent variables with the study outcomes.

Conclusion

The “Post-COVID Brazil” study 2 aims to clarify the impact of long COVID on the quality of life and cardiovascular and non-cardiovascular outcomes of Brazilian patients who have had mild COVID-19.

Read Full Article

Original Article

Aerobic Exercise Prescription in Cardiac Rehabilitation Based on Heart Rate from Talk Test Stages and 6-Minute Walk Test

Amanda Althoff et al. Ariany Marques Vieira Lucas Santos da Silveira Magnus Benetti Marlus Karsten

Abstract

Background

Although the Talk Test (TT) is a reliable and low-cost test, its use for aerobic exercise prescription is still limited.

Objective

To analyze the heart rate (HR) in the stages of the TT and at the peak of the 6-minute walk test (6MWT) as a parameter to prescribe aerobic exercise compared with HR at the first and second ventilatory thresholds (VT1 and VT2) of cardiopulmonary exercise test (CPET).

Methods

Individuals with cardiovascular disease attended three assessment days: 1) anamnesis and CPET; 2) 6MWT; and 3) TT. One-way repeated measures ANOVA or Friedman’s test were used to compare HR at VT1 and VT2 with HR at TT stages: last positive (TT+), first equivocal (TT±), and negative (TT−), and at the peak of the 6MWT. Pearson’s or Spearman’s test assessed correlations between HR at VTs, TT stages, and 6MWT. Statistical significance was set at 5%.

Results

The study included 22 cardiac patients (13 men, 61 ± 8 years). HR at VT1 was similar to HR at TT+ (p = 0.987) and TT± (p = 0.154), and moderately correlated with TT+ (r = 0.479, p = 0.024). HR at VT2 was similar to TT− (p = 0.383), with a strong correlation (r = 0.757, p < 0.001). HR at the peak of the 6MWT was significantly different from HR at TT+, TT±, and VT1 (p = 0.001, p = 0.005, and p < 0.001, respectively) but similar to TT− (p = 0.68).

Conclusions

HR at TT+ and TT− reflect HR at VT1 and VT2, respectively, differently from 6MWT, which was similar only to VT2. TT may be an objective test to assist aerobic exercise prescription in cardiac rehabilitation.

Read Full Article

Original Article

Selvester QRS Score is a Predictor of Mortality in Heart Failure with Preserved Ejection Fraction

Fatih Sivri et al. Yahya Kemal Icen Hasan Koca Mükremin Coşkun … Mustafa Ardınç Orshan Deniz Fatih Necip Arici Mevlüt Koc Hasan Güngör

Abstract

Background

The Selvester QRS (S-QRS) score on a 12-lead electrocardiogram (ECG) is associated with both the amount of myocardial scar and poor prognosis in myocardial infarction patients. However, its prognostic value in heart failure (HF) with preserved ejection fraction (HFpEF) is unknown.

Objective

This study aims to investigate the predictive value of the S-QRS score for mortality in HFpEF.

Methods

359 patients were retrospectively enrolled in this study. Electrocardiographic, echocardiographic, and laboratory features of the patients were recorded. The simplified S-QRS score was measured and recorded. The mean follow-up time of the patients was 38.1±9.5 months. Statistical significance was set at p < 0.05.

Results

Of 359 patients, 270 were in the survivor group, and 89 were in the deceased group. Age, Hs-CRP, troponin, pro-BNP, left atrial (LA) diameter, LA volume index, QRS duration, Tpe, and S-QRS score were statistically high in the deceased group. In multivariate logistic regression analysis, age, Hs-CRP, NT-proBNP, LA diameter, LA volume index, Tpe, and S-QRS score were shown to be independent risk factors for mortality. In the receiver-operating characteristic (ROC) analysis, the cut-off value of the S-QRS score was 5.5, the sensitivity was 80.8%, and the specificity was 77.2% (AUC:0.880, p:0.00). In Kaplan-Meier analysis, it was found that mortality was higher in the group with S-QRS score ≥ 5.5 than in the group with S-QRS score < 5.5. (Long-rank, p:0.00)

Conclusions

We think that the S-QRS score can be used as a prognostic indicator of long-term mortality in patients with HFpEF.

Read Full Article

Viewpoint

Transcranial Direct Current Stimulation in the Management of Hypertension: A Plausible Hypothesis?

Fernando Zanela da Silva Arêas et al. Elizangela Kuster Lenon Corrêa de Souza Wagner Jorge Ribeiro Domingues … João Siqueira Luíz Henrique Aquino Serudo Guilherme Peixoto Arêas

Hypertension (HTN) is the most prevalent chronic disease in the entire world, being one of the most significant cardiovascular risks factors. Among several variables controlling blood pressure (BP), those directly interacting with neural mechanisms involve multiple areas of the central nervous system.

The relationship between brain activity and HTN has been demonstrated by neurophysiological studies on animals showing that direct electrical or chemical stimulation of different structures of the brainstorm and cerebral cortex can significantly modify BP and heart rate.^–

[…]

Read Full Article

Original Article

Association between Morning Surge and Left Ventricular Hypertrophy in Obese Hypertensive Patients

Natascha Gonçalves Francisco Palmeira et al. Henrique Tria Bianco Maria Teresa Nogueira Bombig Fernando Focaccia Povoa … Francisco A. H. Fonseca Maria Cristina Izar José Marcos Thalenberg Braulio Luna Filho Fabiane Marui Simone Matheus Fischer Celso Amodeo Dilma do Socorro Moraes de Souza Rui Povoa

Abstract

Background

Weight gain can trigger mechanisms that increase blood pressure. Nevertheless, obesity causes structural changes in the myocardium, including increased ventricular mass, atrial dilatation, and diastolic and systolic dysfunction. Additionally, blood pressure variations, like morning surge (MS) in obese hypertensive patients may have clinical relevance in cardiovascular events. Although morning blood pressure surge is a physiological phenomenon, excess MS can be considered an independent risk factor for cardiovascular events.

Objective

To evaluate MS values and their association with left ventricular hypertrophy (LVH) and nocturnal dipping (ND) in obese and non-obese hypertensive patients.

Methods

A cross-sectional study that evaluated BP measurements by ambulatory blood pressure monitoring (ABPM) and the presence of LVH by echocardiography in 203 hypertensive outpatients, divided into two groups: 109 non-obese and 94 obese hypertensives patients. The significance level was set at 0.05 in two-tailed tests.

Results

A MS above 20 mmHg by ABPM was detected in 59.2% of patients in the non-obese group and 40.6% in the obese group. LVH was found in 18.1% and 39.3% of patients in the non-obese and obese groups, respectively, p16 mmHg was associated with LVH, [prevalence ratio: 2.80; 95%CI (1.12–6.98), p=0.03]. For the non-obese group, the cut-off point of MS for this association was >22 mmHg.

Conclusion

High MS was positively associated with LVH, with a particular behavior in the hypertensive obese group.

Read Full Article

Case Report

Substrate-Based Ablation of Purkinje-Related Ventricular Fibrillation in an Elderly Patient with Ischemic Cardiomyopathy

Nurullah Çetin et al. Mustafa Özcan Soylu Batuhan Özbaş Özgür Bayturan Uğur Kemal Tezcan

Introduction

Fatal ventricular arrhythmias have an increased incidence in the case of structural heart diseases such as ischemic cardiomyopathy. It is known that ventricular premature contractions (PVCs) originating from Purkinje fibers can induce polymorphic ventricular tachycardia (PMVT) and, subsequently, ventricular fibrillation (VF) in patients with ischemic cardiomyopathy.^, Ventricular arrhythmias associated with Purkinje usually do not respond to conventional antiarrhythmic drugs. Catheter ablation is a favorable and life-saving treatment strategy for VF triggered by Purkinje fibers.

[…]

Read Full Article

Original Article

The Relationship between Nocturnal Dipping Status, Morning Blood Pressure Surge, and Hospital Admissions in Patients with Systolic Heart Failure

Ümmü Taş et al. Sedat Taş Efe Edem

Abstract

Background

Hypertension is a known risk factor for developing heart failure. However, there is limited data to investigate the association between morning blood pressure surge (MBPS), dipping status, echocardiographic parameters, and hospital admissions in patients with systolic heart failure.

Objectives

To evaluate the relationship between morning blood pressure surge, non-dipper blood pressure pattern, echocardiographic parameters, and hospital admissions in patients with systolic heart failure.

Methods

We retrospectively analyzed data from 206 consecutive patients with hypertension and a left ventricular ejection fraction below 40%. We divided the patients into two groups according to 24-hour ambulatory blood pressure monitoring (ABPM) results: dippers (n=110) and non-dippers (n=96). Morning blood pressure surge was calculated. Echocardiographic findings and hospital admissions during follow-up were noted. Statistical significance was defined as p < 0.05.

Results

The study group comprised 206 patients with a male predominance and mean age of 63.5 ± 16.1 years. The non-dipper group had significantly more hospital admissions compared to dippers. There was a positive correlation between MBPS and left atrial volume index (r=0.331, p=0.001), the ratio between early mitral inflow velocity and flow propagation velocity (r= 0.326, p=0.001), and the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/Em) (r= 0.314, p=0.001). Non-dipper BP, MBPS, and E/Em pattern were found to be independently associated with increased hospital admissions.

Conclusion

MBPS is associated with diastolic dysfunction and may be a sensitive predictor of hospital admission in patients with systolic heart failure.

Read Full Article

Original Article

Cardiovascular Risk Scores among Asymptomatic Adults with Haemophilia

Ricardo Mesquita Camelo et al. Camila Caram-Deelder Bruna Pontes Duarte Marilia Carolina Braga de Moura … Neuza Cavalcanti de Moraes Costa Iris Maciel Costa Ana Maria Vanderlei Tania Maria Rocha Guimarães Samantha Gouw Suely Meireles Rezende Johanna van der Bom

Abstract

Background

The mortality rate of Brazilian people with haemophilia (PwH) is decreasing, but the relative incidence of deaths associated with cardiovascular disease (CVD) is increasing.

Objectives

We aimed to describe the CVD risk score of PwH according to Pooled Cohort Equations Risk (PCER) Calculator tool and its treatment recommendations. We also compared the PCER estimates with the respective Framingham Risk Score (FRS).

Methods

This cross-sectional study included male PwH ≥ 40 years treated at the Comprehensive Haemophilia Treatment Centre of Pernambuco (Recife/Brazil). PwH with a previous CVD event or a low-density lipid cholesterol ≥ 5.0 mmol/L were excluded. Interviews, medical file reviews, and blood tests were performed. The PCER tool was used to estimate the CVD risk and compare it with the respective FRS. A p-value < 0.05 was accepted as statistically significant.

Results

Thirty PwH were included. Median age was 51.5 [interquartile range-IQR; 46.0-59.5] years. The prevalence of obesity, systemic arterial hypertension, diabetes mellitus, hypertriglyceridaemia, hypercholesterolaemia, and hypoHDLaemia were 20%, 67%, 24%, 14%, 47%, and 23%, respectively. The median PCER score was 6.9% [IQR; 3.1-13.2], with 50% having a high risk (PCER ≥ 7.5%). Statin use was suggested for 54% of PwH. Blood pressure was poorly controlled in 47% of PwH. The agreement between PCER and FRS was 80% (κ = 0.60; p = 0.001).

Conclusions

Half of the male people with haemophilia aged 40 years or older had a 10-year high risk of developing CVD with strong recommendations to improve control of dyslipidaemia and blood pressure.

Read Full Article

Original Article

Right Ventricular Function and Exercise Tolerance in Patients with ST-Elevation Myocardial Infarction

Denisse Guzman-Ramirez et al. Anival Trujillo-Garcia Meredith Lopez-Rincon Roxella Botello Lopez

Introduction

Right ventricle (RV) dysfunction has a prevalence of 10% in anterior myocardial infarctions and up to 50% in inferior myocardial infarctions. It is responsible for cardiogenic shock secondary to an acute coronary syndrome in 5% of cases. In patients with myocardial infarction, RV dysfunction is an important prognostic factor of mortality, ventricular arrhythmias, mechanical complications, cardiogenic shock, stent thrombosis, and increased in-hospital and one-year mortality.^–

Tajima et al. investigated RV function, its association with exercise tolerance, and the efficacy of phase II cardiac rehabilitation (CR) in patients with ischemic heart disease. RV dysfunction was significantly associated with reduced exercise tolerance by 9% before rehabilitation. However, CR was effective in these patients.

[…]

Read Full Article