Children – ABC CARDIOL

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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.

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IJCS

Review Article

One Size Does Not Fit All: The Need to Rethink the Metabolic Syndrome in Women

Maria Cristina Costa de Almeida et al. Marildes Luiza Castro Larissa Espíndola Neto Luciana Nicolau Aranha … Thaís Salim Gláucia Maria Moraes de Oliveira

Abstract

Metabolic syndrome (MetS) is increasing at epidemic proportions worldwide. MetS and its components are frequent among Brazilian women (41.8%). Women are affected by changes in adipose tissue distribution, lipid profile, insulin resistance (IR), and vascular remodeling during their lives. These changes result from the lack of estrogen after menopause. There have been various attempts to propose a uniform origin for the clustering of the MetS components, including genetics, IR, obesity, lifestyle, sleep disturbances, inflammation, fetal and neonatal programming, and disturbed circadian rhythm of the body functions. The proinflammatory and prothrombotic state in MetS is well-defined. Socioeconomic and lifestyle-related factors are also essential triggers of MetS, which is associated with a higher risk for coronary artery diseases (CAD) and stroke in women. Population measures in health and community medicine, such as continuing education on the importance of lifestyle change to reduce cardiovascular risks from early childhood, are fundamental strategies. Statins reduce high-sensitivity C-reactive protein blood levels and treat high cholesterol. According to the patient, hypoglycemic agents, such as dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1(GLP-1a), and sodium-glucose transport protein 2 (SGLT2) inhibitors, in addition to metformin, have their indication due to their beneficial cardiometabolic and vascular effects. Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) should be the first choice to treat hypertension in postmenopausal womem. The recognition of the different gender- and age-specific risk factors, allowing for specific and targeted interventions, is fundamental, especially for women.

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IJCS

Original Article

Electrocardiogram as Part of the Evaluation of Children and Adolescents Before Starting Physical Exercise

Diego Lineker Marquetto Silva et al. Rossano Cesar Bonatto Celia de Paula Pimenta Bonatto Carlos Roberto Padovani José Roberto Fioretto

Abstract

Background:

Children and adolescents should be encouraged to participate in sports; however, physicians should screen for cardiac abnormalities that can lead to sudden death. The European Society of Cardiology, the Brazilian Society of Cardiology and the Brazilian Society of Sports Medicine indicate performing an electrocardiogram (ECG) in evaluating athletes, while the American Heart Association indicates complementary exams only when there is a personal or family history of cardiovascular diseases or changes in clinical examination.

Objectives:

To evaluate the need for an ECG in evaluating children and adolescents before starting physical activities.

Methods:

We recruited 983 children and adolescents who practiced physical activities for anthropometric assessment, clinical examination and conventional ECG at rest. Variables were analysed using the Goodman test with a significance level of 5%.

Results:

Participants had a higher incidence of overweight, obesity and severe obesity compared to standard World Health Organization (WHO) values. The most common finding in clinical examination was heart murmur (18.5% of participants). Electrocardiographic changes were found in 3.3% of participants, including paroxysmal supraventricular tachycardia and pre-excitation syndrome, which may be responsible for sudden death, even in asymptomatic individuals with no personal or family history of heart disease and no abnormality on clinical examination.

Conclusions:

ECG revealed arrhythmias that were not detected by clinical examination and may precede sudden death in individuals subjected to physical exertion, indicating its role in the assessment of children and adolescents before starting regular physical exercise.

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Editorial

The Electrocardiogram in the Pediatric Population in the 21st Century. How to Keep Evolving after 135 Years of the Method Discovery History

Rogerio Braga Andalaft

Knowledge of the electrocardiogram remains constantly evolving in medical practice. The new interfaces for electrocardiogram (ECG) correlation with cardiac images and heart functional changes increase the method’s applicability. However, in children and adolescents, the constant change generated by these young people’s body and functional development often generates doubts in the interpretation of electrocardiographic tracings, even in the most experienced professionals. Recently, important data on ECG interpretation were extensively reviewed in the IV Guidelines of the Sociedade Brasileira de Cardiologia on Analysis and Issuance of Electrocardiographic Reports published in 2022.

But what is the role of the electrocardiogram, especially applied to pediatrics, in the 21^st century? What is normal for the child? What is the prevalence of electrocardiogram changes in asymptomatic patients?

[…]

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Editorial

How Should We Investigate Cardiovascular Injury In Critically Ill COVID-19 Pediatric Patients In A Scenario Of Socioeconomic Vulnerability?

Gabriela Nunes Leal

Literature published worldwide has extensively documented cardiovascular injury among COVID-19 critically ill patients. Cardiac involvement appears to be a prominent feature of the disease in adults, occurring in 20% to 30% of hospitalized patients and contributing to 40% of deaths. Children and adolescents are mostly spared by COVID-19, with few having severe symptoms and even fewer deaths. However, the description of the multisystem inflammatory syndrome in children (MIS-c) reinforced that, although rare, severe clinical presentation and death are possible in the pediatric population. Cardiovascular compromise in MIS-c associated with COVID-19 is frequent and is one of the World Health Organization (WHO) diagnostic criteria for this pathologic condition ( ).^,

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IJCS

Original Article

School Health Education Program “Happy Life, Healthy Heart”: A Randomized Clinical Trial

Mariana Alievi Mari et al. Paula Portal Teixeira Lucia Campos Pellanda

Abstract

Background:

School interventions based on playful activities have been shown to be good strategies for increasing children’s knowledge about health, which may impact healthy habits.

Objective:

To evaluate whether the school health education program entitled “Happy Life, Healthy Heart” increases health knowledge and causes a change in teachers’ and students’ lifestyles.

Method:

Cluster randomized clinical trial including elementary school students and teachers from public schools in the city of Frederico Westphalen, Brazil. The intervention consisted of the training of teachers on topics of health, followed by classes on topics related to cardiovascular health given by these teachers to the students. The students were evaluated for nutritional status and health knowledge using the CARDIOKIDS and DAFA questionnaires, and teachers were assessed for physical activity. The Student’s t-test, the chi-square test and the two-way ANOVA test were used for comparisons between groups, and McNemar-Bowker for intra-group comparisons. P values of <0.05 were considered statistically significant.

Results:

A total of 473 children were included, 211 (44.6%) in the control group (CG) and 262 (55.4%) in the intervention group (IG), and 32 teachers (control = 14, intervention =18). There was no difference in health knowledge of the students after the intervention (CG 10.53 ± 0.11 vs. 11.19 ± 0.09 p = 0.061, IG 10.20 ± 0.12 vs. 11.09 ± 0, 09 p = 0.416), although 57.7% of the children of the IG reported having stopped eating pizza and drinking soft drinks (p <0.001), following the Brazilian Food Guide recommendations. Among teachers of the IG, an increase of 27.9% in physical activity level was observed.

Conclusions:

The “Happy life, healthy heart” program was able to change students’ eating habits and increase physical activity in teachers.

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Original Article

Physical Activity and Cardiovascular Risk Factors in Children: a Meta-Analysis Update

Claudia Ciceri Cesa et al. Gabriela Oliveira Gonçalves Molino Júlia Lima Raquel Barbiero Pereira … Bruna Eibel Sandra Mari Barbiero Beatriz D. Schaan Lucia Campos Pellanda

Abstract

Background

Obesity and overweight in childhood can increase the risk of developing cardiovascular disease throughout live.

Objectives

This study provides an update of a meta-analysis of randomized clinical trials (RCT) published in 2014, to assess the effects of physical activity interventions on preventing cardiovascular risk factors in childhood.

Methods

This update combines data from the previous search with new data obtained from June 2013 to June 2020. Searches were performed on PubMed, EMBASE and Cochrane CENTRAL. The RCTs enrolled used interventions with physical activity longer than six months in school children aged 6-12 years, and evaluated body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), triglyceride (TG), and low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels. Data analysis was performed using a random-effects model and a P value <0.05 was considered statistically significant.

Results

A total of 28,603 articles were retrieved, and 17 RCTs (11,952 subjects) were included. Physical activity interventions were associated with reduction in SBP [−2.11mmHg (95%CI −3.67, −0.54), I²43%], DBP [−2.08mmHg (95%CI −3.68, −0,49), I²65%] and TG [-0.08mmol/L (95% CI -0.13, -0.03), I²0%], and increase in TC [0.17mmol/L (95%CI 0.04, 0.30), I²0%]. However, the interventions were not associated with reductions in BMI [−0.03 kg/m² (95%CI −0.17, 0.10), I²0%].

Conclusion

This update confirms and reinforces the beneficial effects of physical activity intervention in reducing systolic and diastolic blood pressure and TG levels.

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ABCIC

Original Article

Non-Compacted Cardiomyopathy in Children and Adolescents: From the Challenge of Echocardiographic Diagnosis to Clinical Follow-Up

Ana Flávia Malheiros Torbey et al. Ana Catarina Durán Bustamante Aurea Lucia Grippa de Souza Carmen Zampirole Brandão … Luan Rodrigues Abdallah Yves Pacheco Dias March e Souza Evandro Tinoco Mesquita

Abstract

Background

Non-compacted cardiomyopathy (NCCM) is characterized by hypertrabeculations and deep recesses in the left ventricle, with a heterogeneous clinical presentation, ranging from asymptomatic patients to those with heart failure (HF), thromboembolic events and arrhythmias with risk of sudden death. As it is rare and does not have well-defined diagnostic criteria, its natural history in pediatrics is poorly understood. This study describes the clinical presentation and clinical course of patients with NCCM.

Methodology

Observational, longitudinal, prospective study of pediatric patients seen at a pediatric cardiology referral center from metropolitan region II in the state of Rio de Janeiro, with NCCM phenotype on echocardiogram (ECHO) during a 2-year follow-up, from the ChARisMa registry.

Results

6 patients aged 4 to 14, with NCCM, were analyzed. Mean age 7.5 years (SD: 3.93), 3 males (50%). The patients presented HF (n=2), cardiac murmur (n=1), cardiac arrhythmia (n=1), were asymptomatic (n=1) or were under investigation for a genetic syndrome (n=1). Phenotypes on ECHO: NCCM/dilated cardiomyopathy (n=1) and NCCM/restrictive cardiomyopathy (n=1), isolated phenotype of NCCM (n=4). Cardiac magnetic resonance imaging was performed and confirmed the diagnosis (n=4). The outcomes observed were thromboembolism, indication for heart transplantation, and sustained ventricular tachycardia.

Conclusions

This case series provides relevant data for pediatric NCCM as it shows its heterogeneous clinical presentation and potentially fatal complications. More prospective studies are needed for an accurate diagnosis and to allow its clinical course, therapeutic response and prognosis to be better known.

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ABCHF

Review Article

Acute Myocarditis in Childhood and Adolescence in the Covid-19 Era

Ana Flávia Malheiros Torbey et al. Aurea Lúcia Alves de Azevedo Grippa de Souza Ana Catarina Durán Bustamante Carmen Z. Brandão … Luan Rodrigues Abdallah Yves P. D. March e Souza Evandro Tinoco Mesquita

Abstract

Myocarditis in children and adolescents is an inflammatory myocardial disease with a heterogeneous presentation ranging from oligosymptomatic, with no impaired ejection fraction to catastrophic clinical presentation with cardiogenic shock (fulminant myocarditis) or sudden death. Thus, this condition remains a major challenge from the diagnostic and therapeutic points of view. Despite the different etiologies listed, the most frequent form may be related to viral diseases, and new forms of myocarditis, such allergic ones (eosinophilic and use of medications, particularly cancer immunotherapy), have been currently described. Increasing the rate of suspicion is crucial. Measurement of serum levels of troponin and N-terminal B-type natriuretic peptide, as well as the use of advanced methods of cardiac imaging, such as strain echocardiogram, positron emission tomography, and cardiac magnetic resonance, are integral part of multimodal assessment in suspected patients. Although endomyocardial biopsy remains is still the gold standard for disease diagnosis, currently it tends to be performed in specific situations, such as fulminant clinical presentation and chronic or recurrent myocarditis. The management of this condition includes general supportive care, treatment of heart failure, control of arrhythmias when present, assessment of mechanical support and cardiac transplantation. Treatments based on immunosuppression and immunotherapy are still controversial. In this article, we propose a broad review of diagnostic and treatment methods, as well as the different etiologies in the pediatric population.

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Editorial

Kawasaki Disease: Predictors of Intravenous Immunoglobulin Resistance and Cardiac Complications: New Perspectives?

Isabel Cristina Britto Guimarães

Kawasaki disease (KD) is an acute inflammatory disease of unknown origin and associated with vasculitis. It affects medium-sized vessels. Coronary artery abnormalities (CAA) — aneurysms or dilations — are the main complications of KD, and are currently the most common cause of heart disease acquired in children in developed countries. In the acute phase, the initial standard treatment recommended is intravenous immunoglobulin (IVIG) and aspirin, to reduce the risk of damage to the coronary arteries. However, 10 to 20% of children with KD do not respond to the initial standard treatment, with recurrent fever within 36 to 48 hours after IVIG infusion. Studies show that the likelihood of KD patients resistant to IVIG to have coronary artery lesions is nine times greater than those sensitive to IVIG. This suggests that there is a critical window to block the inflammatory process and prevent CAA in the long term.

The study by Faim et al. aimed to identify predictive factors for resistance to intravenous immunoglobulin (IVIG), calculate the effectiveness of Japanese predictive models and characterize the cardiac complications of patients followed up at a single institution.

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Original Article

Inequalities in Mortality Rates from Malformations of Circulatory System Between Brazilian Macroregions in Individuals Younger Than 20 Years

Thais Rocha Salim et al. Thayanne Mendes Andrade Carlos Henrique Klein Gláucia Maria Moraes de Oliveira

Abstract

Background

Deaths from malformations of the circulatory system (MCS) have a major impact on mortality reduction. given that most cases are avoidable with correct diagnosis and treatment.

Objectives

To describe the distribution of mortality from MCS by sex. age. and macroregion in Brazil. in individuals under the age of 20. between 2000 and 2015.

Methods

A descriptive study of mortality rates and proportional mortality (PM) from MCS. other congenital malformations (OCM). circulatory system disease (CSD). ill-defined causes (IDC). and external causes (EC) in Brazil.

Results

There were 1.367.355 deaths from all causes in individuals younger than 20. 55.0% under 1 year of age. A total of 144.057 deaths were caused by congenital malformations. 39% of them by MCS. In both sexes. the annual mortality from MCS was 5.3/100.000. PM from MCS was 4.2%. CSD 2.2%. IDC 6.2% and EC 24.9%. Unspecified MCS showed the highest PM rates in both sexes and age groups. especially in the north and northeast regions (60%). Deaths from malformations occurred 5.7 times more frequently during the first year of life than in other ages (MCS: 5.0; OCM: 6.4).

Conclusions

MCS was the leading cause of death among all malformations. being twice as important as CSD. mainly under 1 year of age. The frequency of misdiagnosis of MCS as cause of death was high in all ages and both sexes. especially in the north and northeast regions. These findings highlight the need for the development of public health strategies focused on correct diagnosis and early treatment of congenital cardiopathies. leading to a reduction in mortality. (Arq Bras Cardiol. 2020; 115(6):1164-1173)

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Editorial

Physical Activity Knowledge and Levels among Children with Congenital Heart Disease

Adilson Marques et al. Bruna Gouveia

The benefits of physical activity are well documented. Among children and adolescents, physical activity improves cardiovascular, bone and metabolic health, fitness levels, weight status, and sleep. Also, there is evidence of the cognitive, psychological and social benefits of physical activity.The health benefits of physical activity are transversal to all children, including those living with a chronic disease, such as congenital heart disease (CHD), preventing comorbidities, while improving quality of life.^,

The importance of physical activity for children with CHD has been documented for a long time. Engagement in physical activity is of high importance for children with CHD because they are at risk of developing other cardiovascular and metabolic diseases,^, increasing signs of depression and anxiety. In addition, when present, these health problems can be mitigated by an active lifestyle.^–

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IJCS

Original Article

Lipoprotein(a) levels in children and adolescents: Ouro Preto Study

Ana Paula C Cândido et al. Alekson Mendonça-Mendes Débora RC Cândido Roney LC Nicolato George LL Machado-Coelho

Abstract

Background

Lipoprotein (a) is a cardiovascular risk factor in adult. Studies have shown the presence of this emergent risk factor in school children, which may contribute to the development of atherosclerosis in adulthood.

Objective

To evaluate the association between lipoprotein (a) and cardiovascular risk factors in school children.

Methods

Lipoprotein (a) levels were measured in 320 school children (6-14 years) selected from a population survey carried out in Ouro Preto (southeast of Brazil). Demographic (sex and age), biochemical (total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, triglycerides, and glucose), anthropometric (body mass index, waist circumference, body fat percentage), clinical (arterial blood pressure, pubertal stage and birth weight) and economic (family income) parameters, as well as family history (obese and/or hypertensive parents) were analyzed. Non-parametric analysis was used to evaluate lipoprotein (a) levels in each subgroup. Variables with p≤0.20 in the univariate analysis were included in binary regression logistic model. Differences with p < 0.05 were considered significant.

Results

Lipoprotein (a) levels were associated with total cholesterol (p=0.04), body fat (p=0.009), and mother´s systolic (p=0.02) and diastolic blood pressure (p=0.04). In a logistic regression analysis, children with high lipoprotein (a) levels and body fat, and children born from hypertensive mothers were, respectively, at 3.2(p=0.01) and 1.4 (p=0.03) times higher risk than other children. In clustering these factors, elevated lipoprotein (a) was 2.6 times more likely to be seen in school children with high body fat and born hypertensive mothers.

Conclusions

Lipoprotein (a) was correlated with cardiovascular risk factors in children and adolescents. Persistence of these risk factors in childhood suggests a contribution of elevated lipoprotein (a) to future cardiovascular disease. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Letter to the Editor

Do Not Treat Children with Statins

David M. Diamond et al. Uffe Ravnskov Michel de Lorgeril

In their meta-analysis Radaelli et al. conclude that statin treatment is efficient in lowering lipids in children with familial hypercholesterolemia (FH) and suggest that long-term trials should be performed to establish long-term safety. We would warn against their recommendation for several reasons.

As we have shown in a recent paper, there is much evidence that high LDL-cholesterol (LDL-C) is not the cause of premature coronary heart disease in FH; it is most likely inborn abnormal coagulation factors, and only a small minority among those with FH inherits these factors. On average, people with FH live just as long as other people because high LDL-C protects against cancer and infectious diseases. Furthermore, to treat children with statins may ultimately cause them harm because cholesterol is necessary for the developing brain and is an essential precursor for metabolic co-factors and hormones, including vitamin D and all sex steroids.

[…]

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Original Article

Statin Treatments And Dosages In Children With Familial Hypercholesterolemia: Meta-Analysis

Graciane Radaelli et al. Grasiele Sausen Claudia Ciceri Cesa Francisco de Souza Santos … Vera Lucia Portal Jeruza Lavanholi Neyeloff Lucia Campos Pellanda

Abstract

Background:

Children with familial hypercholesterolemia may develop early endothelial damage leading to a high risk for the development of cardiovascular disease (CVD). Statins have been shown to be effective in lowering LDL cholesterol levels and cardiovascular events in adults. The effect of statin treatment in the pediatric population is not clearly demonstrated.

Objective:

To systematically review the literature to evaluate the effects of different statins and dosages in total cholesterol levels in children and adolescents with familial hypercholesterolemia. We also aimed to evaluate statin safety in this group.

Methods:

PubMed, EMBASE, Bireme, Web of Science, Cochrane Library, SciELO and LILACS databases, were searched for articles published from inception until February 2016. Two independent reviewers performed the quality assessment of the included studies. We performed a meta-analysis with random effects and inverse variance, and subgroup analyses were performed.

Results:

Ten trials involving a total of 1543 patients met the inclusion criteria. Our study showed reductions in cholesterol levels according to the intensity of statin doses (high, intermediate and low): (-104.61 mg/dl, -67.60 mg/dl, -56.96 mg/dl) and in the low-density lipoprotein cholesterol level: [-105.03 mg/dl (95% CI -115.76, -94.30), I2 19.2%], [-67.85 mg/dl (95% CI -83.36, -52.35), I2 99.8%], [-58.97 mg/dl (95% CI -67.83, -50.11), I2 93.8%. The duration of statin therapy in the studies ranged from 8 to 104 weeks, precluding conclusions about long-term effects.

Conclusion:

Statin treatment is efficient in lowering lipids in children with FH. There is need of large, long-term and randomized controlled trials to establish the long-term safety of statins.

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Artigo Original

Risk Factors Associated with High Blood Pressure in Two-to Five-Year-Old Children

Paula Azevedo Aranha Crispim et al. Maria do Rosário Gondim Peixoto Paulo César Brandão Veiga Jardim

Background:

Over recent decades, the prevalence of high blood pressure (BP) has increased among children. Several risk factors are involved in the genesis of high BP during childhood, and their early identification can prevent the development of that disease.

Objectives:

To assess the prevalence of high BP and associated factors in children.

Methods:

Cross-sectional, population-based study, carried out at the household. This study included 276 two- to five-year-old children in the city of Goiânia, state of Goiás, and assessed their BP, sociodemographic characteristics, birth weight, high BP family history, passive smoking, maternal breastfeeding, dietary habits, sedentary lifestyle and nutritional status. Poisson regression was used to assess the association between risk factors and high BP.

Results:

Their mean age was 3.1 ± 0.79 years, and high BP and overweight were observed in 19.9% and 11.2% of the children, respectively. Direct association of high BP was identified with age [prevalence ratio (PR) = 2.3; 95%CI: 1.2 – 4.8; p = 0.017] and overweight (PR = 2.0; 95%CI: 1.2 – 3.6; p = 0.014). No other variable associated with high BP.

Conclusions:

The prevalence of high BP in children was high. Overweight and younger children had greater prevalence of high BP.

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Artigo Original

Physical inactivity, TV-watching hours and body composition in children and adolescents

Ivan Romero Rivera et al. Maria Alayde Mendonça da Silva Renata D'Andrada Tenório Almeida Silva Bruno Almeida Viana de Oliveira Antonio Carlos Camargo Carvalho

BACKGROUND: Physical inactivity is a predisposing factor to the onset/worsening of other cardiovascular risk factors, particularly obesity. OBJECTIVE: To determine physical activity level (PAL) and daily number of hours of TV (HTV) and the association and/or correlation of these variables with age, gender, economic class, public/private school, overweight and obesity in children and adolescents. METHODS: Cross sectional study, school-based population, public and private education, primary and secondary education. The sample was calculated based on the minimum expected prevalence of several variables, including physical inactivity. Cluster sampling. Protocol: structured questionnaire, including Physical Activity for Older Children Questionnaire (PAQ-C) measurements of weight, height, body mass index (BMI) and triceps skinfold (TSF). Statistical analysis: Chi-square, linear correlation. RESULTS: Among the 1,253 students, averaging 12.4 ± 2.9 years old, of which 549 were male, there was a prevalence of inactivity in 93.5%, more commonly found in female adolescents and there was no association between PAL and excess weight or body fat, soccer and dance were the most frequent activities in boys and girls, respectively; 60% of students did not have physical education classes. Average and median HTV were respectively 3.6 and 3 hours; there was a significant association between HTV and obesity and significant correlation between PAL and age (negative) and between BMI and TSF (positive). CONCLUSION: Physical inactivity is present in 93.5% of children and adolescents from Maceió. It is more commonly found among teenagers and females, with no association or correlation of this variable with excess weight or body fat; obesity was associated with > 3 HTV.

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Artigo Original

B-type natriuretic peptide assessment in the diagnosis of rejection after pediatric heart transplant

Cristina de Sylos et al. Estela Azeka Luis Kajita Luis Benvenutti … Célia Cassaro Strunz Klébia Castello Branco Arlindo Almeida Riso Carla Tanamati Marcelo Jatene Miguel Barbero-Marcial

BACKGROUND: Rejection is one of the major causes of mortality following pediatric heart transplant. B-type natriuretic peptide (BNP) has been studied as a method for the diagnosis of acute rejection, especially in adult patients undergoing heart transplant. OBJECTIVE: To correlate serum BNP levels with acute rejection as diagnosed by endomyocardial biopsy in patients of the pediatric heart transplant group. METHODS: A total of 50 BNP samples were collected from 33 children in the postoperative period of heart transplant, and data on age, gender, skin color, blood group, immune panel, follow-up time after transplant, functional class, immunosuppressive regimen used and number of rejections were analyzed. RESULTS: Thirty three children with median age of 10.13 years were analyzed; of these, 54% were females and 78% were Caucasians. BNP levels were determined at a mean time from transplant of 4.25 years. Nine episodes of rejection were diagnosed in eight patients (27%) by means of endomyocardial biopsy; of these, three were grade 3A, five were grade 2, and one had humoral rejection. At the moment of biopsy, most patients were asymptomatic. The mean serum BNP level was 77.18 pg/ml, with 144.22 pg/ml in the group with rejection and 62.46 pg/ml in the group without rejection, with p = 0.02. CONCLUSION: Asymptomatic children can present acute rejection in the postoperative period of heart transplant. Serum BNP levels show a statistically significant difference in the group with rejection and thus can be an additional method in the diagnosis of cardiac rejection.

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Artigo Original

Dyslipidemia among adolescents and children from Pernambuco – Brazil

Everaldo de Franca et al. João Guilherme Bezerra Alves

OBJECTIVE: To describe the prevalence of dyslipidemia and overweight among children and adolescents in the state of Pernambuco, Brazil. METHODS: During clinical evaluation, a questionnaire was completed through interviews with parents and included personal details of the children and adolescents. An exclusion criterion was personal or parental history of diabetes or coronary artery disease (CAD). Blood samples were collected from subjects who had been fasting for 12 hours, and the following evaluations were performed using enzymatic methods: serum Total Cholesterol, LDL-Cholesterol, HDL-Cholesterol and Triglycerides. Data were analyzed using the SPSS 11.5 statistical package including Student’s t test and Fisher’s exact test. RESULTS: Of the 414 children and adolescents analyzed in the present study, about 30% presented an atherogenic lipid profile, characterized by higher levels of Triglyceride, Total and LDL- Cholesterol. The prevalence of overweight in this sample from Pernambuco was 4%. Girls had higher levels of Triglycerides and Total Cholesterol than boys. Children and adolescents presented the same values of lipid on blood that is not expected for children in this phase of development. CONCLUSION: In the present population, an unfavorable lipid profile among children and adolescents from Pernambuco suggests that programs targeting the prevention of cardiovascular disease and obesity must begin early in life.

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Artigo Original

Late heart evaluation of children with rheumatic mitral regurgitation submitted to reconstructive surgery with implantation of Gregori's ring

Vitor Hugo Soares Machado et al. Francisco Gregori Júnior

OBJECTIVE: Assess late cardiological evolution of children with rheumatic mitral regurgitation (RMR) who underwent mitral valve reconstructive surgery with implantation of Gregori’s ring (MVR), from 1987 to 2003. METHODS: A study was conducted to analyze a series of cases of 43 children with RMR who underwent MVR with ages ranged from five to twelve years (mean age 9.7 ± 2.2 years); 25 of the patients were females (58.1%). Patients were evaluated as per the following clinical parameters: functional class of heart failure, heart auscultation, electrocardiogram, chest X-ray and echocardiographic findings. RESULTS: Forty-three patients underwent preoperative evaluation during the postoperative period, the number of patients evaluated decreased to 31 due to the fact that 6 patients had died and 6 others underwent valve replacement surgery. Follow-up was carried out for 100% of the patients. A significant reduction of heart failure functional class was observed. Mitral systolic murmur became lesss intense during the postoperative period. The cardiac area on chest X-ray and the presence of left ventricular overload on electrocardiogram were reduced, as well as the mitral regurgitation level on echocardiographic study. After 188 months, the survival rate was 82%, and the annual mortality rate, 0.38%. Thirty-one (72.6%) patients did not require reoperation and the annual rate of patients who required further surgery was 0.51%. CONCLUSION: MVR is an effective procedure for treating RMR in children, resulting in a significant improvement of functional class, mitral systolic murmur and level of mitral regurgitation, as shown on Doppler echocardiogram.

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Artigo Original

Coarctation of the aorta in infants under one year of age: an analysis of 20 years of experience

Gabriel Lorier et al. Orlando Wender Renato A.K. Kalil Javier Gonzalez … Gustavo Hoppen Christiano Barcellos Abud Homsi-Neto Paulo R. Prates João R.M. Sant'Anna Ivo A. Nesralla

OBJECTIVE: A review of experience with techniques of correction used, in the last 20 years, in children younger than one year old. METHODS: In the period from 1978 to 1998, 148 patients (pt) with coarctation of the aorta (CoAo), under one year of age, with or without associated intracardiac defects, were submitted to surgery. Median age 50 days, 92 female pt (62.1%). The average weight was 4,367± 1,897 gr. The average follow-up was 1,152±1,462 days. The population was divided in 3 groups: Group I, isolated CoAo: 74 pt (50%); Group II, CoAo and interventricular communication (IVC): 41 pt (27.7%) and Group III, CoAo with complex intracardiac malformations: 33 pt (22.3%). RESULTS: The total mortality was of 43 patients (29%). In patients younger than 30 days, the mortality was 53%, p=0.009, DR=4.5, between 31 and 90 days, 14.7%, p=0.69, and over 91 days, 15%, p=0.004. The probability of actuarial survival of the whole population was 67% at 5 and 10 years. Thirty-six patients (24.3%) had recoarctation, from which 18 patients (50%) were younger than 30 days, DR=6.,35. The incidence of recoarctation was with Waldhausen technique in 4 patients (10%) and with the classic termino-terminal technique in 19 patients (26%) p=0.03, and isthmusplastic operation in 6 patients (37.5%). The patients younger than 30 days showed a relative risk for recoarctation de DR=6.35. The probability of actuarial survival, free of coarctation repair, at 5 and 10 years was of 69% with Waldhausen’s technique and 63% with the classic termino-terminal technique. CONCLUSION: Patients younger than 30 days showed increased mortality and recoarctation risk. Waldhausen’s technique in patients older than 30 days showed effective. The classic termino-terminal technique did not show to be a good option in all age ranges, being imperative to carry out more radical technical variations, such as the extended termino-terminal.

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Artigo Original

How can the echocardiogram be useful for predicting death in children with idiopathic dilated cardiomyopathy?

Vitor Manuel Pereira Azevedo et al. Francisco Manes Albanesi Fº Marco Aurélio Santos Márcia Bueno Castier Bernardo Rangel Tura

OBJECTIVE: To determine the echocardiographic predicting factors of death in children with idiopathic dilated cardiomyopathy. METHODS: A retrospective study of 148 children with idiopathic dilated cardiomyopathy diagnosed between September 1979 and March 2003 was carried out. The inclusion criteria were as follows: heart failure and a reduction in contractility on the echocardiogram in the absence of congenital or secondary heart disease. Four hundred and seventy examinations during a period of 244.8 months of evolution were analyzed. The following parameters were assessed: left atrial dimension (LAD); left atrium/aorta ratio (LAD/Ao); left ventricular systolic (LVSD) and diastolic (LVDD) dimensions; left ventricular mass (LVmass); right ventricular dimension (RVD); left ventricular ejection fraction (LVEF); left ventricular shortening fraction (% SH); severity of the insufficiency of the atrioventricular and pulmonary valves; and right ventricular systolic (RVSP) and diastolic (RVDP) pressures. The significance level adopted was alpha < 0.05. RESULTS: The mean age was 2.37 years, and 35 patients died (23.7% – 95 CI = 17.1% to 31.2%). The analysis of variance showed the following: LAD (p<0.0001); LAD/Ao (p<0.0001); LVSD (p=0.0061); LVDD (p=0.0086); LVmass (p<0.0001); LVEF (p=0.0074); %SH (p=0.0072); and RVD (p<0.0001). Worsening of mitral (MI) (p=0.0113) and tricuspid (TI) insufficiencies (p=0.0044) were markers of death, and the presence of MI, TI, and moderate/severe pulmonary insufficiency were deleterious to survival. The Cox proportional hazards regression model showed the following independent predictors of death: LAD/Ao (p=0.0487); LVEF (<0.0001); and the presence of moderate/severe MI (p=0.0419). CONCLUSION: Patients with a progressive increase in LAD/Ao, a reduction in LVEF, and progressive worsening of MI, regardless of the clinical treatment, should be considered for early heart transplantation.

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Original Article

Prevalence of systemic hypertension in students aged 7 to 14 years in the municipality of Barbacena, in the State of Minas Gerais, in 1999

Dilermando Fazito de Rezende et al. Ricardo Augusto Baêta Scarpelli Guenael Freire de Souza José Orleans da Costa … Adelaide Maria Baêta Scarpelli Paulo Antônio Scarpelli Guilherme Bahia de Carvalho Hélius Moreira D'Agostini Josuela Cabral Pedrosa

OBJECTIVE: To detect the prevalence of systemic hypertension in children and to establish the relation between blood pressure levels and sex, age, ethnicity, weight, and height. METHODS: The prevalence of systemic hypertension and its relation to sex, age, ethnicity, weight, and height were studied in 611 students aged 7 to 14 years out of 19.928 students classified according to age, ethnicity, and sex, who underwent anthropometric evaluation and blood pressure measurement. Hypertensive individuals were considered those whose blood pressure level was > the 95th percentile for age and sex, confirmed on 3 examinations. RESULTS: The prevalence of hypertension was 16.6% in the first evaluation, and 4.6% and 2.5% in the subsequent evaluations. The mean blood pressure levels increased with age. Weight was important, not only to determine blood pressure in healthy children, but also to determine systemic hypertension in children, which was not observed with height despite the different studies. The prevalence of systemic hypertension in the different ethnic groups and the mean blood pressure levels according to sex were similar. CONCLUSION: In addition to routine physical examinations, age, weight, and appropriate cuff size should be considered when assessing blood pressure in children to prevent hypertension, morbidity and mortality, and to avoid placing a financial burden on health care providers.

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Original Article

Initial diagnostic errors in children suspected of having heart disease: prevalence and long-term consequences

Fernando Amaral et al. João A. Granzotti

OBJECTIVE: To access the incidence of diagnostic errors in the initial evaluation of children with cardiac murmurs. METHODS: We evaluated our 7-years of experience in a public pediatric cardiology outpatient clinic. Of 3692 patients who were sent to the hospital, 2603 presented with a heart murmur and were investigated. Patients for whom a disagreement existed between the initial and final diagnoses were divided into the following 2 groups: G1 (n=17) with an initial diagnosis of an innocent murmur and a final diagnosis of cardiopathy, and G2 (n=161) with an initial diagnosis of cardiopathy and a final diagnosis of a normal heart. RESULTS: In G1, the great majority of patients had cardiac defects with mild hemodynamic repercussions, such as small ventricular septal defect and mild pulmonary stenosis. In G2, the great majority of structural defects were interventricular communication, atrial septal defect and pulmonary valve stenosis. CONCLUSION: A global analysis demonstrated that diagnostic error in the initial evaluation of children with cardiac murmurs is real, reaching approximately 6% of cases. The majority of these misdiagnoses were in patients with an initial diagnosis of cardiopathy, which was not confirmed through later complementary examinations. Clinical cardiovascular examination is an excellent resource in the evaluation of children suspected of having cardiopathy. Immediate outpatient discharge of children with an initial diagnosis of an innocent heart murmur seems to be a suitable approach.

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