2018;31(3) – ABC CARDIOL

IJCS

ABC Family | IJCS

Original Article

Epidemiological Characteristics and Mortality Predictors in Patients Over 70 Years Submitted to Coronary Artery Bypass Grafting

Renato Kaufman et al. Vitor Manuel Pereira Azevedo Rodrigo Mazzarone Gomes de Sá Mauro Geller … Regina Maria de Aquino Xavier Rogério Brant Martins Chaves Marcia Bueno Castier

Abstract

Background:

Coronary artery disease is the leading cause of death worldwide, with age being an independent risk factor for mortality in patients submitted to surgical revascularization.

Objective:

To evaluate the mortality risk predictors in patients older than 70 years submitted to myocardial revascularization.

Methods:

This is a retrospective cohort study of a cardiac surgery database. Logistic regression was used to assess independent death predictors.

Results:

A total of 372 patients submitted to surgical revascularization from 2004 to 2012 were assessed. The main cardiovascular risk factor was hypertension, followed by diabetes mellitus. Mortality at 30 days was 19.35%. The presence of peripheral vascular disease (OR: 2,47), emergency surgery (OR: 4,86) and combined valve procedure (OR: 3,86) were independent predictors of death.

Conclusion:

The surgical procedure in elderly patients showed a higher mortality than in the general population. Peripheral vascular disease, emergency surgery and combined valve procedures increased the risk of death in these patients.

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Original Article

Acute Effect of Manual Lymphatic Drainage on Natriuresis and Lipolysis in Young Women

Érica A. M Camargo et al. Filipy Borghi Aglécio Luiz de Souza Denise Maria Marcorin … Luana de Lima Rodrigues Danilo Roberto Xavier de Oliveira Crege Larissa Yuri Ishizu Priscila Cristina da Silva Dora Maria Grassi-Kassisse Maria Silvia Mariani Pires-de-Campos

Abstract

Background:

The importance of scientific validation of supporting techniques to various treatments is unquestionable. In this context, the influence of manual lymphatic drainage (MLD) on natriuresis and lipolysis and its interaction with oral contraceptives still need to be investigated.

Objectives:

To evaluate the acute effect of MLD on natriuresis and lipolysis in young women using or not oral contraceptives.

Methods:

Twenty-nine non-users of oral contraceptives and 29 oral contraceptive users, self-reported healthy, sedentary, normal weight women were enrolled. Analyses were conducted on two different days – control (C), without therapeutic intervention and MLD day. Four urine samples were collected at 60-minute intervals. MLD was performed in lower limbs and abdomen for 45 min following the Leduc method. Urinary flow rate and urinary sodium, glycerol and atrial natriuretic peptide excretion were analyzed. Data normality was tested by the Shapiro-Wilk test. Data without normal distribution were expressed as median and interquartile range (25%-75%), while normally distributed data were expressed as mean ± standard error. Mann-Whitney test was used for unpaired data and Wilcoxon test for paired data. Data with normal distribution were evaluated by the unpaired t-Student test. Statistical significance was set at 5%.

Results:

One MLD session had an acute effect on both groups, increasing natriuresis in non-users of oral contraceptives and glycerol and atrial natriuretic peptide excretion in oral contraceptive users.

Conclusion:

Oral contraceptives influence the effect of MLD on natriuresis.

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Case Report

Hemochromatosis: Reversible Cause of Heart Failure

Cassia Pereira Kessler Iglesias et al. Paulo Vinicios Falcão Duarte Jacqueline Sampaio dos Santos Miranda Luana da Graça Machado Caio Ribeiro Alves Andrade

Introduction

GCW, age 33, presents acute heart failure (HF), amenorrhea and darkening of the skin. Three months after this initial situation, the patient is referred to a large cardiology centre and is submitted to HF screening, and the suspicion of hemochromatosis is promptly raised. This disease affects the heart in only 15% of cases. It has been shown that early recognition and intervention may change the prognosis. This is a diagnosis that should be considered in all cases of HF screening since it is easy to diagnose and its treatment can drastically change the prognosis of the disease.

Hereditary hemochromatosis (HH) is a genetic disease of iron metabolism characterized by increased intestinal absorption and progressive accumulation of it in different organs. HH is the most common autosomal disease in Caucasians, particularly those with Nordic or Celtic ancestors, affecting one in each 220-250 individuals. According to the mutations found, HH can be classified as: Hemochromatosis associated with HFE (classical hemochromatosis) and hemochromatosis not associated with HFE: Hereditary hemochromatosis due to mutation at the receptor 2 of transferrin-TfR2, juvenile hemochromatosis (hemojuvelin mutation – HJV gene and hepcidin mutation – HAMP gene), ferroportin disease and African iron overload. The vast majority (80-85%) of HH cases that have northern European ancestors are associated with HFE, while 10-15% of HH cases are not associated with HFE.

[…]

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Original Article

Spatial Analysis and Mortality Trends Associated with Hypertensive Diseases in the States and Regions of Brazil from 2010 to 2014

Marcos Antonio Almeida-Santos et al. Beatriz Santana Prado Deyse Mirelle Souza Santos

Abstract

Background:

Systemic Arterial Hypertension (SAH) represents the most relevant worsening factor and one of the major risk factors for cardiovascular diseases.

Objectives:

To analyze trends in the mortality rate associated with hypertensive diseases in Brazil from 2010 to 2014, for states as well as regions.

Methods:

An epidemiological study was performed from aggregate data obtained in populational strata. Cartographic data of the Brazilian territory in “shapefile” were provided by IBGE. Records of mortality associated with arterial hypertension were obtained in DATASUS, through notifications filtered by category I.10 of the International Classification of Diseases (ICD-10). The criterion of statistical significance was a two-tailed p-value < 0.05.

Results:

The increase in age was progressively associated with an increase in the mean number of deaths related to hypertensive diseases between the years 2010 and 2014. In the age groups between 50-59 years, 60-69 years, 70-79 years and 80 or more years, the mean and standard deviation for the mortality rate were, respectively: 15.11% (35.35); 24.14% (55.34); 35.07% (81.03) and 57.87% (139.08). The overall mortality rate per 10,000 inhabitants varied between the regions: north (1.25); northeast (2.69); center-west (2.06); southeast (2.48) and south (2.04).

Conclusions:

The mortality rate associated with hypertensive diseases was higher in the southeastern and northeastern states of Brazil, and remained stable between 2010 and 2014. Increased age and brown color were predictors of higher mortality.

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Original Article

Additional Cardiac Remodeling Induced by Intense Military Training in Competitive Athletes

Paulo Dinis et al. Hélder Dores Rogério Teixeira Luís Moreno … Joselito Mónico Marie Bergman Hanna Lekedal Maria Carmo Cachulo Joaquim Cardoso Lino Gonçalves

Abstract

Background:

Cardiac remodeling depends on the intensity, duration, and training method.

Objective:

To evaluate if the training performed in a Portuguese military special operations troop increases cardiac remodeling in a sample of young individuals who previously practiced competitive sports.

Methods:

A prospective study involving 76 military candidates for military special operations, 45 of whom previously practiced at competitive level (> 10 hours per week). Of these military athletes, only 17 successfully completed the course. The evaluation was performed at 6 months intervals and included a complete clinical history, physical examination, vital signs, anthropometric data and echocardiographic evaluation. Statistical significance was considered when p < 0.05, with a 95% confidence interval.

Results:

At the end of the course, there was a decrease in the percentage of fat mass (19.1 ± 3.3% vs. 13.1 ± 3.5%; p < 0.01), an increase in the percentage of lean mass (41.3 ± 2.1% vs. 44.4 ± 1.8%; p < 0.01), and decreased systolic and diastolic blood pressure and heart rate. Regarding cardiac remodeling, there was an increase in left ventricular diastolic diameter (49.7 ± 3.2 mm vs. 52.8 ± 3.4 mm; p < 0.01), an increase trend in left atrial volume (27.3 ± 4.5 mL/m² vs. 28.2 ± 4.1 mL/m²; p = 0.07) and increased left ventricular mass (93.1 ± 7.7 g/m² vs. 100.2 ± 11.4 g/m²; p < 0.01). Functional variables also changed, with an increase in S' (15 (13-16) cm/s vs. 17 (16-18) cm/s; p < 0,01) and a decrease in left ventricular ejection fraction (60 ± 6% vs. 54 ± 6%; p < 0.01).

Conclusion:

Intense military physical training resulted in additional cardiac remodeling in athletes of competitive level, both structural and functional.

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Case Report

Hypertrophic Cardiomyopathy, All Phenotypes in one

Aníbal M Arias et al. Diego Perez de Arenaza Rodolfo Pizarro Ricardo G Marenchino … Fernando Garagoli Hernán Garcia Rivello César Belziti

Introduction

Hypertrophic cardiomyopathy (HCM) is an intrinsic myocardial disorder characterized by cardiac hypertrophy (wall thickness ≥ 15 mm), that is not explained by conditions of pressure overload (eg, hypertension, severe aortic stenosis). HCM is the most common genetic primary cardiomyopathy, with a prevalence estimated to be about one in 500 adults in the general population.

More than 450 mutations have been identified in the 20 genes that cause different phenotypes. In most cases, HCM is associated with sarcomere protein gene mutations, and exhibits multiple phenotypic expressions. We present a case that combines all phenotypes.

[…]

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Original Article

Correlation Between the Complexity of Coronary Lesions and High-Sensitivity Troponin Levels in Patients with Acute Coronary Syndrome

Monique Rodrigues Cardoso et al. Delcio Gonçalves da Silva Junior Eduardo Alves Ribeiro Alfredo Moreira da Rocha Neto

Abstract

Background:

Cardiovascular diseases are the leading cause of death in Brazil. Biochemical markers have diagnostic and prognostic importance in acute coronary syndromes (ACSs), with troponin as the preferred biomarker. Studies have already demonstrated a positive relationship between increased levels of high-sensitivity troponin (hsTn) and prognosis. However, few studies have correlated hsTn levels with the complexity of coronary lesions.

Objectives:

To compare hsTn levels with the complexity of coronary lesions according to the SYNTAX score, and to correlate the levels of this biomarker with the TIMI and GRACE scores in patients with ACS.

Methods:

Retrospective, cross-sectional study with 174 patients with ACS. The correlation between variables was assessed by the nonparametric Spearman’s rank correlation, and statistical analysis was performed by the SPSS program, with a significance level of 5%.

Results:

Mean age was 63 years, and most patients were women (52.9%), hypertensive, non-diabetic and non-smokers. Nineteen percent of the patients had STEMI, 43.1% NSTEMI, and 36.8% unstable angina. Most were in Killip 1 (82.8%). Median hsTn was 67 pg/mL. Median risk scores were 3, 121 and 3 in the TIMI, GRACE and SYNTAX scores, respectively. There was a correlation of hsTn with SYNTAX (p <0.001, r = 0.440), TIMI (p < 0.001, r = 0.267) and GRACE (p = 0.001, r = 0.261) scores.

Conclusion:

A positive linear correlation was found of hsTn levels with the complexity of coronary lesions, and with the TIMI and GRACE clinical scores.

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Original Article

Metabolic Syndrome and Insulin Resistance by HOMA-IR in Menopause

Érika Joseth Nogueira da Cruz Fonseca et al. Tânia Pavão Oliveira Rocha Iara Antônia Lustosa Nogueira Jorgileia Braga de Melo … Bianca Lima e Silva Elenice Jardim Lopes Claudiana Batalha Serra Maria Vaneide Gomes Andrade Surama Maria Bandeira de Sousa José Albuquerque de Figueredo Neto

Abstract

Background:

Metabolic syndrome is an important cardiovascular risk factor, and its prevalence increases after menopause. However, it is still uncertain whether menopause is an independent risk factor for metabolic syndrome. One of the pathophysiological basis for metabolic syndrome is insulin resistance, which can be calculated by the Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) method, and the association between insulin resistance and menopause is little known.

Objective:

To evaluate the association between metabolic syndrome and insulin resistance in menopausal women.

Method:

Descriptive study, which evaluated 150 women, aged 40 to 65, treated at a Gynecology Outpatient Clinic of a tertiary public hospital, from May to December of 2013. The sample was divided into two groups: Group I, comprising women in the premenopausal period and Group II, comprising women in the post-menopausal period. The presence of metabolic syndrome and its components were evaluated, as well as occurrence of insulin resistance in both groups. The association of menopausal status and the assessed variables was assessed using the Mann-Whitney, Chi-square and Fisher’s exact tests. The significance level was set at 5%. The statistical analysis was performed using STATA 12.0.

Results:

Metabolic syndrome and its components were more prevalent in postmenopausal women. Postmenopausal women also had a higher prevalence of insulin resistance, but no statistical association was observed between the findings.

Conclusion:

The menopausal status was not significantly associated with metabolic syndrome and insulin resistance. Insulin resistance was considered an independent risk factor for the development of metabolic syndrome only in the postmenopausal group.

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Review Article

Clinical Usefulness of Cystatin C to Assess the Prognosis of Acute Coronary Syndromes: A Systematic Review and Meta-Analysis

Karine Farnese Costa Martucheli et al. Caroline Pereira Domingueti

Abstract

Cystatin C is used as a marker of renal function and has been shown to be promising for evaluating the prognosis of acute coronary syndromes (ACSs). To evaluate the prognostic value of cystatin C in patients with ACSs. The articles were searched using PubMed, Web of Science and Scielo databases. Observational cohort studies that evaluated the association between increased cystatin C and the development of cardiovascular events and mortality in patients with ACSs were included. Only studies that evaluated similar outcomes, studies that compared the highest with the lowest quartiles of cystatin C, and studies that performed multivariate analysis that included glomerular filtration rate or serum creatinine, were included in the meta-analysis. Methodological quality of the articles was assessed using the Newcastle-Ottawa Scale questionnaire for cohort studies. After applying the eligibility criteria, 17 studies were included in the systematic review. All included studies reported a significant association between higher levels of cystatin C and outcomes. The meta-analysis demonstrated that elevated levels of cystatin C are associated with increased risk of cardiovascular mortality or non-fatal myocardial infarction in patients with ACSs, and such association is independent of renal function [OR = 1.65 (1.464 – 1.861), p < 0.001]. Among the studies included, 4 have good quality and 13 have excellent methodological quality.The systematic review and meta-analysis demonstrated that there is a significant association between increased cystatin C levels and the development of cardiovascular events and mortality in patients with ACSs.

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Original Article

Heart Failure: Correlation between Anthropometric Parameters, Body Composition and Cell Integrity

Tathiana Carestiato Faria et al. Denise Tavares Giannini Patrícia Vasconcelos Fontana Gasparini Ricardo Mourilhe Rocha

Abstract

Background:

Knowledge about phase angle and its use as a prognostic determinant in patients with heart failure is still scarce.

Objective:

To evaluate the correlation between anthropometric indicators, cardiac function and cell integrity in patients with heart failure with reduced ejection fraction.

Methods:

This was a cross-sectional study that evaluated patients with heart failure with reduced ejection fraction by anthropometry and bioelectrical impedance analysis. Chi-square test and Student’s t test were used to analyze differences, and Pearson’s linear correlation was used to evaluate associations, using p < 0.05 to indicate statistical significance.

Results:

We evaluated 41 subjects aged 30-74 years, of which 34 were men (82.9%). Mean phase angle was higher among women (7.1%), but significant differences between men and women were found only for body fat percentage. Phase angle correlated with body mass index (r = 0.44, p = 0.004) and there was a trend of correlation of the phase angle with waist-to-height ratio (r = 0.29, p = 0.06) and the left ventricular ejection fraction (r = 0.29, p = 0.07).

Conclusions:

Phase angle showed a good correlation with body mass index and showed a trend of correlation with the left ventricular ejection fraction, supporting the obesity paradox and the prognostic importance of this marker. Further studies on the applicability of the phase angle in the prognosis of these patients are still needed.

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Editorial

The Heart of Physically Active Young Individuals can be Remodeled with an Intense 35-Week Military Training

Claudio Gil Soares de Araújo

Physicians are educated and trained to treat diseases and save lives. This is particularly noticeable and valued among cardiologists. However, not every physician, living a busy professional life, manages to see the other “extreme”. We quite often fall ill because we do not properly take care of our health, by failing to adopt a healthy lifestyle and to embrace the most recommended preventive strategies. It seems increasingly important to anticipate the disease and act to prevent it. In such context, the regular practice of physical exercise becomes a significant, if not the major priority. However, there is this natural clinical concern about “excessive” exercise practice, which would jeopardize the health and the physical integrity of the individuals. The study by our Portuguese and Swedish coleagues published in this issue of the International Journal of Cardiovascular Sciences is worth reading.

Dinis et al. have studied 76 young Portuguese individuals who had already achieved high levels of regular physical activity (> 10 hours/weeks) before entering a special military training program. That special training program consisted of 20 hours of different types of exercise practice at a purposely high intensity, divided into five days a week for 35 weeks. Because of the extremely rigorous characteristic of that special program, only 17 of those young individuals, all with previous experience on sports competition, managed to complete the 35-week training.

[…]

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Original Article

Low to Moderate Alcohol Consumption and Myocardial Ischemia on Exercise Stress Echocardiography

Vítor Joaquim Barreto Fontes et al. Maria Júlia Silveira Souto Antônio Carlos Sobral Sousa Enaldo Vieira de Melo … Flávio Mateus do Sacramento Conceição Caio José Coutinho Leal Telino Mirella Sobral Silveira Jéssica Aparecida de Santana Dória Carlos José Oliveira de Matos Joselina Luzia Menezes Oliveira

Abstract

Background:

The impact of alcohol consumption on the development of myocardial ischemia remains uncertain. Studies diverge whether low to moderate alcohol consumption provides cardioprotection or whether it is a risk factor for myocardial ischemia.

Objective:

To study the relationship between low to moderate alcohol consumption and myocardial ischemia on exercise stress echocardiography (ESE).

Methods:

Cross-sectional study with 6,632 patients with known or suspected coronary artery disease undergoing ESE between January/2000 and December/2015. The patients were divided into two groups: G1, composed of 2,130 (32.1%) patients whose report showed maximal consumption of 1 drink per day on average for women or of 2 drinks per day for men; G2, composed of individuals denying any alcohol consumption. For comparing between the groups, Student t test was used for quantitative variables, and chi-square test or Fisher exact test, for categorical variables. The significance level adopted was p < 0.05. Logistic regression was also used to evaluate independent risk factors for myocardial ischemia.

Results:

G1 had a higher number of men (77.1%; p < 0.001), lower mean age (54.8 ± 10.3 years old; p < 0.001) and higher frequency of myocardial ischemia on ESE (p = 0.014). Age, male sex, dyslipidemia, systemic arterial hypertension, diabetes mellitus, smoking and family history were independently associated with myocardial ischemia on ESE. Independent association between low to moderate alcohol consumption and myocardial ischemia on ESE (OR 0.96; 95%CI: 0.83 to 1.11) was not observed. However, age, male sex, smoking and dyslipidemia were associated with alcohol consumption.

Conclusion:

Low to moderate alcohol consumption was not an independent predictor of myocardial ischemia on ESE. Nevertheless, we observed a predominance of the male sex, dyslipidemia and smoking habit, important predictors of myocardial ischemia, in the group of alcohol consumers.

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Original Article

Use of GATED-SPECT for Ventricular Desynchronization Evaluation in Patients with Heart Failure Submitted to Cardiac Resynchronization Therapy

Christiane Cigagna Wiefels et al. Erivelton Alessandro do Nascimento Christiane Rodrigues Alves Fernanda Baptista Ribeiro … Fernando de Amorim Fernandes Mario Luiz Ribeiro Claudio Tinoco Mesquita

Abstract

Background:

Approximately 20 to 40% of patients with heart failure do not respond to cardiac resynchronization therapy (CRT). To improve patient selection, phase analysis by myocardial perfusion scintigraphy (GSPECT) was developed.

Objectives:

To evaluate the clinical and scintigraphic response of patients with heart failure (HF) submitted to CRT using GSPECT.

Method:

This was an interventional study that included consecutive patients assessed by GSPECT four weeks prior to CRT implantation and six months after it for comparison. These patients also answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The categorical variables were compared using Fisher’s exact test and chi-square test, whereas Student’s t-test was used for numerical variables. The level of statistical significance was set at 5%. The scintigraphic variables analyzed were left ventricular ejection fraction, end-systolic volume, end-diastolic volume, left ventricular mass, standard deviation and bandwidth, as well as QRS duration and the Minnesota Quality of Life Questionnaire score. The presence of mechanical dyssynchrony was defined as standard deviation > 43º.

Results:

Nine patients were included in the study. After the cardiac resynchronization therapy, there was a significant improvement (p < 0.05) in the end-systolic volume (206 ± 80 mL vs. 158 ± 108 mL), QRS (180 ± 18 ms vs. 120 ± 9 ms), left ventricular mass (248 ± 65 g vs. 193 ± 52 g) and Minnesota Quality of Life Questionnaire score (63 ± 16 vs. 34 ± 20). All patients with scintigraphic criteria of mechanical dyssynchrony showed clinical improvement. Two patients had only electrical dyssynchrony and did not achieve significant clinical improvement, although they showed QRS duration reduction.

Conclusion:

GSPECT was able to differentiate patients with isolated electrical dyssynchrony from those with associated mechanical dyssynchrony, through the intraventricular dyssynchrony parameters. The cardiac resynchronization therapy is associated with the improvement of both mechanical and electrical dyssynchrony. Pre-implantation GSPECT showed that patients with associated electrical and mechanical dyssynchrony had a better response to cardiac resynchronization therapy than those with isolated electrical dyssynchrony.

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Review Article

Accuracy of Impedance Cardiography in Acute Myocardial Infarction: A Literature Review

Lucelia dos Santos Silva et al. Fernanda Faria Reis Monyque Evelyn Santos Silva Dalmo Valerio Machado de Lima

Introduction

Hemodynamic monitoring of individuals with acute myocardial infarction, for evaluation of progression and prognosis of the patient’s clinical picture, has been studied for years.

The Swan-Ganz catheter is an invasive hemodynamic monitoring measurement, indicated for clinical situations, such as acute heart failure (e.g. acute myocardial infarction, complicated by progressive hypotension or cardiogenic shock); mechanical complications of acute myocardial infarction; right ventricular infarction; refractory congestive heart failure; pulmonary hypertension.

[…]

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Original Article

Association of Respiratory Mechanics with Oxygenation and Duration of Mechanical Ventilation After Cardiac Surgery

André Luiz Lisboa Cordeiro et al. Livia Freire de Lima Oliveira Thaynã Caribé Queiroz Verena Lourranne Lima de Santana … Thiago Araújo de Melo André Raimundo Guimarães Bruno Prata Martinez

Abstract

Background:

Mechanical ventilation (MV) and extracorporeal circulation (ECC) are associated with a decline in pulmonary mechanics that may affect gas exchange.

Objective:

To evaluate the impact of pulmonary mechanics on MV duration and gas exchange in the postoperative period of cardiac surgery.

Methods:

This was a cohort study in patients undergoing cardiac surgery. All patients underwent evaluation of pulmonary mechanics (static compliance and airway resistance) and arterial blood gas analysis upon admission to the intensive care unit (ICU) and were followed up until extubation and hospital discharge.

Results:

The study included 50 patients (46 women, 52%) with a mean age of 57.5 ± 13.5 years. The MV duration was 7.7 ± 3.0 hours, static compliance was 35.5 ± 9.1 cm H₂O, resistance was 6.0 ± 2.3 cm H₂O, mean length of ICU stay was 2.9 ± 1.1 days, and oxygenation index was 228.0 ± 33.4 mmHg. No significant correlation was found between MV duration and static compliance (p = 0.73), but a strong correlation was found between static compliance and gas exchange (r = 0.8 and p < 0.001).

Conclusion:

Pulmonary mechanics have a strong correlation with gas exchange and a weak correlation with MV duration after cardiac surgery.

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