2019;32(2) – ABC CARDIOL

IJCS

ABC Family | IJCS

Original Article

Evaluation of Galectin-3 and Myocardial Fibrosis in Patients with Hypertrophic Cardiomyopathy

Murillo de Oliveira Antunes et al. Edmundo Arteaga-Fernández Fabio Fernandes Carla David Soffiatti … Paula de Cássia Buck Ester Cerdeira Sabino Carlos Henrique Valente Moreira Charles Mady

Abstract

Background:

Galectin-3 is the designation given to the protein that binds to ß-galactosides, expressed by activated macrophages and described as a cardiac fibrosis mediator. In hypertrophic cardiomyopathy (HCM), myocardial fibrosis is an independent predictor of adverse outcome; however, the association between Galectin-3 and myocardial fibrosis has not been studied in this cardiopathy.

Objective:

To evaluate the association of Galectin-3 and the presence of myocardial fibrosis in a patient with hypertrophic cardiomyopathy.

Methods:

Galectin-3 was measured in automated equipment using the Elisa technique in 100 participants divided into two groups: 50 patients with hypertrophic cardiomyopathy and 50 healthy control subjects. All patients with hypertrophic cardiomyopathy underwent magnetic nuclear resonance with the late enhancement technique to investigate myocardial fibrosis. For the statistical analysis, p values < 0.05 were considered statistically significant.

Results:

Galectin-3 levels were low and did not show significant differences between patients with hypertrophic cardiomyopathy and the control group, 10.3 ± 3.1 ng/dL and 11.3 ± 2.6 ng/dL (p = 0.12) respectively. Myocardial fibrosis was a common finding and was identified in 84% (42/50) of patients with HCM, but no differences were observed between Galectin-3 levels when comparing patients with and without fibrosis, 10.3 ± 2.4 ng/dL and 10.1 ± 2.1 ng/dL (p = 0.59).

Conclusion:

The results did not show an association between Galectin-3 and myocardial fibrosis in patients with hypertrophic cardiomyopathy, suggesting that non-inflammatory mechanisms of myocardial fibrosis formation and cardiac remodeling are involved in this cardiopathy.

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Review Article

Risk Factor Differences in Acute Myocardial Infarction between Young and Older People: A Systematic Review and Meta-Analysis

Liu Lei et al. Zeng Bin

Abstract

Acute myocardial infarction (AMI) is less frequent in young individuals (≤ 45 years) than in older ones (> 45 years). Young AMI patients differ from older AMI patients in different ways. This article aims to assess the differences between young and older AMI patients. A search was made in the database of Cochrane Library, PubMed, BioMed Central and Embase, sence their establishment to December 2016, using the key words: risk factors, clinical characteristics, acute myocardial infarction and young. Meta-analysis was performed by using the Review Manager 5.3 software, pooled odds ratios and 95% confidence intervals were used to assess the strength of differences. Eight studies with fairly quality, enrolling 13,358 patients in the analysis. Compared with older AMI patients, young AMI patients had a higher rate of smoking and obesity (OR = 2.71,95%CI:1.87 to 3.92; OR = 1.76,95%CI:1.13 to 2.74), higher rate of family history of coronary artery disease and alcohol consumption (OR = 2.36,95%CI:1.22 to 4.59; OR = 1.76,95%CI:1.04 to 2.97). Moreover, Young AMI patients had a lower rate of hypertension and diabetes mellitus (OR = 0.52,95%CI:0.37 to 0.73; OR = 0.58,95%CI:0.50 to 0.67). No significant differences were observed in hyperlipidemia, a subgroup data-analysis showed a higher total cholesterol, triglyceride lipase, and low-density lipoprotein levels (p < 0.05), and lower levels of high-density lipoprotein (p < 0.01) in young AMI patients. Smoking, family history of coronary artery disease, obesity and alcohol consumption are the most main risk factors of AMI among young individuals, and young AMI patients have better prognosis than older ones.

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Original Article

Telecardiology on the Diagnostic Support of Chest Pain in Twenty-Two Emergency Care Units (UPA 24h) in The State of Rio de Janeiro

Simone Farah et al. Bruno Rustum Andréa Rogério Casemiro da Silva Alexandra Monteiro

Abstract

Background:

Telecardiology may be a useful support in diagnosis and management of chest pain.

Objective:

Evaluate the application of telecardiology to support the differential diagnosis of chest pain in patients admitted to Emergency Care Units.

Method:

Observational, retrospective and documental study of 5,816 patients admitted with supposedly cardiological chest pain in twenty two Emergency Care Units in the state of Rio de Janeiro. Data were tabulated and analyzed by Excel^® software, using simple descriptive statistics, from the database of the Cardiology Consultancy Nucleus.

Results:

Diagnostic disagreement was found in 1,593 (27.39%) cases. Of these, 1,477 (92.72%) were diagnosed locally as non-ST-elevation myocardial infarction (non-STEMI), 74 (4.64%) as acute myocardial infarction with ST-segment elevation (STEMI), 40 (2.52%) as acute pulmonary edema (APE) and 2 (0.12%) as tachyarrhythmia. Intensive care referral was requested to 100% of these patients. After telecardiology, the diagnoses were: 385 (24.17%) unstable angina, 289 (18.14%) congestive heart failure, 212 (13.31%) APE, 174 (10.92%) STEMI, 152 (9.54%) hypertensive emergency, 113 (7.09%) acute chronic renal failure, 89 (5.59%) non-STEMI, 89 (5.59%) pneumonia, 39 (2.45%) sepsis, 26 (1.63 %) myopericarditis, 20 (1.26%) tachyarrhythmia and 5 (0.31%) orovalvar disease. The outcome after telecardiology was 1,178 discharges (73.94%), 338 (21.21%) referrals, 62 (3.90%) deaths and 15 (0.95%) unknown.

Conclusion:

Telecardiology was effective in chest pain diagnosis and management, optimizing hospital admission in the public health system.

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Case Report

Percutaneous Coronary Arteriovenous Fistula Occlusion in Infants with Left Ventricular Dysfunction

Maria Fernanda F. B. Jacob et al. Darcio Gitti de Faria Jose Luiz Balthazar Jacob

Introduction

Congenital coronary fistulas are rare anomalies in which there is connection from the coronary arteries to large vessels or cardiac chambers, without the need for anomalies of number, origin or course of coronary arteries. They usually present in an isolated way, and can have severe hemodynamic consequences. Diagnosed in one of every 50,000 live births, it has an incidence of approximately 0.4% among congenital heart diseases.^–

Most of them involve the right coronary artery (50%), followed by the left coronary artery (30%) and both left and coronary arteries (5%). They most commonly drain into a right sided cardiac chamber (more than 90%).^, The clinical presentation depends upon the size and location of the fistula, and may vary from just auscultation of heart murmurs, in general continuous, to severe heart failure.^,

[…]

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Editorial

Simplicity and Complexity of the Six-Minute Walk Test

José Antônio Caldas Teixeira

The cardiopulmonary exercise testing (CPET) is known to be the gold standard method for the assessment of functional capacity. However, the method is expensive, often not well tolerated by the patients, and may not be a good strategy to evaluate activities of daily living (ADL). Functional tests are indirect method to assess functional status or functional capacity of an individual to perform ADL and meet their metabolic demands. These tests are considered objective measures that can monitor the clinical course of several diseases as well as responses to interventional therapies.

Walking and running tests were originally developed to evaluate and estimate aerobic physical fitness of healthy individuals and correlate it with maximal aerobic power (peak VO₂). Balke, in the sixties, followed by Cooper and his 12-minute test, used to evaluate physical performance in healthy subjects, motivated, according to them, by the need of field tests for screening of large populations. These methods showed good correlation with laboratory measurements of aerobic capacity (peak VO₂ and anaerobic threshold).

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Editorial

Carnival and Energy Drinks: a Dangerous Combination to the Heart

Claudio Tinoco Mesquita

Every year, millions of people of different ages and origins go to the streets in many countries around the world to celebrate carnival (). In Brazil, the most popular carnival celebrations and parades take place in the city of Rio de Janeiro and in the Brazilian states of Bahia and Pernambuco. Rio de Janeiro’s carnival alone drew more than 5 million people in the last years. One of the most common activities during carnival is taking part in the Samba Parade, a beautiful festival where people dance on the streets.

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Case Report

Variant Type of Stress Cardiomyopathy: Inverted Takotsubo Syndrome

Roberto Ramos Barbosa et al. Mayara da Silva Marcelo Vaz de Mello Demian Luiz Fernando Machado Barbosa

Introduction

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is a rare condition characterized by transient systolic and diastolic LV dysfunction, with akinesia of the apex and compensatory basal hyperkinesia, giving the heart the aspect of “apical ballooning”, described for the first time in 1990 in Japan. Its clinical presentation mainly includes chest pain, which often has typical angina characteristics, and dyspnea, being an important differential diagnosis from a classic acute coronary syndrome (ACS).

TTS is observed predominantly among postmenopausal women, and the emotional stress is considered a precipitating factor in most studies. Its etiology is still controversial, and the excess of circulating catecholamine is the most acceptable mechanism.^–

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Viewpoint

Effect of Açaí (Euterpe Oleracea) Intake on Vascular Function and Lipid Profile: What is the Recommendation?

Heitor Oliveira Santos

Introduction

The açaí palm tree (Euterpe oleracea Mart.) is mostly native to Brazil, and its fruit, açaí berry, is very popular among physically active individuals. The açaí berry pulp, very pleasing to the taste buds, has gained adepts in Brazil, Europe and USA in recent years, being even considered a “superfruit”.

The açaí berry pulp is rich in anthocyanins, which is reflected on its deep purple color, in addition to other bioactive substances, such as phenolic compounds and flavonoids. Because of its content of such substances, the açaí fruit has been claimed to have a significant pharmacodynamic effect, mainly on the cardiovascular physiology, affecting dyslipidemia and arterial hypertension.

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Review Article

Cardiac Magnetic Resonance and amyloidosis: Review

Vaneza Ferreira Ribeiro et al. Diogo Costa Leandro de Oliveira Daniel Gama das Neves Nágela Simão Vinhosa Nunes … Humberto Villacorta Junior Marcelo Souto Nacif

Abstract

Amyloidosis is a disease caused by extracellular deposition of insoluble protein fibrils, that results in changes in tissue architecture and consequently modification of the organ structure. Cardiac involvement is common in amyloidosis. Two major types of systemic amyloidosis affect the myocardium – immunoglobulin light chain and transthyretin amyloidosis – each leading to different prognosis. Early detection and diagnosis of cardiac amyloidosis are the main objectives in the assessment of the disease. New techniques of magnetic resonance imaging have minimized the need for biopsies for the diagnosis. Late gadolinium enhancement technique, and more recently T1 mapping, have allowed a simplified evaluation of amyloid deposits and extracellular volume. The aim of this review was to describe basic concepts and updates of the use of magnetic resonance imaging for the diagnosis amyloidosis and evaluation of its severity.

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Editorial

Biomarkers and Mortality in ST-Segment Elevation Myocardial Infarction

Pedro Pimenta de Mello Spineti

Biomarkers have been increasingly used in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) for diagnosis, stratification, and short-and long-term prognosis. However, they play a less decisive role in ST-segment elevation myocardial infarction (STEMI) where ST-segment elevation in ECG remains the most important tool for diagnosis and treatment decision.

Troponin has been the most widely used biomarker to evaluate the prognosis in STEMI, but other biomarkers may also be used to assess the potential causes and complications of myocardial infarction (MI). High sensitivity C-reactive protein (hs-CRP) is substantially increased in STEMI as a result of the inflammatory response to myocyte necrosis, and is associated with the subsequent risk for death or heart failure.^– Natriuretic peptides reflect the hemodynamic impact of MI and are associated with its prognosis. Although both natriuretic peptides and CRP enhance risk assessment, no clear guidance is available on how to direct specific therapeutic maneuvers in the setting of STEMI based on these biomarkers.

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Original Article

Drug Interactions and Adverse Events in a Cohort of Warfarin Users Attending Public Health Clinics

Christiane de Fátima Colet et al. Tania Alves Amador Isabela Heineck

Abstract

Background:

Warfarin is an oral anticoagulant involved in important interactions with foods and other drugs.

Objectives:

To evaluate the occurrence of adverse events reported by warfarin users and their relationship with drug interactions.

Methods:

This was an open cohort, prospective study conducted in an 18-month period with warfarin users attending public health clinics of the city of Ijuí, Brazil. Data were collected by means of interviews administered at patients’ home every month. Patients’ responses were confirmed by review of medical records when patients sought medical care. Data were analyzed by descriptive statistics. Potential drug interactions were evaluated in a database and vitamin K consumption was quantified using a validated method.

Results:

A total of 68 patients were followed-up; 63 completed the study and 5 died in the study period. Mean number of medications taken by the patients was 9.6 ± 4.5, and mean number of interactions involving warfarin was 2.91 ± 1.52. Most potential interactions increased the risk of bleeding, 61 of them severe interactions and 116 moderate interactions. Eighty-seven episodes of bleeding and 4 episodes of thrombosis were reported by a total of 37 and 4 patients, respectively. At the occurrence of these events, 56.5% of warfarin users were also taking omeprazole, 35.9% were taking simvastatin and 25.0% paracetamol. Most patients had a low vitamin K intake.

Conclusions:

A high frequency of potential interactions between warfarin and other drugs was detected, but a low intake of foods that could possibly affect the effects of warfarin was observed. Based on our results, it seems prudent to follow patients on warfarin therapy for drug-drug interactions, aiming to control adverse effects and to promote a safe and effective therapy.

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Original Article

Acuracy and Concordance of Anthropometric Indicators and Body Composition in Heart Failure

Daniela de Oliveira Rocha et al. Raquel Costa Silva Dantas Fernanda Lambert de Andrade Regina Ranielly dos Santos Avelino … Clélia de Oliveira Lyra Rosiane Viana Zuza Diniz Niethia Regina Dantas de Lira Karine Cavalcanti Mauricio Sena-Evangelista

Abstract

Background:

Anabolic/catabolic disorder in heart failure (HF) favors cardiac cachexia, implying a reduction in HF survival.

Objectives:

To assess the accuracy and concordance of the diagnosis of protein malnutrition and excess fat among the anthropometric and body composition methods in individuals with HF.

Method:

A study of accuracy that included 60 individuals with HF. Body mass index (BMI), arm circumference (AC), triceps skinfold thickness (TST), adductor pollicis muscle thickness (APMT), arm muscle circumference (AMC) and corrected arm muscle area (cAMA). Fat free mass index (FFMI) and body fat percentage (BF%), obtained by electrical bioimpedance (EBI), were used to compare the diagnosis of protein malnutrition and excess fat. Accuracy was assessed by calculating sensitivity, specificity, positive and negative predictive value. The concordance of the EBI diagnosis and other methods was performed by the chi-square test and kappa (k) statistic, where p<0.05 was considered significant.

Results:

Higher frequencies of protein malnutrition were identified by cAMA and AMC, and excess fat by BF%. BMI presented low sensitivity (43%) and accuracy (38.5%), with moderate concordance (0.50). AMC sensitivity was 86%, accuracy 66.4%, and acceptable concordance (0.36) compared to FFMI. Similar percentages of moderate sensitivity and low accuracy were observed for TST and BMI.

Conclusion:

AMC may be useful to identify protein malnutrition and TST has not been adequate to diagnose adiposity. BMI was not sensitive to assess muscle and adipose reserve. EBI was more accurate.

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Original Article

An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital

Guilherme Pinheiro Machado et al. Fernando Pivatto Junior Rodrigo Wainstein Gustavo Neves de Araujo … Christian Kunde Carpes Mateus Correa Lech Felipe Homem Valle Luiz Carlos Corsetti Bergoli Sandro Cadaval Gonçalves Marco Vugman Wainstein

Abstract

Background:

Although new studies and guidelines can be considered useful tools, it does not necessarily mean they are put into clinical practice.

Objective:

The aim of the current analysis was to assess the changes in primary percutaneous coronary intervention (PCI) and mortality in a tertiary university hospital in southern Brazil during a six-year period.

Methods:

We have included consecutive patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI between March 2011 and February 2017. Previous clinical history, characteristics of the procedure, and reperfusion strategies were collected. In-hospital, short and long-term mortalities were also evaluated. The significance level adopted for all tests was 5%.

Results:

There was an increase in the use of radial access in patients from 20.0% in 2011 to 62.7% in 2016 (p_trend < 0.0001). Moreover, thrombus aspiration decreased significantly from 66.7% in 2011 to less than 3.0% in 2016 (p_trend < 0.0001). In-hospital, short and long-term mortalities remained reasonably stable from 2011 to 2016 (p_trend > 0.05). However, a lower in-hospital mortality was observed in patients treated through radial access (p < 0.001). Cardiogenic shock occurred in 11.1%, without statistical differences in the period (p_trend = 0.39), while long-term mortality rate decreased from 80.0% in 2011 to 27.3% in 2016 in this patient group (p_trend = 0.29).

Conclusions:

During a 6-year follow-up period, primary PCI characteristics underwent important modifications. Radial access became widely used, with a decrease in mortality with the use of this route, while aspiration thrombectomy became a rare procedure. The incidence of cardiogenic shock remained stable, but has shown a reduction in its mortality.

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Original Article

Behavior of Pulmonary Function after Hospital Discharge in Patients Submitted to Myocardial Revascularization

André Luiz Lisboa Cordeiro et al. Letícia Gardênia Romualdo da Silva Milena Oliveira Pinto Jaclene da Silva Araújo … André Raimundo Guimarães Jefferson Petto

Abstract

Background:

Coronary artery bypass grafting (CABG) is a type of surgery where there is a compromise in one or more coronary arteries, with the objective of restoring function to the areas that have been compromised in the heart, possibly leading to respiratory compromise and postoperative complications. The return time of the pulmonary function to the preoperative condition is still indeterminate in the literature.

Objective:

To describe the behavior of pulmonary function after hospital discharge in patients submitted to CABG.

Methods:

This is a prospective cohort study. Only patients undergoing MRI, whose lung function was evaluated preoperatively, at hospital discharge and 30 days after surgery, were evaluated. This evaluation consisted of maximum inspiratory pressure (MIP) and expiratory (MEP), vital capacity (VC) and expiratory flow peak (EFP).

Results:

A total of 30 patients were evaluated, of which 18 (60%) were males, mean age 62 ± 9 years. A reduction in lung function from preoperative time to hospital discharge was observed in all variables. There was improvement in MIP (88 ± 9 vs 109 ± 5, p < 0.001), MEP (67 ± 10 for 90 ± 8, p < 0.001) and EFP (310 ± 59 for 390 ± 32, p < 0.001), high for review. At the time of the review, no variables returned to their preoperative value: MIP (116 ± 5 for 109 ± 5, p = 0.43), MEP (111 ± 8 for 90 ± 8, p < 0.001), VC (45 ± 12 for 39 ± 7, p = 0.33) and EFP (430 ± 40 for 390 ± 32, p < 0.001).

Conclusion:

It is concluded that MRI surgery reduces lung function and is not reestablished after 30 days of the procedure. Being the expiratory muscular force and the peak of expiratory flow the most affected.

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Original Article

Determinants of the Distance Covered During a Six-Minute Walk Test in Patients with Chronic Heart Failure

Elizabeth Rodrigues de Morais et al. Salvador Rassi

Abstract

Background:

The evaluation of the functional capacity of patients with chronic heart failure (HF) by means of the distance covered in the six-minute walk test (6MWT) has assumed great importance, since the 6MWD is a predictor of mortality and hospitalization in this population, however the determinants of better distance traveled in patients with HF are little explored, especially in the Brazilian population.

Objective:

To evaluate the determinants of 6MWD in patients with chronic HF.

Methods:

A cross-sectional study was performed with 81 HF patients in outpatient treatment. 6MWD was used as the outcome variable and sociodemographic, clinical, physical-functional and emotional data were submitted to multiple regression analysis using the stepwise method with a significance level of 5%.

Results:

Mean age of participants was 56.71 years; the 6MWD showed a bivariate correlation with age (r = -0.27, p = 0.01), maximal inspiratory pressure (r = 0.42, p < 0.01), maximal expiratory pressure (r = 0.36, p < 0.01), handgrip strength (r = 0.38, p < 0.01), Borg scale (-0.22, p = 0.04), Charlson index (r = -0.25, p = 0.02) and modified Medical Research Council (mMRC) dyspnea scale (r = -0.42, p < 0.01). In the multivariate analysis, the variables gender (p = 0.001), age (0.004), forced vital capacity (FVC) (p = 0.016) and mMRC (p = 0.001) simultaneously explained 37% of variance in the 6MWD.

Conclusion:

Higher levels of dyspnea on daily life activities, female sex, older age and lower forced vital capacity are determinants of a shorter 6MWD in patients with chronic HF.

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Original Article

C-reactive Protein is a Predictor of Mortality in ST-segment Elevation Acute Myocardial Infarction

Sibele Sauzem Milano et al. Orlando Victorino de Moura Júnior Arthur Augusto Souza Bordin Gustavo Lenci Marques

Abstract

Background:

Inflammation is a major component of the response to tissue injury caused by myocardial infarction. High-sensitivity C-reactive protein (hs-CRP) levels might be a simple marker of the severity of this inflammatory response, providing prognostic information.

Objective:

To associate hs-CRP level on admission and other clinical characteristics with in-hospital mortality of patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods:

A retrospective cohort study of patients admitted with STEMI was carried out. Patients were analyzed regarding clinical characteristics, reperfusion therapy, hs-CRP on admission and outcomes. Continuous variables were analyzed by non-parametric Mann-Whitney U test and categorical variables by chi-square test. A p value of < 0.05 was considered statistically significant.

Results:

Of the 118 patients analyzed, 20 died during hospitalization. Higher levels of hs-CRP (p = 0.001) and older ages (p = 0.003) were observed among those patients who died. Logistic regression showed that a one unit increase in hs-CRP increased the risk of death by 15% (p = 0.0017), after adjustment for established risk factors. Similarly, each one-year increase in age increases the risk of death by 6.6% (p = 0.003).

Conclusion:

Our results demonstrate a strong association between hs-CRP obtained on admission and in-hospital mortality after STEMI. It suggests that hs-CRP can be a marker of inflammatory response to myocardial ischemia, providing prognostic information regarding the risk of death.

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