2020;33(1) – ABC CARDIOL

IJCS

ABC Family | IJCS

Editorial

Challenges for Anticoagulation in Atrial Fibrillation

Ana Inês da Costa Bronchtein

Atrial fibrillation (AF) is the most prevalent arrhythmia in the world. It is considered a current epidemic and one of the main causes of ischemic stroke, usually with severe and debilitating conditions, and is responsible for systemic cardioembolic phenomena, increased number of cases of congestive heart failure (CHF), cognitive impairment related to silent embolic phenomena, and increased overall mortality in affected patients.

Vitamin K antagonists (VKA) represented in the vast majority of studies with warfarin have been widely used for many years; however, they have complex adherence due to several factors, including the need for frequent INR monitoring, regular dose adjustments for maintaining a suitable time in therapeutic range (TTR) (>= 70%) and interactions with a number of drugs and foods, which contributed to its ever decreasing use. Direct-acting anticoagulants (DACs), represented by dabigatran, rivaroxaban, apixaban and, more recently, edoxaban, offer an alternative to VKA, without the disadvantages presented by the latter.

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Editorial

Biological and Mechanical Heart Valves Under a New Spotlight: Paradigm Shift and New State of the Art

Domingo Marcolino Braile et al. Idiberto José Zotarelli Filho

With the growth in life expectancy observed in recent decades in Brazil and worldwide, implantation of cardiac valve prostheses has been one of the recommended procedures for patients with valve diseases. In Brazil, this approach is the second most performed surgery among highly complex cardiovascular procedures. According to DATASUS, between January 2008 and May 2018, 900 implants were performed.

The 2017 European Society of Cardiology / European Association for Cardio-Thoracic Surgery (ESC/EACTS3) guidelines established that the choice between a mechanical (MV) and biological valve (BV) in adults is primarily determined by estimating the risk of bleeding related to anticoagulation, thromboembolism, and the risk of structural deterioration of BV, considering the patient’s lifestyle and preferences. This risk/benefit ratio of MV and BV led the US and European guidelines to recommend the use of prostheses in patients under 60 years of age. Nevertheless, the use of BV has increased significantly in all age groups in recent decades.

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Review Article

Molecular Imaging in the Diagnosis of Infectious Endocarditis – the Role of PET and SPECT

Domenico Albano et al. Francesco Bertagna Raffaele Giubbini

Abstract

18-fluorine-fluorodeoxyglucose positron emission computed tomography (18F-FDG PET/CT) and singlephoton emission computed tomography (SPECT) using radiolabeled white blood cells (WBC) are non-invasive techniques widely used in the diagnosis of infections, like endocarditis. The aim of our paper was to provide a systematic review of the published data on the use of 18F-FDG PET/CT and SPECT in infective endocarditis (IE). A comprehensive literature search of the PubMed/ MEDLINE, Scopus, Embase and Cochrane library databases was conducted to find relevant published articles about the diagnostic performance of SPECT using WBC and 18F-FDG PET/CT in the diagnosis of infectious endocarditis. Twenty papers were included, with a total of 1,154 patients (166 studies with WBC SPECT and 988 with 18F-FDG PET/CT). From the analyses of the studies, the following results were obtained: both SPECT and PET/CT had good diagnostic accuracy in the study of endocarditis. 18F-FDG PET/CT had good specificity (85.8%) and lower sensitivity (68%), with high heterogeneity among the studies; WBC SPECT/ CT had an overall sensitivity of 80% and specificity of 98%. Specific preparations for PET/CT can affect the diagnostic accuracy of the test. Both 18F-FDG PET/CT and WBC SPECT are useful for the diagnosis of IE, and WBC SPECT appears to be slightly more specific than 18F-FDG PET/CT. A specific diet could influence the diagnostic performance of PET/CT.

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Editorial

Obesity: A Risk Marker or an Independent Risk Factor for Coronary Artery Disease?

Tufi Dippe Jr et al. Rodrigo Julio Cerci

We congratulate Pereira et al. for their study investigating the role of obesity as a risk factor for coronary artery disease (CAD) using coronary computed tomography angiography. The study included 1,383 patients, none with a history of CAD.

Obesity is a multifactorial chronic disease, characterized by accumulation of subcutaneous and visceral fat, that predisposes individuals to metabolic disorders. Several mechanisms are involved in the association between obesity and atherosclerosis, including lipid abnormalities, insulin resistance, chronic inflammation, endothelial dysfunction, reduction of fibrinolysis and hypercoagulability. In addition, the production of proinflammatory cytokines, such as IL-6, TNF-alpha, MCP-1 and leptin contributes to chronic subclinical inflammation. More recent data have indicated that impaired autophagy and altered gut microbiome homeostasis are contributing factors for the development of atherosclerosis in obese individuals.

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Editorial

The Ejection Fraction Returns to Hyde Park Session's Speakers' Corner

Wolney de Andrade Martins et al. Antonio José Lagoeiro Jorge

The ejection fraction returns to Hyde Park Session’s Speakers’ Corner

About two decades ago, the Heart Failure Society of America created the Hyde Park Session at its annual meeting. The analogy with the free and innovative proposals that took place in the historic London park were transposed to that scientific event. One of the first proposals made there was the extinction of the left ventricular ejection fraction (LVEF) as if it was an absolutist tyrant determining the life of his/her subjects. The proposition took no breath. The overwhelming majority of heart failure (HF) trials used LVEF as an inclusion criterion. The cutoff points varied. Magical numbers had little pathophysiological or clinical foundation. LVEF was measured by noninvasive methods, especially echocardiography, with high intra-and inter-examiner variability, dependent on preload and afterload changes.

Later, in 2001, a clinical entity was recognized, where acute pulmonary edema of cardiogenic cause occurred despite LVEF at levels above 50%. The following years saw incredulous initial acceptance until the epidemiological and clinical characterization of what we today call “heart failure with preserved ejection fraction (HFpEF).” From rare, it became frequent, especially in primary care. Considered benign, the prognosis became almost as reserved as heart failure with reduced ejection fraction (HFrEF). There were different proposals for diagnosis, prognostic scores, but such evolution in the knowledge of HFpEF resulted in a frustrating succession of negative therapeutic trials.

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Brief Communication

Takotsubo Syndrome in the Context of Transmural Acute Myocardial Infarction: Prevalence and How to Differentiate?

João Paulo Soares Costa et al. Luiz Eduardo Fonteles Ritt Rafael Modesto Fernandes Felipe Alvarenga Duarte Campos … Queila Borges Eduardo Sahade Darzé

Introduction

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction culminating in acute cardiac dysfunction. It is frequently preceded by emotional or physical stress.^,

The most common symptoms at presentation are chest pain and dyspnea. Because the presentation of TTS is similar to that of acute coronary syndrome (ACS), the differential diagnosis is difficult, especially from ST-elevation myocardial infarction (STEMI). Absence of coronary artery disease in the affected area must be confirmed to establish the diagnosis of TTS. To facilitate the diagnosis of TTS, the European Society of Cardiology has recently developed the InterTAK diagnostic score, a promising tool that estimates the probability of a TTS event.^,

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Editorial

Coarctation of the Aorta: Its Importance for Pediatricians and Cardiologists

Gesmar Volga Haddad Herdy

Coarctation of the aorta is a congenital defect that affects 5-8% of live births, with different degrees of severity. It may remain unnoticed throughout childhood or, in contrast, progress to heart failure and cardiogenic shock.^– The most common location for coarctation of the aorta is near the ductal remnant and left subclavian artery.

The main clinical signs of coarctation of the aorta are heart murmur, diminished pulses in lower extremities, arterial hypertension, left ventricular hypertrophy. It is commonly associated with a bicuspid aortic valve. In adults, in addition to hypertension with increased systemic vascular resistance, retinal arteriolar abnormality and lower extremity claudication may also occur.

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Editorial

Pain after Cardiac Surgery

Tirone E. David

Most cardiac operations are performed via median sternotomy and cardiopulmonary bypass. Both thoracic incision and cardiopulmonary bypass cause major disturbances in the homeostasis of the patient. Disruption of the tissues by the incision initiates an immediate neurological reaction perceived as pain and an intense biochemical and cellular response to repair the wound. Cardiopulmonary bypass causes far more serious systemic changes in homeostasis than pain, and that is probably the main reason why cardiac surgery is behind other surgical specialties in the development of minimally invasive procedures. Pain associated with surgical incision is largely self-limited and resolves with time and, luckily, so do the changes caused by cardiopulmonary bypass. Obviously, surgical incisions that cause less tissue damage are associated with lower degrees of pain and metabolic disturbance than larger and more traumatic incisions.

In this issue of the International Journal of Cardiovascular Sciences, Silva and colleagues, from the University of Fortaleza, Brazil, report a comparative study on postoperative pain following conventional median sternotomy and right mini-thoracotomy. The study has limitations because of the sample size (there were only 17 patients in each arm), the endpoint of the study was largely subjective, and patients were not randomized. However, as one would expect, both groups of patients complained of pain in the first three days but fewer patients with mini-thoracotomy complained of pain by the seventh postoperative day. In addition, mini-thoracotomy was associated with pain of lower intensity, fewer sites, and shorter duration than median sternotomy.

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Original Article

Decompensated Heart Failure with Mid-Range Ejection Fraction: Epidemiology and In-Hospital Mortality Risk Factors

Gabriela Paiva Cavalcanti et al. Camila Sarteschi Glory Eithne Sarinho Gomes Carolina de Araújo Medeiros … José Henrique Martins Pimentel André Rabelo Lafayette Maria Celita Almeida Paulo Sérgio Rodrigues Oliveira Silvia Marinho Martins

Abstract

Background:

Recently, a new HF entity, with LVEF between 40-49%, was presented to comprehend and seek better therapy for HF with preserved LVEF (HFpEF) and borderline, in the means that HF with reduced LVEF (HFrEF) already has well-defined therapy in the literature.

Objective:

To compare the clinical-therapeutic profile of patients with HF with mid-range LVEF (HFmrEF) with HFpEF and HFrEF and to verify predictors of hospital mortality.

Method:

Historical cohort of patients admitted with decompensated HF at a supplementary hospital in Recife/PE between April/2007 – August/2017, stratified by LVEF (< 40%/40 – 49/≥ 50%), based on the guideline of the European Society of Cardiology (ESC) 2016. The groups were compared and Logistic Regression was used to identify predictors of independent risk for in-hospital death.

Results:

A sample of 493 patients, most with HFrEF (43%), HFpEF (30%) and HFmrEF (26%). Average age of 73 (± 14) years, 59% men. Hospital mortality 14%, readmission within 30 days 19%. In therapeutics, it presented statistical significance among the 3 groups, spironolactone, in HFrEF patients. Hospital death and readmission within 30 days did not make difference. In the HFmrEF group, factors independently associated with death were: valve disease (OR: 4.17, CI: 1.01-9.13), altered urea at admission (OR: 6.18, CI: 1.78-11.45) and beta-blocker hospitalization (OR: 0.29, CI: 0.08-0.97). In HFrEF, predictors were: prior renal disease (OR: 2.84, CI: 1.19-6.79), beta-blocker at admission (OR: 0.29, CI: 0.12-0.72) and ACEI/ ARB (OR: 0.21, CI: 0.09-0.49). In HFpEF, only valve disease (OR: 4.61, CI: 1.33-15.96) and kidney disease (OR: 5.18, CI: 1.68-11.98) were relevant.

Conclusion:

In general, HFmrEF presented intermediate characteristics between HFrEF and HFpEF. Independent predictors of mortality may support risk stratification and management of this group.

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Original Article

Bioprosthesis versus Mechanical Valve Heart Prosthesis: Assessment of Quality of Life

José Carlos Molero Junior et al. Rodrigo Daminello Raimundo, Joice Anaize Tonon do Amaral Luiz Carlos de Abreu João Roberto Breda

Abstract

Background:

The aim of this study was to evaluate the QoL of patients undergoing heart valve replacement using the SF-36 questionnaire, compare it between patients with mechanical prosthesis and patients with bioprosthesis, and correlate the results with sociodemographic variables.

Objective:

To assess the QoL of patients undergoing heart valve replacement and compare it between patients with bioprosthetic valves and patients with mechanical prosthetic valves.

Methods:

We included 36 consecutive patients (16 men) with a mean age of 51 years and six months, who underwent mitral or aortic valve replacement from September 2007 to December 2011. The study was conducted between March and May 2012 and involved the application of the SF-36 survey and a sociodemographic questionnaire. Statistical tests were performed, and data are expressed as absolute frequency and percentile, and median and interquartile range (P25 and P75) (Mann-Whitney test), considering a significance of 95%.

Results:

The average time of surgery was 32.5 months (8-61 months). Participants were asked about the practice of physical activity, and 41.7% were physically active. For the SF-36 domains, the highest scores were observed for the social domain whereas the lowest scores were found for mental health, with a mean of 89.25 and 54.44, respectively. In the statistical analysis, we found statistically higher values in emotional functional for patients with mechanical valve prosthesis (p = 0.0084).

Conclusion:

The QoL of the patients undergoing heart valve replacement improves considerably after the surgery, except for the mental health domain, probably due to the low practice of physical activity. The type of prosthesis seems not to influence the QoL or the patients in the late postoperative period.

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Original Article

Cardiac Autonomic Modulation of Healthy Individuals and Patients with Chronic Obstructive Pulmonary Disease During Spontaneous and Controlled Breathing

Mario Augusto Paschoal et al. Livea Gianfrancesco Luisa Torres Camargo Náira Bueno Seixas Ana Beatriz Paschoal

Abstract

Background:

Lung diseases and different forms of breathing may interfere with cardiac autonomic modulation (CAM).

Objective:

To compare CAM in individuals with chronic obstructive pulmonary disease (COPD) with healthy individuals during spontaneous breathing (SB) and controlled breathing (CB).

Methods:

Cross-sectional study involving 30 individuals selected by convenience, divided into COPD group (n = 19) and control group (CG; n = 12). All participants were submitted to heart beat recordings during five minutes at rest (SB) and another five minutes during CB performed at six cycles/min. CAM was made by assessment of the heart rate variability (HRV) through time domain (TD) and frequency domain (FD). Comparisons between groups were performed by Mann Whitney test, and significance level was set at p < 0.05.

Results:

During SB, HRV TD and FD indices were higher in the controls than in the COPD group, respectively – RR intervals (53.2 ms versus 36.6 ms), RMSSD (42.1 ms versus 26.6 ms) (p < 0.05), total power (28322.8 ms²/Hz versus 2011.6 ms²/Hz), and high-frequency band (800.5 ms⁽²⁾ versus 330.7 ms²). During CB, the CG also showed higher values for the TD parameters pNN50 (11.7% versus 5.1%), RMSSD (48.3 ms versus 26.7 ms), and SD of RRi (64.9 ms versus 44.7 ms), as well as for the low-frequency component of FD analysis (2848.6 ms² versus 1197.9 ms²).

Conclusion:

COPD patients have different CAM when compared with healthy individuals during spontaneous (SB) and controlled breathing (CB).

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Original Article

Trends and Predictors of Oral Anticoagulation in Patients with Atrial Fibrillation: A Serial Cross-Sectional Study from 2011 to 2016

Maria de Fátima de Araújo Geraldes et al. Eduardo Sahade Darze Paulo Novis Rocha

Abstract

Background:

Despite the efficacy of vitamin K antagonists against stroke in patients with atrial fibrillation (AF), the underuse of this therapy is well documented.

Objectives:

To evaluate trends and predictors of oral anticoagulants utilization in patients with AF.

Methods:

Observational, retrospective, serial cross-sectional study between 2011-2016. Comparisons between groups were performed using the Student t, Mann-Whitney and Chi-square tests. Logistic regression was used to identify independent predictors of anticoagulation. A p value < 0.05 was considered significant.

Results:

A total of 377 patients were analyzed. The mean age was 70 ± 15 years; 52% were male and 75% were anticoagulated (20% with VKA and 55% with DOAC). Over 5 years, the overall frequency of anticoagulation increased by 22.4%. The use of DOACs increased from 29% to 70%, whereas the use of VKA decreased from 36% to 17%. The use of antiplatelet agents alone also fell from 21% to 6%. The predictors of anticoagulation were previous episodes of AF (OR 3.1, p < 0.001), hypertension (OR 3.0, p < 0.001) and HASBLED score (OR 0.5, p < 0.001). The predictors of DOAC use were serum creatinine (OR 0.2, p = 0.002), left atrial size (OR 0.9, p = 0.003) and biological valve prosthesis (OR 0.1, p = 0.007). Of the 208 patients using DOACs, 63 (30%) received inadequate prescriptions: 5 with severe drug interactions and 58 with incorrect dosing.

Conclusions:

Between 2011 and 2016, DOACs were rapidly incorporated into clinical practice, replacing AVKs and antiplatelets, and contributing to greater use of anticoagulation in patients with AF.

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Editorial

Diabetes Mellitus, Insulin Use, and Infective Endocarditis

Rubens Antunes Cruz Filho

The prevalence of diabetes mellitus (DM) is very high in Brazil and worldwide. It is estimated that there are now more than 12 million diabetics in Brazil, not counting those who already have the disease but have not yet been diagnosed. Since the introduction of insulin, the treatment of DM has been constantly changing, according to treatment guidelines proposed by diabetes societies, from the diagnosis to more advanced stages of the disease. More stable insulins, as well as incretin-based therapy for subcutaneous use, have been proposed in the treatment of type 2 DM patients. These therapies have not only contributed to the better treatment of the most prevalent type of diabetes, but also introduced the use of a parenteral medication other than insulin.

Infective endocarditis (IE) is a relatively rare, serious cardiovascular disease with a hospital mortality rate of 17-25%, despite all therapeutic advances. In an observational study by Bezerra et al., published in this issue of the IJCS, the association between the use of insulin and IE is discussed. In this retrospective study involving 211 patients, 17 with DM (nine insulin users), there was a higher proportion of S. aureus infection in diabetics using insulin. However, mortality rate was not higher among diabetics when compared to non-diabetics. There is a lack of studies on IE in DM and regarding the use of insulin and IE, data are even more scarce. So, the study by Bezerra et al., assumes an importance in this area of knowledge, since we are talking about a highly prevalent disease (DM) and a serious comorbidity (IE) with a still high risk of mortality.

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Original Article

Minimally Invasive Cardiac Surgery versus Sternotomy – Pain Investigation

Juliana Fernandes Silva et al. Marcela Paula Cavalcante Roger Benevides Montenegro Romulo Lira … Emanuel Carvalho Mel Josue Viana Castro

Abstract

Background:

Treatment of postoperative (PO) pain is essential after surgery, as it contributes to a faster rehabilitation. Assessment of PO pain after minimally invasive (MI) surgery has not been regularly addressed, especially when compared with median sternotomy (MS).

Objective:

This study aims to evaluate the intensity of thoracic pain in the PO period in patients subjected to MI surgery and MS.

Methods:

This study compared the intensity of thoracic pain in 34 patients subjected to minimally invasive (MI; n = 17) and median sternotomy (MS; n = 17) from June 2015 to June 2016. The intensity and sites of pain in the PO period, assessed using the visual numeric pain scale, and the need for pain medications were analyzed using the Student’s t-test and the z test, with confidence level of 95% (p < 0.05).

Results:

Almost all patients reported pain on the third PO day (MS = 94.1% and MI = 88.2%; p = 0.5410). On the seventh PO day, there were significantly more patients free of pain in the group of patients subjected to the MI procedure (MS = 94.1% and MI = 64.7%; p = 0.0341). also, these patients reported fewer pain sites (3^rd PO day: MS = 3.2 ± 1.5; MI = 1.5 ± 1.2; p = 0.001; 7^th PO day: MS = 3.1 ± 1.4; MI = 0.9 ± 0.9; p = 0.000). Patients undergoing MS reported higher pain intensity and longer lasting pain (3^rd PO: MS = 4.8 ± 2.2; MI = 3.0 ± 1.6; 7^th PO: MS = 5.3 ± 2.0; MI = 1.2 ± 1.3; p = 0.001), with no difference in pain intensity between the third and the seventh PO days (p = 0.4931). In addition, patients subjected to MI procedure had a significant decrease in pain intensity from the third to the seventh PO days (p = 0.001).

Conclusion:

According to these results, we concluded that a MI procedure leads to lower intensity of pain in the PO period (from the third PO day on) when compared to a MS; also, patients undergoing MI patients reported fewer pain sites.

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Original Article

Coarctation of The Aorta: A Case-Series from a Tertiary Care Hospital

Joaquim Barreto et al. Juliana Roda Carlos Wustemberg Germano Ana Paula Damiano Thiago Quinaglia

Abstract

Background:

Coarctation of the aorta is a congenital segmental narrowing of the aortic arch with severe hemodynamic repercussions and increased cardiovascular mortality. Early surgical correction and life-time echocardiographic follow-up must be performed to improve prognosis. However, this goal has been challenged by high rates of underdiagnosis, which delay surgical correction, and by recoarctation in up to one third of operated patients.

Objectives:

The objectives of this study were: (i) to register the frequency of common clinical signs at diagnosis of coarctation of the aorta; (ii) to describe the course of echocardiographic parameters before and during the follow-up of coartectomized subjects; (iii) to analyze the clinical prognosis of patients according to baseline characteristics, occurrence of recoarctation and associated malformations.

Methods:

Case-series of 72 patients coarctectomized between June 1996 and November 2016 in a tertiary care hospital. Clinical, echocardiographic and surgical variables were considered. All patients were submitted to coarctectomy by posterolateral thoracotomy and end-to-end anastomosis. Data were classified as parametric or non-parametric by Kolmogorov-Smirnov test. Parametric data were expressed as mean and standard deviation, and non-parametric data as median and interquartile range. Continuous variables were analyzed using paired t-tests, and categorical variables were compared by chi-square test. For all analysis, a p-value of less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS, version 20.0 (IBM, Chicago, IL, USA).

Results:

The mean follow-up time was 5.8 years (range: 0-20 years). At diagnosis, most patients had heart murmur (88%), non-palpable pulse in the lower limbs (50%), left ventricular hypertrophy (78%), and bicuspid aortic valve (33%), with a mean aortic peak gradient of 55 mmHg. After surgical correction, those without recoarctation were less symptomatic (60 vs 4.5%; p < 0.001), had lower aortic peak gradient (54 ± 3.8 vs 13 ± 0.8; p = 0.01) and left ventricle mass (95 ± 9.2 vs. 63 ± 11; p = 0.01), and the most common complications were late hypertension (39.2%), and recoarctation (27.6%). Recoarcted patients did not show improvement of neither clinical nor echocardiographic variables. Age at repair and bicuspid aortic valve groups had comparable results with controls. Surgical procedure was safe; mean time of hospitalization was 10 days and mean surgery time 2.3 hours.

Conclusions:

Coarctectomy improves cardiac symptoms and left ventricular hypertrophy, with a slight effect on the incidence of hypertension. Recoarctation occurs in one-third of patients and draws attention for the need of lifelong surveillance by echocardiography.

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Original Article

Association between Insulin use and Infective Endocarditis: An Observational Study

Renato Lott Bezerra et al. Thales Figueiredo de Carvalho Ricardo dos Santos Batista Yago Machado da Silva … Bruno Fiuza Campos João Henrique Máximo de Castro Matheus de Carvalho Alves Pedro Ivo Palhares Monteiro Raimundo Matos Bezerra Filho Eduardo Luis Guimarães Machado

Abstract

Background:

The association between Diabetes Mellitus (DM) and Infective Endocarditis (IE) is controversial in the literature, since many controversial results have been published. However, when evaluating specifically the evidence on IE and individuals with DM using insulin, we found only two observational studies that considered this variable, with discordant results regarding the prognosis and prevalence of Staphylococcus sp in insulin users compared to non-users. Despite the lack of evidence, in clinical practice the insulin use could be interpreted as minor criteria “injection drug use”, using the modified Duke criteria for IE diagnosis.

Objectives:

To compare the microbiological and valvar profile, as well as the outcome of non-diabetic and diabetic patients with IE who were insulin users or not.

Methods:

This was an observational, analytical and retrospective study of patients diagnosed with IE between 2003 and 2015 in three tertiary care centers. A total of 211 patients were included, of which 17 were diabetics and 9 were insulin users. Patients were compared using the Shapiro-Wilk normality test and Fisher’s exact test, with a significance level of 5%.

Results:

The mortality from IE in diabetic individuals was higher than that of non-diabetic patients, but with no statistical significance (35.29% vs. 21.1%; p = 0.221), even when the groups were divided into insulin-user diabetic, non-insulin user diabetic and non-diabetic patients (33.3% vs. 37.5% vs. 21.1%, p = 0.229). There was a difference regarding the prevalence of IE caused by S. aureus (57.1% vs. 14.3% vs. 17.4%, p = 0.029) and the involvement of the tricuspid valve (33.3% vs. 0.00% vs. 10.0%, p = 0.034) among insulin users.

Conclusion:

In our sample, insulin use or the presence of DM did not mean higher in-hospital mortality from IE. It is not possible to generalize the microbiological and valvar findings due to the lack of studies evaluating insulin users in IE; however, particularities have been previously reported and may indicate a different behavior of IE in these patients. New studies considering the insulin use variable are required to elucidate the association between DM and IE.

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Case Report

Complete Interruption of Aortic Arch and Non-Immune Hydrops Fetalis: A Case Report with Autopsy

Cesar Cilento Ponce

Introduction

Interrupted aortic arch (IAA) occurs in three births per million, and accounts for approximately 1% of congenital heart diseases (CHDs).^– The first case reported with these anomalies appears to be the one by Seidel in 1818.

IAA is a severe form of CHD characterized by a lack of luminal continuity between the ascending and the descending thoracic aorta. The two most common associated cardiac anomalies are ventricular septal defect (90%) and patent ductus arteriosus (98%). Isolated IAA is very uncommon^, and it is considered incompatible with life.

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Case Report

A Rare Case of Cardiorespiratory Arrest after Metoclopramide Infusion

Cássio Alexandre Oliveira Rodrigues et al. Eduardo Queiroz da Cunha Priscila Ribeiro de Paula Rand Randall Martins

Introduction

Commonly used as an antiemetic and prokinetic agent, especially in critically-ill patients to reverse gastroparesis and increase in gastric emptying, metoclopramide use can result in important adverse reactions, leading the European Medicines Agency to recommend its use at minimum doses and for a short period of time, due to the risk of neurotoxicity.

Although often associated to neurological events, reactions to this drug affecting the cardiovascular system are less frequent when compared to those that affect the central nervous system. There have been reports of total atrioventricular block and sinus arrest, but the occurrence of metoclopramide-induced cardiorespiratory arrest (CRA) is a rare and poorly described event.

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Original Article

Relationship between Obesity and Coronary Artery Disease Defined by Coronary Computed Tomography Angiography

Lara Luiza Silvello Pereira et al. Gisele Marochi de Moraes Adriano Camargo de Castro Carneiro Valéria de Melo Moreira … Juliana Hiromi Silva Matsumoto Bello Carlos Eduardo Elias dos Prazeres Carlos Eduardo Rochitte Tiago Magalhaes

Abstract

Background:

Although associated with traditional cardiovascular risk factors, it is unclear whether obesity alone is associated with coronary artery disease (CAD).

Objective:

To investigate the role of obesity as a risk factor for CAD, defined by coronary computed tomography angiography (CCTA).

Methods:

This study retrospectively included 1,814 patients referred for CCTA in a hospital in São Paulo, from August 2010 to July 2012. CAD was identified by coronary calcium score and presence of coronary stenosis > 50%. Images were analyzed by two specialists, and the coronary findings were compared between obese and non-obese groups. A multivariate analysis model was used to assess obesity as an independent variable for the occurrence of obstructive CAD.

Results:

Among the study population, mean age was 58.5 +/- 11.5 years, 22.8% were obese (BMI = 30 kg/m2) and 66.3% were male. The prevalence of obstructive CAD was 18.4% in both groups. Obese patients had higher median calcium score compared to non-obese subjects (14.7 vs. 1.4, respectively, p = 0.019). In the multivariate analysis, obesity was not an independent factor for obstructive CAD (coefficient = -0.035, p = 0.102).

Conclusion:

Although no differences were observed in the prevalence of obstructive CAD between obese and non-obese individuals, coronary calcium scores were significantly in lower the latter group.

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