2021;34(3) – ABC CARDIOL

IJCS

Família ABC | IJCS

Editorial

AVC – Optimizing Pre-Hospital Care For A Time-Sensitive Disease

André Volschan

The care of patients with acute illnesses, in which the time to start treatment can have an important influence on the prognosis, requires a strategy based on well-defined structure and processes. Acute stroke is a disease whose prognosis is causally related to the length of care, and the possibility of implementing cerebral reperfusion therapies and neuroprotective measures. The recommendations suggest that the time should be optimized in the different phases of care, in the recognition of signs and symptoms, medical evaluation, computed tomography and thrombolysis, for patients who meet the criteria for their performance. The instruction of the population to identify the clinical manifestations of stroke, prioritizing the search for assistance, is an important step in this chain of treatment, which can modify the outcomes of this disease.

As a result, access to treatment is another major challenge. Interventions that effectively demonstrated an impact on outcomes in acute ischemic stroke, need a structure that can be supported, in large part, by telemedicine, significantly increasing patient access. National experiences have shown important results in improving the rate of pharmacological thrombolysis and thrombectomy, when designing a service network strategy with the support of neurologists, neuroradiologists and neurointerventionists.

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Editorial

A Burden of Physical Inactivity in School-Age Students: The Early Beginning of Cardiometabolic Risk

Pedro Paulo da Silva Soares et al. Gabriel Dias Rodrigues

It is well-known that sedentarism has a close association with the risk of cardiovascular and metabolic diseases. The physical inactivity lifestyle contributes to the prevalence of obesity and hypertension in children, highlighting a big health problem since most individuals who were hypertensive and obese in childhood/adolescence become hypertensive and obese adults. On the other hand, physical exercise is a frontline non-pharmacological strategy to control and treat hypertension, as well as to prevent obesity, which should be encouraged among children/adolescents to reduce cardiometabolic risk in adulthood. In this context, the mapping of risk factors associated with hypertension at the early age should be considered a primary step to plan public policies for disease prevention and health promotion, reducing the burden on healthcare resources. Both obesity and high blood pressure have multifactorial causes, among them low levels of physical activity in adults, children, and adolescents. It is of utmost relevance to investigate the prevalence of physical activity levels in scholars, mainly in a country such as Brazil, with enormous disparities among regions.

In the current issue of the International Journal of Cardiovascular Sciences, Azevêdo et al. investigated physical activity levels, as well as the anthropometric and cardiovascular profile in school-age students attending public schools in the state of Sergipe, northeast of Brazil. The study reported high rates of physical inactivity for both boys and girls, and increased blood pressure in overweight school-age students. Regarding anthropometric profiles, intriguing data showed a high prevalence of low body weight in the age group from 16 to 17 years for both sexes. In contrast, a previous study found a high prevalence of overweight/obesity in school-age students in a city of the Brazilian South region, suggesting a discrepancy between the Brazilian South and Northeast regions that must be considered for Brazilian public policies in health promoting at the primary care level. From a practical perspective, physical education classes, as well as the public schools’ pedagogic programs, must work together for health promoting and health education, and physical activity should be encouraged to prevent cardiovascular risk starting from childhood to adult life.

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Original Article

Reference Equation for the Six-Minute Walk Test in Brazilian Patients with Obesity

José Carlos do Vale Quaresma et al. João Regis Ivar Carneiro Norma Ferreira Marschhausen Gustavo Gavina da Cruz … José Fernandes Filho Ronir Raggio Luiz

Abstract

Background:

Obesity has repercussions on functional capacity (FC). The six-minute walk test (6MWT) is a useful tool for assessing submaximal FC, and the distance reached at 6 minutes of walking (D6MW) is a relevant prognostic marker.

Objective:

This paper aims to establish a reference equation for the distance predicted in 6MWT in obese Brazilian subjects.

Methods:

This study included 460 patients (306 women), with a body mass index (BMI) > 30 kg/m², 71% (328) of whom presented a grade III obesity (BMI ≥ 40 Kg/m²) and were evaluated with 6MWT. Heart rate, blood pressure, oxygen saturation and Borg scale perception of effort were recorded before and after the 6MWT. For statistical analysis, Kolmogorov-Smirnov tests, an unpaired T-Test, Pearson’s correlation, and multiple linear regression were used, together with a significance level set at p<0.05.

Results:

Gender, age, and BMI were significantly correlated with D6MW and were identified by multiple linear regression as the best predictors of the D6MW. Together, they explain 48.7% of the D6MW variance for obese Brazilian subjects. Based on these findings, an equation was proposed – D6MW = 930.138 + (27.130 x Genderfemales = 0; males = 1) − (5.550 x BMI kg/m²) − (4.442 x Age years). When the average of the D6MW obtained with the above equation was compared to the average calculated with the equations described in medical literature for healthy and obese individuals, the latter tended to overestimate the D6MW.

Conclusion:

The proposed reference equation exhibited better assessment of FC in obese Brazilian patients, providing proper subsidies for the follow up ofinterventions in this population..

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Viewpoint

Marginalization, Vulnerability and Economic Dynamics in COVID-19

Andres Felipe Valencia Rendon et al. Isabela Mendes Volschan Manoella de Novais Pereira Alessandra de Freitas Pimentel … Wagner Lima Monteiro Gláucia Maria Moraes de Oliveira

Abstract

COVID-19, caused by the coronavirus family SARS-CoV-2 and declared a pandemic in March 2020, continues to spread. Its enormous and unprecedented impact on our society has evidenced the huge social inequity of our modern society, in which the most vulnerable individuals have been pushed into even worse socioeconomic situations, struggling to survive.

As the pandemic continues, we witness the huge suffering of the most marginalized populations around the globe, even in developed, high-income latitudes, such as North America and Europe. That is even worse in low-income regions, such as Brazil, where the public healthcare infrastructure had already been struggling before the pandemic.

Cities with even more evident social inequity have been impacted the most, leaving the most socioeconomically disadvantaged ones, such as slum residents and black people, continuously inflating the statistics of COVID-19 sufferers.

Poverty, marginalization, and inequity have been well-known risk factors for morbidity and mortality from other diseases. However, COVID-19 has deepened our society’s wound. It is up to us to heal it up. If we really care for the others and want to survive as a species, we must fight social inequity.

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Editorial

Prolonged Ventilation after CABG: an Important Issue

Leonardo Secchin Canale

Coronary artery bypass surgery (CABG) is the most commonly performed heart operation in most countries, and its mortality and morbidity results are one of the most studied and scrutinized in the world. As a large operation involving long surgical times, sternotomy and cardiopulmonary bypass, long-term postoperative ventilation is a dreaded possible complication. Failure to wean from the ventilator can result both as a consequence of previous risk factors and as a cause of future morbidity and mortality. Not only it impacts patients’ well-being and recovery times, but also can lead to further complications such as lung infections, sepsis, loss of general muscle function and need for tracheostomy.

Therefore, the current study of Dallazen-Sartori et al. is a timely and useful attempt to better characterize the incidence and risk factors for the development of prolonged ventilation (PV) after CABG. As previous authors did before, the authors focus on preoperative and per-operative factors to try to expose, by multiple logistic regressions, which ones are causally associated to PV in order to construct a practical Risk Score. It is needless to stress the importance of such a study in our Brazilian population, which might behave differently from well-known previous reports from other countries. Unfortunately, we still face a paucity of local and regional studies that would better represent our own results, outcomes and challenges. The situation when we need to base our decisions in external sources of data instead of using the national one happens very often. The current study by Dallazen-Sartori et al, is an attempt to change that.

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Letter to the Editor

The Big Mistake of not Considering Physical Activity an Essential Element of Care During the Covid-19 Pandemic

Francisco José Gondim Pitanga et al. Carmem Cristina Beck Cristiano Penas Seara Pitanga

Dear Editor,

In response to the letter to the editor entitled “Declaring physical activity as ‘essential’ during the Covid-19 pandemic may not be a good measure” that presented contributions to our point of view entitled “Should physical activity be considered essential activity during the Covid-19 pandemic?” we thank you for the suggestions and we present a reply letter with our arguments:

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Original Article

Pre-hospital Care for Suspected Stroke Patients, Cared for by Mobile Emergency Care Units in Northern Minas Gerais

Lorenn Lages Gusmão et al. Israel Junior Borges do Nascimento Gabriel Almeida Silqueira Rocha João Antonio de Queiroz Oliveira … Geisiane Sousa Braga Machado Izabella de Oliveira Antunes Romeu Vale Sant’anna Breno Franco Silveira Fernandes Ubiratam Lopes Correia Antonio Luiz Pinho Ribeiro Milena S. Marcolino

Abstract

Background

Stroke management require rapid identification, assessment, and transport of patients to qualified health care centers. However, there is little description in the literature on the multiple challenges associated with the pre-hospital transport of suspected stroke patients.

Objective

To characterize the pre-hospital care provided to suspected stroke patients by the Brazilian Emergency Medical Service (SAMU in Portuguese), by means of a descriptive case study.

Methods

This is a descriptive study of a series of cases. Data from the SAMU regarding the responses to emergency calls from suspected stroke patients were collected. Independent reviewers confirmed the diagnostic hypothesis and all discordances were assessed using kappa statistics. Clinical data and transport times were described as frequency and proportion or central tendency and dispersion measures. Normality of continuous variable distribution was assessed using the Kolmogorov-Smirnov test. The Mann-Whitney U test was used for comparison of medians, with a 5% significance level.

Results

During the studied period, 556 suspected stroke patients were treated. The kappa index was 0.82 (95% CI 0.737 to 0.919) CI. In 74.7% of the cases, the symptom onset time was not recorded. The median time elapsed between the call for emergency services and the ambulance arrival was 18 minutes, and the median transport time was 38 minutes. A total of 34% of the patients were taken to referral hospitals for stroke.

Conclusion

This study revealed a low level of knowledge regarding the need to determine the exact time of symptom onset of suspected stroke patients. Also, the study showed the low rate of patients taken to referral hospitals. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Original Article

Acute Blood Pressure Response to Different Resistance Programs in Trained Men

Ariani França Conceição et al. Daniell Lima Muniz Clarcson Plácido Conceição dos Santos Ciro Oliveira Queiroz

Abstract

Background

Resistance training is used in different exercise programs, with different objectives and different levels of physical fitness. Training-related variables, such as volume, rest time and intensity, can affect the response of blood pressure (BP), but studies on the effect of these variables on BP are still needed.

Objective

To evaluate the acute response of BP in trained individuals undergoing two different methods of resistance training.

Methods

The sample was divided into three groups: (1) the German volume training (GVT) (n= 15), which consisted of 10 series of 10 repetitions at 50% of 1-repetition maximum (RM) with intervals of 30 seconds; (2) the sarcoplasm stimulating training (SST) (n= 16), performed at 8 RM and 85% of 1-RM and interval of 10 seconds until failure, followed by removal of 20% of weight and repetition of the whole series (total of three sets), and the control group (CG) (n= 15) who underwent BP measurements only. The two-way repeated measures ANOVA was used for analysis of variations, and a p< 0.05 was considered statistically significant.

Results

In the within-group analysis, a significant lowering of systolic blood pressure (SBP) was found at 10 minutes (125.4±10.8 mmHg, p= 0.045) and 20 minutes (124.5±8.5 mmHg, p= 0.044) post-training compared with immediately after training. In the between-group comparison, higher SBP values were observed immediately after training in the SST group (142.1±28.2, p= 0.048) compared with the CG.

Conclusion

High-volume and high-intensity resistance training programs did not cause abnormal changes in blood pressure. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Original Article

Athletes Health during Pandemic Times: Hospitalization Rates and Variables Related to COVID-19 Prevalence among Endurance Athletes

Fabricio Braga da Silva et al. Beatriz Fonseca Fernanda Domecg Marcelo Riccio Facio … Christiane Prado Leandro Toledo Walter Tuche

Abstract

Background

The SARS-COV2 pandemic has deeply affected the availability for training and competing for recreational and professional athletes. However, to date, the disease’s course among the athletic population has not been *studied .

Objectives

To compare the observed and expected rates of hospitalization for COVID-19 and to establish relationships between demographics and sportive characteristics of an athletic sample, and the COVID-19 infection rate.

Material and Methods

This study uses cross-sectional data sampling through an online questionnaire to collect data from recreational and professional athletes. Based on self-reports, athletes were grouped in COVID-19 and Non-COVID-19 cases. To decrease detection bias for each four patients who reported being hospitalized, one additional virtual patient was added to the sample. The observed rate of hospitalization (ORH) was compared with age expected rate of hospitalization (ERH) from the literature data. A multivariate model (MM) was developed to establish independent relationships between the prevalence of COVID-19 cases and the variables mentioned above. The statistical significance level was defined for a p-value<0.05.

Results

Answers from 1,701 individuals were analyzed. The COVID-19 group was comprised of 99 (5.8%) individuals, four of whom reported having been hospitalized. ORH and ERH were respectively of 5.0% and 18.1% (p=0.001). In the MM female gender (OR=2.02, 95% CI 1.28 to 3.19), cycling (OR=2.91, 95% CI 1.58 to 5.39), swimming (OR=2.97, 95% CI 1.14 to 7.74), and triathlon (OR=2.10, 95% CI 1.13 to 3.91) were independently associated with a COVID-19 prevalence.

Conclusion

Self-reported rates of hospitalization for COVID-19 among athletes were much lower than expected. The prevalence of positive cases of COVID-19 was independently higher for cyclists, triathletes, and swimmers than for runners.

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Original Article

Potential Impact of the New American High Blood Pressure Guidelines on Hypertension Prevalence in a Primary Health Care Unit in Rio de Janeiro – the LapARC Study

Marcelle Guimarães de Oliveira et al. Angélica Furriel de Almeida da Silva Taissa Lorena dos Santos Mariana Loureiro Cunha … Bruna Rosenbrock Ferreira Taveira Elizabeth Silaid Muxfeldt

Abstract

Background

The new American Heart Association guidelines for hypertension (HT) proposed a reduction of the diagnostic cut-off point, leading to a substantial increase in the prevalence of HT.

Objectives

To assess the prevalence of HT determined by the traditional criteria, the AHA criteria, and home blood pressure monitoring (HBPM) in a population of young adults attending a primary healthcare unit, and its association with cardiovascular risk.

Methods

A cross-sectional population study on adults aged from 20 to 50 years attending a primary healthcare unit, in Rio de Janeiro, Brazil. Sociodemographic and anthropometric data, cardiovascular risk factors, office blood pressure and HBPM were registered. The diagnosis of HT was defined by traditional criteria (office BP ≥ 140 x 90 mmHg) and by the new (AHA) criteria (office BP ≥ 130 x 80 mmHg). Bivariate analysis was used for comparisons between the two diagnostic criteria, and Kappa coefficient was used to assess the agreement in diagnosis between office BP and HBPM. The level of significance adopted was 5% (p<0.05).

Results

A total of 472 individuals were evaluated (male: 39%; mean age: 38.5 ± 8.7 years). The prevalence of HT was 23.5% and raised to 41.1% with the new AHA criteria. The prevalence of HT using HBPM was 25.5%, but the diagnostic agreement was low (kappa=0.028) with changes in diagnosis in 18% of the cases.

Conclusion

The prevalence of HT almost doubled with the new AHA diagnostic criteria for HT. HBPM seemed to be an important instrument in HT diagnosis in this population. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Review Article

Cardiopulmonary Resuscitation in Prone Position

Leandro Menezes Alves da Costa et al. Rafael Amorim Belo Nunes Thiago Luis Scudeler

Abstract

Mechanical ventilation in prone position is an alternative strategy for patients with acute respiratory discomfort syndrome (ARDS) to improve oxygenation in situations when traditional ventilation modalities have failed. However, due to the significant increase in ARDS cases during the SARS-CoV-2 pandemic and the experimental therapeutic use of potentially arrhythmogenic drugs, cardiopulmonary resuscitation in this unusual position could be needed. Therefore, we will review the available scientific evidence of cardiopulmonary resuscitation in prone position.

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Original Article

Drug Profile and Therapeutic Adherence of African-Brazilians with Apparent Resistant Hypertension

Pedro Henrique Andrade Araújo Salvatore Barletta et al. Júlia Lasserre Moreira Vitor Fernandes de Almeida Mateus Andrade Bomfim Machado … Breno Lima de Almeida Tayla Samanta Silva dos Santos Yana Mendonça Nascimento Thaise Almeida Silva Roque Aras Cristiano Macedo

Abstract

Background

Resistant hypertension (RH) is manifested by the presence of blood pressure values resistant to antihypertensive therapy. RH is highly prevalent among black individuals, increasing cardiovascular risk in this population and requiring effective control of this comorbidity.

Objectives

To investigate the medication profile and therapeutic adherence in black people with apparent RH.

Methods

This is a cross-sectional study, with a convenience sample of individuals with apparent RH. Data were obtained from medical records. Therapeutic adherence was assessed using the Morisky Therapeutic Adherence Scale of 8 items (MMAS-8) and statistical analysis was performed using the SPSS, version 23. Significance was set at p <0.05.

Results

Of the 120 individuals, 90 (75%) were women and 72 (60%) were black. Mean SBP was 153.09 (SD 25.59) mm Hg and mean DBP, 90.82 (SD 16.91) mm Hg, with a statistical difference in relation to the target pressure for SBP. Regarding the medication profile, 79.2% of the individuals used the recommended regimen for RH (ACEI / ARB + Diuretic + CCB), with the fourth most used drug being beta-blockers. The average score in MMAS-8 was 6.62 (SD 1.38) points, with 19.2%, 50.0%, and 30.8% showing low, medium, and high adherence, respectively.

Conclusions

It was evidenced that two-thirds of the individuals did not have high therapeutic adherence and not all used the ideal regimen for the management of RH, nor full doses. Thus, most individuals were probably affected by pseudoresistance, which was initially diagnosed as apparent RH. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Original Article

Physical Activity Level, Anthropometric and Cardiovascular Profile Among Students in Sergipe State Attending Public Schools

Luan Morais Azevêdo et al. Lucas Souza Santos Emerson Pardono Jeeser Alves Almeida Aldemir Smith Menezes

Abstract

Background

Cardiovascular diseases are the leading cause of mortality among adults. Evidence has shown that sedentary behaviors are the main preventable outcome, however, many sedentary children also become sedentary adults. Therefore, identifying potential risk factors as early as possible contributes to therapeutic success.

Objective

To achieve an anthropometric and cardiovascular mapping of school-age students from Sergipe State, Brazil.

Methods

A school-based cross-sectional study with a representative sample from public schools in the state of Sergipe (n= 4700). Anthropometric and blood pressure measurements were performed, and the Global School-based Student Health Survey was used to assess the physical activity level. An independent samples t-test was performed for all comparisons, and significance was established at 5% (p<0.05).

Results

Despite showing mean blood pressure values within reasonable limits (SBP = 114.1±12.4 mm Hg and DBP = 66.3±8.1 mm Hg), school-age students did not comply with global recommendations for health promotion. It was also observed a high rate of low body weight (42.6%), suggesting dietary compromises, which can interfere with the development of this population. In addition, only 7.3% of students met the minimum physical activity criteria proposed for maintaining their health status.

Conclusion

The findings of the present study emphasize the importance of maintaining Physical Education classes as an essential curricular component, since they provide several health benefits and ensure that this population reaches the minimum daily recommendations, preventing diseases in adult life. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Original Article

Risk Score for Prolonged Mechanical Ventilation in Coronary Artery Bypass Grafting

Fernanda Dallazen-Sartori et al. Luciano Cabral Albuquerque João Carlos Vieira da Costa Guaragna Ellen Hettwer Magedanz … João Batista Petracco Rodrigo Bodanese Mario Bernardes Wagner Luiz Carlos Bodanese

Abstract

Background

Prolonged mechanical ventilation (MV) after cardiac surgery imposes a significant burden on the patient in terms of morbidity and financial hospital costs.

Objective

To develop a risk score model to predict prolonged MV in patients undergoing coronary artery bypass grafting (CABG) surgery.

Methods

This was a historical cohort study of 4165 adult patients undergoing CABG between January 1996 and December 2016. MV for periods ≥ 12 hours was considered prolonged. Logistic regression was used to examine the relationship between risk predictors and prolonged MV. The variables were scored according to the odds ratio. To build the risk score, the database was randomly divided into 2 parts: development data set (2/3) with 2746 patients and internal validation data set (1/3) with 1419 patients. The final score was validated in the total database and the model’s accuracy was tested by performance statistics. Significance was established at p < 0.05.

Results

Prolonged MV was observed in 783 (18.8%) patients. Predictors of risk were age ≥ 65 years, urgent/emergency surgery, body mass index ≥ 30 kg/m², chronic kidney disease, chronic obstructive pulmonary disease, and cardiopulmonary bypass time ≥ 120 minutes. The area under the ROC curve was 0.66 (95% CI, 0.64-0.68; p<0.001), the Hosmer-Lemeshow chi-square test was χ²: 3.38 (p=0.642), and Pearson’s correlation was r = 0.99 (p<0.001), indicating the model’s satisfactory ability to predict the occurrence of prolonged MV.

Conclusion

Selected variables allowed the construction of a simplified risk score for daily practice, which may classify the patients as having low, moderate, high, and very high risk. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Case Report

Acute Coronary Syndrome in a Patient With Single-Vessel Coronary Artery: Case Report

Bruno Dala Vedova Gomes Beato et al. Carolina de Souza Galvão Eduardo Belisário Falchetto Eduardo Kei Marquesini Washizu … Fábio Ávila Tofani Juliano Moreira Reis Filho

Introduction

Anomalies of coronary arteries affect 1-2% of the population.^, They are associated with increased risk of sudden death and coronary artery injury during surgical procedures.^, Among the coronary artery anomalies, the single-vessel coronary artery disease subtype has a low incidence – 0.03-0.04% in patients without other heart diseases and 0.024% in patients with other heart diseases. Concomitant presence of acute coronary syndrome in these patients may have an impact on their prognosis and survival.

Here we report a rare and challenging case of an 81-year-old woman with high-risk unstable angina undergoing emergency catheterization which indicated the presence of single-vessel coronary artery disease with lesions in multiple segments.

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Case Report

Reactive Pericarditis post Meningococcal Vaccine: First Case Report in the Literature

Ebrahim Khalid Al-Ebrahim et al. Alaa Algazzar Mohammed Qutub

Introduction

Autoimmune allergic reaction causing myopericarditis following vaccination is extremely rare and, in this regard, much attention has been paid to smallpox vaccine. Halsell et al., reported 18 cases of probable myopericarditis in 230,734 primary vaccines after smallpox vaccination (an incidence of 7.8 per 100,000 over 30 days). No cases of myopericarditis following smallpox vaccination were reported among 95,622 vaccines who were previously vaccinated. A causal relationship was supported by the close temporal clustering (7-19 days; mean, 10.5 days following vaccination) and wide temporal distribution, occurrence in only primary vaccinees, and lack of evidence for alternative etiologies associated with myopericarditis.

The meningococci causing primary meningococcal pericarditis (PMP) are usually of serotype C (88% of cases in one series) or, less commonly, serotypes B or W135. PMP is a purulent pericarditis caused by N. meningitidis, with no evidence of previous meningococcemia or meningitis, with development of cardiac tamponade in many cases. Evaluation of PMP versus viral pericarditis is important since the former usually requires pericardial drainage in addition to antibiotics.

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