2021;34(5 Supl 1) – ABC CARDIOL

IJCS

Família ABC | IJCS

Editorial

Public Health Programs and Cardiovascular Diseases

Paolo Blanco Villela et al. Larissa Franco de Andrade

For decades, cardiovascular diseases, mainly coronary artery disease and stroke, have been the main cause of death in Brazil. In 2017, they accounted for 27.3% of all deaths in the country, with an age-standardized mortality rate of 178 per 100,000 inhabitants. In the same year, cerebrovascular diseases had an age-standardized mortality rate of 80 per 100,000 inhabitants. With respect to the burden of cardiovascular diseases, the number are even more concerning, with 1,602.4 disability-adjusted life years (DALYs) per 100,000 inhabitants for coronary disease and 1,145.3 DALYs per 100,000 inhabitants for stroke.

Although these numbers represent a decrease when compared with numbers in the year of 1990, the control of cardiovascular risk factors is clearly important. In this regard, in addition to the traditional risk factors, socioeconomical factors are known to play an important role in the development of these diseases. Investigators of the Prospective Urban Rural Epidemiologic (PURE) study evaluated socioeconomic status and educational attainment in adults aged between 35 and 70 years from 367 urban and 302 rural communities in 20 countries (five low-income countries, 11 middle-income and five low-income countries), with a total of 164,169 participants. The authors concluded that people with a lower level of education had higher mortality rates from cardiovascular events in all the countries. However, the authors discuss that these findings may be explained not only by the higher prevalence of risk factors, but also by the lower access to secondary prevention and medical management of chronic diseases such as hypertension and diabetes mellitus compared with people with higher level of education. This is in line with the study by Schultz et al., who demonstrated that even in high-income countries, factors like employment status, educational attainment, income level, and neighborhood socioeconomic factors are related to cardiovascular diseases. Thus, the authors consider the access to health services as part of a high-quality health care of low socioeconomic status populations. Therefore, it is possible to infer that, compared with absolute income, inequality levels are more stronger determinants of cardiovascular outcomes.

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Editorial

TG/HDL-c Ratio as a Predictor of Cardiovascular Risk

Luciana Nicolau Aranha

Cardiovascular diseases (CVD) continue to be an important public health problem and one of the main causes of morbidity and mortality worldwide, generating economic and social impacts., In Brazil, CVD costs have been increasing significantly and are the highest when compared to other causes of hospitalization. Moreover, as the population ages, and with the increase in CVD prevalence, these expenses tend to be even higher. Therefore, early detection and possible changes in cardiovascular risk factors can be important in order to reduce hospitalization and negative outcomes, as well as to improve the population’s quality of life.

In an attempt to identify asymptomatic individuals with a greater predisposition for the disease and define therapeutic goals, many evaluation tools have been developed to estimate risks for CVD, such as Framingham’s Global Risk Score (GRS), adopted by the Department of Atherosclerosis of the Brazilian Society of Cardiology (SBC-DA, in Portuguese) and which evaluates the risk of cardiovascular events over a 10-year period through the variables of age, sex, high-density lipoprotein cholesterol (HDL-c), total cholesterol, systolic blood pressure, smoking, and diabetes.

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Editorial

Cardiotrophin-1 in Patients with Acute Coronary Syndromes: Does it Have a Role?

Humberto Villacorta

Acute coronary syndromes are among the most common diagnoses in the emergency department (ED). It has been estimated that 300,000 to 400,000 cases are seen each year in Brazil. The diagnosis of acute myocardial infarction (AMI) is made on the basis of symptoms, electrocardiogram, and biological markers of myocardial necrosis. Troponins are the most specific cardiac markers, and in the era of highly sensitive assays, they have been shown to make the exclusion of AMI in the ED more rapid, being particularly helpful in patients with atypical presentations.

Cardiotrophin-1 (CT-1) is a member of the interleukin-6 superfamily of proinflammatory cytokines. It is expressed in many tissues, including heart and vessels. CT-1 is upregulated in cardiac fibroblasts and cardiomyocytes in response to mechanical, humoral, metabolic, and hypoxic stress (). It is elevated in the myocardium and plasma of heart failure (HF) patients and has also been associated with hypertension, diabetes, cardiac hypertrophy, and fibrosis, both in patients and experimental studies., CT-1 is expressed after an AMI and seems to be involved in the healing and remodeling process that occurs after myocardial infarction., In the study by Freed et al., CT-1 was able to initiate each of the processes related to scar formation, including fibroblast migration and proliferation, and collagen synthesis.

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Editorial

Clinical Characteristics and Mid-Term Follow-Up of Patients with Severe Aortic Stenosis and Those not Eligible for TAVI

Gilberto Eder de Oliveira Júnior et al. Rogerio Sarmento-Leite

Aortic stenosis is an insidious disease with a long-term period of latency. It progresses rapidly after symptoms appear, esulting in a high mortality rate (approximately 50% in the first 2 years) in untreated symptomatic patients, with sudden death being common in these individuals.

Approximately 30% of the patients aged 75 years or over are not candidates for surgical procedure due to their advanced age, female sex, functional class, operatory emergency, ventricular dysfunction, pulmonary hypertension, previous heart surgery, associated coronary artery disease, among others. In the age range of patients in their 80s, those who remain in clinical treatment have a survival rate of 65.8% in the first year and 41.8% in the second year of follow-up.

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Editorial

Back to The Future: How To Define Prognosis in MINOCA?

Luiz Eduardo Fonteles Ritt et al. Mateus dos Santos Viana

Myocardial Infarction with non-Obstructive Coronary Arteries (MINOCA) is the final diagnosis in 6-10% of all acute coronary syndromes (ACS). It is mostly present in female individuals. MINOCA was defined by the European Society of Cardiology (ESC) in 2017, and the Fourth Universal Definition of Myocardial Infarction (2018) further reinforced this concept. ,

Dreyer et al., analyzing Medicare data in the United States, determined an incidence for MINOCA of 5.9%. Lower rates of one-year MACE (1.7% vs 27.6%), mortality (12.3% vs 16.7%) and re-hospitalization for ACS (1.3% vs 6.1%) were observed in MINOCA compared with ACS with coronary obstruction. Although the prognosis of MINOCA seems to be better than conventional ACS, a better understanding of which conditions are associated with better or worse prognosis within the MINOCA spectrum is needed.

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Editorial

The Importance of Early Diagnosis and Treatment for Pericardial Effusion and Cardiac Tamponade

Carlos Aurélio dos Santos Aragão et al. Vera Maria Cury Salemi

Pericardial effusion has several etiologies, such as primary pericardial diseases, cardiac surgery, trauma and systemic conditions, including hypothyroidism, renal failure, chronic neoplastic infiltration, autoimmune inflammation, systemic lupus erythematosus, and rheumatoid arthritis.’ Queiroz et al., published an interesting paper on 254 patients with pericardial effusion at a quaternary institution, 40.4% with severe pericardial effusion and 44.1% with cardiac tamponade. Retrospective cohorts of critically ill patients are rare in the literature. The most frequent etiology was idiopathic, but postoperative, neoplasia, and postinterventional procedures were also common. Although the main etiology is idiopathic in developed countries, infectious causes are prominent in developing countries, such as tuberculosis, which reaches a frequency above 60%. During the current COVID-19 pandemic, SARS-CoV-2 is of great importance in etiological investigation.

In Queiroz et al., pericardial effusion was diagnosed by echocardiography, a widely available and inexpensive method that can be performed at bedside. In addition to clinical and epidemiological aspects, Doppler echocardiography, magnetic resonance imaging, nuclear medicine tests, and laboratory analysis of the pericardial fluid could provide additional information about the etiology. However, the gold standard diagnostic exam is pericardial biopsy, which is indicated for diagnostic investigation in patients with persistent pericarditis refractory to clinical treatment and no definitive diagnosis.

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Original Article

Pericardial Effusion and Cardiac Tamponade: Etiology and Evolution in the Contemporary Era

Claudio Martins de Queiroz et al. Juliano Cardoso Felix Ramires Barbara Ianni … Viviane Tiemi Hotta Charles Mady Paula de Cassia Buck Ricardo Ribeiro Dias Luciano Nastari Fábio Fernandes

Abstract

Background:

Pericardial effusion is a relatively common finding and can progress to cardiac tamponade; etiological diagnosis is important for guiding treatment decisions. With advances in medicine and improvement in the social context, the most frequent etiological causes have changed.

Objectives:

To evaluate the clinical and laboratory characteristics, etiology, and clinical course of patients with pericardial effusion and cardiac tamponade.

Materials and methods:

Patients with pericardial effusion classified as small ( 20 mm) were included. Data from the clinical history, physical examination, laboratory tests, and complementary tests were evaluated in patients with pericardial effusion and cardiac tamponade. The significance level was set at 5%.

Results:

A total of 254 patients with a mean age of 53.09 ± 17.9 years were evaluated, 51.2% of whom were female. A total of 40.4% had significant pericardial effusion (> 20 mm). Pericardial tamponade occurred in 44.1% of patients. Among pericardial effusion patients without tamponade, the most frequent etiologies were: idiopathic (44.4%) and postsurgical (17.6%), while among those with tamponade, the most frequent etiologies were postsurgical (21.4%) and postprocedural (19.6%). The mean follow-up time was 2.2 years. Mortality was 42% and 23.2 in those with and without tamponade, respectively (p=0.001).

Conclusions:

There is an etiological difference between pericardial effusion patients with and without cardiac tamponade. An idiopathic etiology is more common among those without tamponade, while postinterventional/postsurgical is more common among those with tamponade. The tamponade group had a higher mortality rate.

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Viewpoint

Mentoring in cardiology: A New Teaching Tool in a Rapidly Transforming World

Evandro Tinoco Mesquita et al. Amanda Cunha Soares Ricardo Cardoso de Matos

Abstract

This is an article aimed at showing the mentoring role in a fast-changing society, particularly during and after the COVID-19 pandemic. The intense flow of information feelings and new knowledge makes it necessary for medical education to be updated to keep up with social and professional dynamics, according to health requirements and new knowledge demands. The mentoring program is a development process in which the mentor promotes the mentee professional and personal growth, by the exchange of visions and experiences. It allows an increase in the repertoire of solutions, particularly important in such an unstable context imposed by the pandemic. The mentor and mentee are challenged to move from a traditional to a virtual environment, characterized by physical distancing, development of digital medicine and distance learning.

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Original Article

Optimal Cutoff of the TG/HDL-c ratio for Cardiovascular Risk in Hypertensive and Diabetic Patients Monitored by Primary Health Care in a city in Minas Gerais

Eunice Ferreira da Silva et al. Rosângela Minardi Mitre Cotta Érica Toledo Mendonça Deíse Moura de Oliveira … Silvia Almeida Cardoso Renata Maria Colodette Tiago Ricardo Moreira

Abstract

Background

The analysis of the atherogenic potential of the lipid profile for biomarkers, such as the TG/HDL-c ratio, predicts cardiovascular risk better than isolated lipids.

Objective

To identify the TG/HDL-c cutoff points for multiple risks (hypertension, Diabetes Mellitus, obesity) and to evaluate the association between sociodemographic, clinical, laboratory, anthropometric, and life habit variables and the TG/HDL-c ratio in hypertensive and/or diabetic individuals in the context of Primary Health Care.

Methods

This was a cross-sectional study with 833 hypertensive and/or diabetic patients, conducted between August 2017 and April 2018. The cutoff point of the TG/HDL-c were obtained by the ROC curve. Cardiovascular risk was discriminated by TG/HDL-c, categorized by the cutoff and evaluated in relation to multiple risks. The magnitude of the association between TG/HDL-c and independent variables was estimated by logistic regression. The significance level of p<0.05 was adopted for all tests.

Results

The cutoff values of TG/HDL-c (3.26 for men and 2.72 for women) were more sensitive and less specific than those in the literature. Women (OR=1.90 and 95% CI 1.13-3.20) and men (OR=4.58 and 95% CI 1.78-11.76) with multiple risks, and white men, alcohol users, with a history of stroke, had a higher chance of altered GT/HDL-c. Increases in glycosylated hemoglobin, glycemia, and phosphorus in women, and cholesterol, glycemia, and microalbuminuria in men increased the chances of altered TG/HDL-c. Being a former smoker and black reduced the chance of altered TG/HDL-c in women.

Conclusions

TG/HDL-c proved to be a good indicator for habitual use in Primary Care.

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Original Article

Spirituality, Religiosity and Quality of Life of Hypertensive and Diabetic Patients in a Referral Hospital in Pernambuco

Gabriela de Paula Lopes Brito et al. Maria Eduarda Farias Barbosa Vera Azevedo Bérgamo Barrêto Bruna Almeida Andrade Velloso … Rafaela Siqueira Duarte Ribeiro Sophia Barreto Tenório Luna Leopoldo Nelson Fernandes Barbosa Arturo de Pádua Walfrido Jordán

Abstract

Background

Religiosity is a system of worship and doctrine that is shared by a group, and spirituality is the individual search for the meaning of life. The relationship between spirituality/religiosity (S/R) and health has a long history, and a positive correlation between spirituality and chronic diseases has been described in scientific literature, showing a decrease in morbidity and mortality in general.

Objective

To evaluate the association between S/R and the quality of life of patients with diabetes and/or systemic arterial hypertension.

Method

An observational, analytical, cross-sectional, quantitative study was conducted with a sample consisting of 40 patients treated at the hypertension and diabetes outpatient clinic of a medical center in Recife. The collection used three assessment instruments (SSRS, Duke-DUREL scale, and WHOQOL-BREF). Data from the questionnaires were analyzed using descriptive (frequency and percentage) and inferential statistics (chi-square test and F test) using the R software, version 3.4.3. The level of significance in all analyses was 5%. The study was approved by CEP/IMIP, according to report no. 2.890.126.

Result

All four domains of the quality-of-life scale (WHOQOL-BREF) showed a positive relationship when correlated with the religiosity scale (DUREL), with statistical significance in the relationship between organizational religiosity and the environmental domain. When correlated with the spirituality scale (SSRS), WHOQOL-BREF also showed a positive relationship, except in the physical domain.

Conclusion

A positive relationship between quality of life and S/R was shown, thus confirming its importance for patients with diabetes and SAH.

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Original Article

Congenital Heart Disesase: A Retrospective Analysis from a Tertiary Referral Centre in Portugal

Diogo Faim et al. Joaquim Tiago Rui Castelo Andreia Francisco … Rosa Alves António Pires

Abstract

Background:

Congenital heart disease is the leading cause of mortality among all congenital malformations.

Objectives:

To evaluate the incidence of congenital heart diseases in a central maternity hospital in Portugal from January 2003 to December 2018 and to determine survival in the first year of life.

Methods:

Retrospective analysis of newborns diagnosed with congenital heart diseases within 72 hours after birth. Malformations were divided according to pathophysiology. Cumulative survival analysis was performed by the Kaplan-Meier test. Stastical significance was set at p <0.05.

Results:

A total of 297 newborns with cardiac malformation was recorded among 47,198 live births (incidence of 6:1000), 16% associated with extra-cardiac disease. The most frequent congenital heart diseases were left-to-right shunt lesions (n = 216), followed by cyanotic (n = 41), acyanotic obstructive (n = 31) and miscellaneous (n = 9). Seventy (24%) patients had prenatal diagnosis, 88% of them cyanotic defects, and a positive association was found between prenatal diagnosis and mortality (p <0.001). Coarctation of the aorta was associated with gestational diabetes (p = 0.014). Atrial septal defect was more common in females (p = 0.02). Mortality rate due to heart disease was 3.4%. Patients with cyanotic disease, 99%, 97%, 97%, respectively, for patients with left-to-right shunt lesions, and 97%, 97%,97% for those with obstructive lesion cases.

Conclusion:

The incidence of congenital heart disease was 6:1000, mostly left-to-right shunt lesions. Heart disease accounted for only half of deaths, and cyanotic diseases have a high nonspecific mortality rate.

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Original Article

Clinical Characteristics and Mid-Term follow-up of Elderly Patients with Severe Aortic Stenosis not Eligible for TAVI

Mariana Oliveira Rezende et al. Natasha Soares Simões dos Santos Alexandre Aguiar Andrade Mônica Serrano Francischini … Decarthon Vitor Dantas Targino Caio Simoes Souza Carolina de Paulo Maldi Dimytri Alexandre Alvim de Siqueira David Costa de Souza Le Bihan Ibraim Pinto Auristela Isabel de Oliveira Ramos

Abstract

Background:

The treatment for symptomatic severe aortic stenosis (AS) is the correction of valve stenosis by surgical valve replacement and more recently by transcatheter aortic valve implant (TAVI). However, in some high risk surgical patients, TAVI is not possible for technical or clinical reasons or due to the unavailability of the endoprosthesis.

Objective:

The aim of this study was to evaluate a mid-term follow-up of symptomatic severe AS patients who are not eligible for TAVI trials, as well as to identify the clinical features of these patients.

Methods:

This was an observational, retrospective study conducted with 475 symptomatic severe AS patients, evaluated by the Heart Team between 2000 and 2017. Inclusion criterias were: patients considered not to be eligible for TAVI. The Shapiro-Wilk test was applied to evaluate normality. Non-paired t and Mann-Whitney tests were applied for continuous variables, while the chi-squared and Fischer exact tests were applied for categorical variables, with a level of significance of p<0,05.

Results:

The heart team evaluated 475 patients: 25 (5.26%) died before any intervention could be proposed; 326 (68.3%) were submitted to TAVI, so the study population consisted of 124 patients not eligible for TAVI. Of these, 31 (25%) underwent surgery and 93 (75%) remained in clinical treatment. In a mean 56 months- follow-up the mortality in clinical group was 46.2%. In the surgical group the mortality was 23.9% (in-hospital 12.9% and late mortality 11% in a mean 47.4 months follow-up). The patients that died presented a significantly lower left ventricle ejection fraction (LVEF), a smaller valve area, and a larger end-systolic diameter of the LV.

Conclusion:

The mortality of the clinical group’s patients was significantly higher than the surgical mortality (46.2% vs. 12.9%; p=0.021). The patients of the clinical group were older, weighed less, and had a higher incidence of renal failure and a higher STS score.

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Original Article

Influence of Factors Affecting Quality of Life on in-Hospital Cardiovascular Events of Patients with Acute Myocardial Infarction with and without ST-segment Elevation

Monique Tavares de Jesus et al. Ingrid Maria Novais Barros de Carvalho Costa Danielle Góes da Silva José Rodrigo Santos Silva … José Augusto Soares Barreto-Filho Marcos Antonio Almeida-Santos Joselina Luzia Meneses Oliveira Mirella Dornelas Batalha Moreira Buarque Fabrício Anjos de Andrade Antônio Carlos Sobral Sousa

Abstract

Background

Acute myocardial infarction (AMI), with and without ST-segment elevation (STEMI and NSTEMI, respectively), is the principal cause of cardiovascular morbidity and mortality in Brazil and around the world. Modifiable risk factors (RF) and quality of life (QOL) may correlate with the type of AMI.

Objective

To evaluate the influence of QOL and RF on the type of AMI and in-hospital cardiovascular events in STEMI and NSTEMI patients.

Methods

This was an observational, cross-sectional study. Patients with AMI attending four referral hospitals (three private and one public) for cardiovascular disease treatment were assessed for QOL using the Brazilian version of the 36-item short form survey. A p < 0.05 was considered statistically significant.

Results

We evaluated 480 volunteers; 51% were treated in one of the private hospitals. In total, 55.6% presented with STEMI, and 44.4% with NSTEMI. Patients from the public hospital were 8.56 times more likely to have STEMI compared to those from the private hospitals. There was a higher prevalence of smokers in STEMI (p < 0.028) patients. QOL was not associated with the type of AMI. A negative patient perception of the physical health and pain domains was observed. Although a significant difference between the physical and the mental health domains was not observed, individual domains were correlated with some in-hospital outcomes.

Conclusion

There was a higher prevalence of smokers among individuals with STEMI. Domains of QOL showed a statistically significant relationship with the occurrence of in-hospital cardiovascular events, with no difference between the types of AMI.

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Original Article

Prevalence of Frailty in Patients Undergoing Cardiac Valve Surgery: Comparison of Frailty Tools

Gabriela Harada et al. Monique Carvalho Andrade Julia Nobrega Brito Caio de Assis Moura Tavares … Flávio Tarasoutchi Pablo Maria Alberto Pomerantzeff Luiz Bortolotto Maria Ignez Zanetti Feltrim

Abstract

Background

There is no consensus among tools for assessing frailty.

Objective

To evaluate the prevalence of frailty according to different tools in patients referred for elective valve cardiac surgery.

Methods

This is a cross-sectional study. All patients were ≥ 18 years of age, clinically stable. The following patients were excluded: those unable to perform the tests because of physical, cognitive, or neurological limitations; those requiring non elective/emergency procedures or hemodynamic instability. During the preoperative cardiology visit, frailty was assessed by the Short Physical Performance Battery (SPPB), the Frailty Deficit Index (FDI), handgrip strength, and gait speed 3m. For the entire analysis, the statistical significance was set at 5%.

Results

Our cohort consisted of 258 subjects. From the total cohort, 201 were ≤ 70 years of age (77.9%), the predominant etiology according to rheumatic disease (50.7% vs 8.8%; p=0.000) with double mitral lesion (24.9% vs 0%; p=0.000). Frailty was present in 32.9% according SPPB, 29.1% with reduced muscular strength. and 8.9% with FDI. Handgrip strength was weaker in elderly patients (26.7 vs 23.6; p=0.051) and gait speed was lower in the younger group, in which 36% were considered frail (36% vs 14%; p=0.002). Variables associated with frailty were age ≥ 70 years, female gender, aortic stenosis, and regurgitation.

Conclusion

Frailty in adult patients who will have elective heart valve surgery is present even in the younger groups, although the older group with comorbidities are more frail. Frailty was more clearly shown by the SPPB than by the FDI and handgrip tests.

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Original Article

Acute Myocardial Infarction with Non-Obstructive Coronary Arteries – Stratifying the Risk of a “new” Clinical Entity using an “Old” Tool

Pedro Carvalho et al. Mariana Caçoilo Vera Afreixo José Mesquita Bastos … Lisa Ferraz Manuela Vieira Luís Santos Anabela Gonzaga Raquel Ferreira Tiago Adrega Ana Faustino Ana Briosa

Abstract

Background

Some of the patients admitted for acute myocardial infarction have non-obstructive coronary artery disease (MINOCA). Their prognosis is not always benign, making it necessary the development of tools for risk stratification of these patients.

Objectives

To describe the characteristics of a sample of patients admitted for suspected MINOCA and to evaluate the prognostic value of GRACE score in this population.

Methods

This was a retrospective, observational, single-center, cohort study involving 56 consecutive patients with MINOCA. During one-year follow-up, patients were assessed for mortality and major adverse cardiovascular events (MACE) – a composite of all-cause mortality and hospitalization due to acute myocardial infarction, heart failure, ischemic stroke, and acute limb ischemia. Statistical analysis was performed using a non-parametric approach, with the Mann-Whitney U test for quantitative variables and ROC curves for assessing the discriminatory power of the Grace score in predicting cardiovascular events. The level of significance was set at 5%.

Results

Of the 56 MINOCA patients included in the study (median age 67 years), 55.4% were female. During the one-year follow-up, mortality rate was 5.5% and 9.1% of patients had MACE. A higher GRACE score was associated with mortality (p = 0.019; AUC 0.907; 95%CI 0.812–1.000; cut off 138) and MACE (p =0.034; AUC 0.790; 95%CI 0.632–0.948; cutoff 114).

Conclusion

The definition of MINOCA includes various diagnoses and prognoses, and the GRACE score is useful for risk stratification of patients with this condition.

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Original Article

Stroke and Myocardial Infarction: Effects of the “Hiperdia” and “Mais Médicos” Programs on the Hospitalizations Trends in Brazil

Júlio Martinez Santos et al. Alessandra Barboza Resende Martinez Emerson de Jesus Silva Gustavo Roberto Santana Souza Johnnatas Mikael Lopes

Abstract

Background

Stroke and acute myocardial infarction (AMI) are cardiovascular diseases commonly characterized by the development of atheromatous plaques associated with major complications and high mortality rates.

Objective

To identify an epidemiological trend in hospitalizations due to stroke and AMI and to analyze the relationship between health programs applied in Primary Health Care, gender and the Federative Unit.

Methods

Ecological study with a time series design between 1998 and 2018, collecting data from all federal units in Brazil stratified by, gender and place of residence. There were analyzed Hospitalization Authorizations (AIH) for stroke and MI, consulting the Hospital Admissions System (SIH) of the Informatics Department of the National Health Service with p <0.05.

Results

From 1998 to 2018, the rate of hospitalization for AMI increased in Brazil approximately 42.58 events per 100 thousand inhabitants annually (p<0.001), while hospitalizations for stroke declined 32.17 cases (p=0.03). This pattern was observed in both sexes in AMI and stroke. There is also evidence of the effect of the Hiperdia (p<0.001) and Mais Médicos (p=0.001) program in reducing stroke and Hiperdia cases in mitigating the evolution of AMI cases (p = 0.0001).

Conclusion

Although these diseases remain as an important cause of death, stroke hospitalization has reduced significantly in the period evaluated. National programs as the Hiperdia and Mais Médicos showed an impact in the acute cases of strokes and AMI.

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Original Article

The Correlation between Cardiac Enzymes and Cardiotrophin-1 Levels in Patients with Acute Coronary Syndrome

Ufuk Polat et al. Ali Aydinlar Serhat Caliskan Ferit Boyuk Orcun Unal

Abstract

Background

In the current era, there is always search for better cardiovascular biomarkers to early diagnose the disease.

Objectives

We aimed to investigate the association between a novel biomarker, cardiothropin-1 (CT-1), and standard markers of myocardial ischemia in patients with acute coronary syndrome (ACS) in Turkey.

Patients and Methods

In this prospective cohort study, patients who were admitted to our institution between July 2012 and July 2013 with the diagnosis of ACS were included. The standard markers of myocardial necrosis and CT-1 were evaluated at the time of admission and after 6 hours. Changes in laboratory parameters were statistically tested and correlated with routinely used markers of myocardial ischemia. The distribution of the data was analyzed by the Kolmogorov-Smirnov test. Proportional analysis and changes in laboratory parameters were evaluated with Chi-Square test and Fisher Exact test. Statistical significance was defined as p<0.05.

Results

The study enrolled 24 patients (14 male, 10 female) with ST-segment elevation myocardial infarction (STEMI) and 16 patients (9 male, 7 female) with non-ST-segment elevation myocardial infarction (NSTEMI) with elevated cardiac enzymes such as creatine kinase (CK), creatine kinase-MB (CK-MB) and Troponin-T (Tn-T). The average age of the patients was 61.45 ± 11.04 years. Increasing CT-1 levels were correlated with the increasing CK (p=0.035 and p=0.018, respectively), CK-MB (p=0.006 and p=0.096, respectively), and Tn-T (p=0.041 and p=0.000, respectively) at first and at the 6th hour measurements. The CT-1 values were found to be more increased in the STEMI group (p=0.0074).

Conclusion

CT-1 is one of the novel biomarkers for cardiac injury. It is correlated with standard markers of myocardial ischemia and the results suggest that CT-1 can be used as a new biomarker.

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Case Report

Kounis Syndrome: Case Report in Goiânia/BR

Marília Pereira et al. Gabriela Lima Vieitas Anna Ilona Hunkar Freitas Karoly Gyula Olivas Hunkar

Abstract

22-year-old male patient with no heart disease, who was given an ambulatory medication with analgesics due to an acute renal crisis. After the drug administration, the patient presented dyspnea, cyanosis, and hemoptysis. There was suspicion of anaphylactic shock, which was treated, but there was no improvement in the clinical condition. The patient was referred to the Intensive Care Unit, where tests were performed showing elevated cardiac enzymes and Immunoglobulin E and Computed Tomography of Thoracic revealed alveolar hemorrhage. He developed clinical worsening and died after sepsis. The final diagnosis was of kounis syndrome due to the hypersensitivity reaction to the analgesics introduced in the patient, generating an acute coronary syndrome (ACS). The purpose of this case report was to highlight a syndrome that is little reported because it is not part of the differential diagnosis routines of ACS, but it generates important complications.

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Original Article

Accuracy of Self-Reported Arterial Hypertension in Brazil: Systematic Review and Meta-Analysis

Jessica Pronestino de Lima Moreira et al. Renan Moritz Varnier Rodrigues de Almeida Ronir Raggio Luiz

Abstract

Background

Self-reported hypertension is a useful method to estimate prevalence in the population. However, it is necessary to evaluate its accuracy, in relation to the gold-standard diagnostic methods of the disease.

Objectives

To estimate combined measures of sensitivity and specificity for self-reported hypertension, using Brazilian validation studies that included gold standard methods.

Methods

A systematic review and a meta-analysis were developed. Two independent examiners evaluated 1389 and read 113 potentially eligible articles. Since self-reported morbidity is influenced by the cultural and economic characteristics of a population, as well as by its accessibility to medical care, only studies from one country (Brazil) were included. First, a qualitative analysis was performed, evaluating the relationship between self-reported hypertension and its measurement through gold-standard methods. Subsequently, a meta-analysis estimated the combined sensitivity and specificity for the included studies. Due to a high heterogeneity among studies, the meta-analysis used a random effects model. Bias risks were evaluated by the QUADAS-2 protocol and the standard significance level of 10% was used in all modelling.

Results

Five studies were included in the qualitative analysis; and four had the necessary information for inclusion in the meta-analysis. Patient selection and Index Test (the question allowing for self-reporting) were the domains with the highest risk of bias. In the meta-analysis, combined sensitivity and specificity were 77%(95%CI:[74.5-79.0%]) and 88%(95%CI:[86.3-88.6%]), respectively.

Conclusions

The analysed studies allowed for the estimation of more reliable values for combined sensitivity and specificity. These values were higher than those usually found in studies with greater population heterogeneity.

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Case Report

Renal Sympathetic Denervation Using a Novel Device: A Clinical Case Discussion and Literature Update

Esmeralci Ferreira et al. Valerio Fuks Rodolfo Staico Roberto Esporcatte … Andréa Araujo Brandão Denilson Campos Albuquerque

Introduction

Resistant hypertension (RH) is directly related to increased mortality, severe renal changes, and cardiac and cerebrovascular diseases, due to lack of adequate drug treatment. Cardiovascular disease mortality increases progressively and linearly as BP increases, whereas BP lowering is associated with significantly reduced risks.^– Increased sympathetic tone in renal arteries is one of the major components of RH, and catheters have been developed using several technologies which allow for radiofrequency ablation (RA) and blood pressure (BP) reduction. The discussions and controversies about the effectiveness of this treatment are quite broad, especially when associated with the use of new devices. In this clinical case study, with an 18-month follow-up, we describe the development of knowledge regarding this technique and its evidence basis.

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Viewpoint

Association between Periodontitis and Myocardial Infarction: Systematic Review and Meta-Analysis

Luiz Carlos Bodanese et al. Gabriel Campos Louzeiro Gabriela Agne Magnus Ângela Hamann Baptista … Fernanda Gonçalves Salum Rita Mattiello

Abstract

The association between periodontitis and myocardial infarction remains unclear in the literature. Few studies have addressed periodontitis exposure as a predisposing factor for the development of myocardial infarction. Therefore, the present systematic review aims to analyze the association between periodontitis and myocardial infarction. This meta-analysis systematically searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register, SCIELO, LILACS, CINAHL, Scopus, Web of Science and grey literature for studies estimating the association between periodontitis and myocardial infarction. Quality of evidence was assessed for all studies. The meta-analysis was conducted using random-effects models. Four of the six studies selected were included in the meta-analysis, including 1,035,703 subjects. The association between periodontitis and myocardial infarction was: RR: 5.99 (95% CI: 1.17-30.68), but with high heterogeneity (I² = 100%; p <0.01). The results including only the highest quality articles, was lower: RR: 2.62 (95% CI: 1.47-4.70 3.83), but with lower heterogeneity (I² = 85.5%; p < 0.01).The present systematic review with meta-analysis showed an association between periodontitis and acute myocardial infarction, but with a high level of heterogeneity.

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Original Article

QTc, Tp-e Interval and Tp-e/QTc Ratio in Patients with Hypocalcemia-case Control Study

Begum Seyda Avci et al. Akkan Avci Arif Aksu Muge Gulen … Onder Yesiloglu Hasan Koca Salim Satar

Abstract

Background:

To the best of our knowledge, there are studies related to QT and QTc interval in patients with hypocalcemia, but there are no studies evaluating T wave peak and end interval (Tp-e interval), Tp-e/QT and Tp-e/QTc ratios used to evaluate cardiac arrhythmia risk and ventricular repolarization changes rates.

Objectives:

Therefore, we aimed to investigate whether there is a change in Tp-e interval, Tp-e/QT and Tp-e/QTc ratios in patients with hypocalcemia.

Methods:

Retrospectively, 29 patients with hypocalcemia in the emergency department were included in the study. Twenty-nine patients with similar age and sex distribution were included in the study as the control group. All patients underwent 12-lead electrocardiography (ECG). In addition to routine measurements, Tp-e interval, Tp-e/QT and Tp-e/QTc ratios were measured on ECG. The study data were grouped as patients with and without hypocalcemia.

Results:

The mean age of the patients was 66.24 ± 4.95 years. QTc interval, Tp-e interval and Tp-e/QTc values were found to be significantly higher in patients with hypocalcemia (p <0.001 for each). QTc interval, Tp-e interval and Tp-e/QTc ratio showed a significant negative correlation with calcium levels.

Conclusion:

Tp-e interval and Tp-e/QTc ratios are significantly increased in patients with hypocalcemia compared to those without hypocalcemia and this can be used more effectively in the follow-up of cardiac fatal arrhythmias.

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Case Report

High-Grade Pleomorphic Sarcoma of the Left Atrium after Incomplete Resection and Adjuvant Chemotherapy

Ricardo J. Razera et al. Amanda Mendonça de Araújo Viviane Pereira Bernardes Fernanda Miranda Moisés … Leonardo Santos Mundim Rogério A. Araújo

Introduction

Primary cardiac tumors are extremely rare, found in only 0.02% of all autopsies. These tumors are malignant in only 25% of the cases, 75% of which are sarcomas, frequently affecting young people with no risk factors.² The median overall survival is less than 1 year,³ ranging from 9 to 16 months,^, with rapid proliferation and deaths caused by arrhythmias, thrombosis, pulmonary embolism, and, most importantly, heart failure. Due to its rarity, reports in the literature about the best treatment are scarce, especially in malignant tumors.¹ The aim of the present work is to report a case of an undifferentiated pleomorphic sarcoma (UPS) in the left atrium in which surgical treatment was associated with chemotherapy, with an overall and progression-free survival of neoplastic disease higher than the median described in previous manuscripts.

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Case Report

Oral Antibiotic Therapy for Infective Endocarditis Due to Enterococcus Spp. After Hemorrhagic Stroke and Heart Surgery

Guilherme Augusto Reissig Pereira et al. Graziela Regina Kist Tiago Santini Machado Christiano da Silveira de Barcellos

Introduction

Infectious endocarditis (IE) is a severe infectious disease with an annual incidence of 3 – 7 cases per 100 000 people, and is considered the 3rd most life-threatening infection after pneumonia and intra-abdominal abscess. Intra-hospital mortality ranges from 15 to 30% and patients affected today are older and have more comorbidities than in the past.

In IE the treatment is traditionally performed in hospitalized patients, due to the need for intravenous antibiotics. Patients with IE on the left side of the heart are typically treated for 2 – 6 weeks, according to the American and European Guidelines. ^– Enterococcus spp. is the third cause of IE, representing 10% of cases in non-users of intravenous drugs, and is considered to be a bacterium that is difficult to eradicate, requiring 6 weeks and the combination of antibiotics.

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