2022;35(1) – ABC CARDIOL

IJCS

Família ABC | IJCS

Editorial

Cause or Consequence? What is the Relationship between Cardiac Injury and COVID-19 Severity?

Claudio Tinoco Mesquita

In most patients, coronavirus disease-2019 (COVID-19) causes minor respiratory symptoms or even no symptoms. SARS-CoV-2 infection can also cause extrapulmonary manifestations and complications. COVID-19 is more severe and fatal among patients with pre-existing cardiovascular risk factors or diseases. Increases in cardiac troponin (cTn) are indicative of myocardial injury and frequently found in patients with COVID-19. The Chinese Center for Disease Control and Prevention published a survey demonstrating that among patients diagnosed with COVID-19, 13% had hypertension, 5% had diabetes mellitus, and 4% had a history of cardiovascular disease. However, in this same cohort, among patients who had not survived, 40% had hypertension, 20% had diabetes, and 22% had pre-existing cardiovascular disease. Patients with cardiovascular disease had the highest case fatality rate (10.5%).

In this issue of the International Journal of Cardiovascular Sciences, Rocha et al. , studied 192 patients admitted with COVID-19 in a quaternary care cardiac hospital in Rio de Janeiro, Brazil. Mortality rate was 28%. Multivariate analysis demonstrated that elevated cTnI levels (OR=9.504; 95% CI=1.281–70.528; P=0.028) upon admission and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360–923.706; P=0.012) were independent predictors of death during hospitalization. The main limitations of the study are a sample from a single Brazilian metropolitan region and a short follow-up period. However, these limitations do not invalidate the main message of the study: the measurement of cardiac troponin at hospital admission may be useful for identification of high-risk patients infected by SARS-CoV-2.

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Viewpoint

Smartphone-Based Screening for Cardiovascular Diseases: A Trend?

Thiago Mazzu-Nascimento et al. Danilo Nogueira Evangelista Obeedu Abubakar Meliza Goi Roscani … Rodrigo Santos Aguilar Silvana Gama Florêncio Chachá Priscila Raupp da Rosa Diego Furtado Silva

Abstract

Cardiovascular diseases are the leading cause of death in the world. People living in vulnerable and poor places such as slums, rural areas and remote locations have difficulty in accessing medical care and diagnostic tests. In addition, given the COVID-19 pandemic, we are witnessing an increase in the use of telemedicine and non-invasive tools for monitoring vital signs. These questions motivate us to write this point of view and to describe some of the main innovations used for non-invasive screening of heart diseases. Smartphones are widely used by the population and are perfect tools for screening cardiovascular diseases. They are equipped with camera, flashlight, microphone, processor, and internet connection, which allow optical, electrical, and acoustic analysis of cardiovascular phenomena. Thus, when using signal processing and artificial intelligence approaches, smartphones may have predictive power for cardiovascular diseases. Here we present different smartphone approaches to analyze signals obtained from various methods including photoplethysmography, phonocardiograph, and electrocardiography to estimate heart rate, blood pressure, oxygen saturation (SpO₂), heart murmurs and electrical conduction. Our objective is to present innovations in non-invasive diagnostics using the smartphone and to reflect on these trending approaches. These could help to improve health access and the screening of cardiovascular diseases for millions of people, particularly those living in needy areas.

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Editorial

Exercise Testing Protocols to Detect the Presence of Coronary Artery Disease: Bruce or Ramp?

Ricardo Vivacqua Cardoso Costa

The investigation of ischemic response through clinical, metabolic, hemodynamic, and electrocardiographic parameters displayed in the exercise stress test (ET) in multifactorial analysis increases the ET’s diagnostic and prognostic accuracy indication of ischemic response.

Coronary artery disease (CAD) is a pathology that requires quick and safe decisions for the patient, and it is always a challenge. The protocols for performing the ET, whether on a cycle ergometer or a treadmill, must be adapted to the patient’s biomechanical conditions so that they are comfortable and can reach the criteria that define a maximum or close to the maximum effort level. The protocol must seek a satisfactory mobilization of myocardial reserves so that the sensitivity to the presence of an ischemic response can be increased.

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Editorial

Abdominal Subcutaneous Adipose Tissue, Diet, and Risk of Cardiovascular Disease: What do we Know?

Camila Weschenfelder et al. Penny M. Kris-Etherton

Excess adiposity increases the risk of cardiovascular disease (CVD) due to dyslipidemia, systemic inflammation and other risk factors. The distribution of body fat depots, and central adiposity in particular, is related to cardiometabolic diseases. The different adipose tissue depots in the body, ie, epicardial adipose tissue, visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT), have different biochemical characteristics and produce unique biologically active molecules that affect normal and pathological processes related to CVD risk.^, Abdominal SAT is classified as superficial or deep. Deep subcutaneous adipose tissue (DSAT) has a higher ratio of saturated to monounsaturated fatty acids, and, consequently, is more saturated than superficial subcutaneous adipose tissue (SSAT). Despite being in the subcutaneous compartment, DSAT differs from VAT because of differences in gene transcription, having different metabolic functions than SSAT.

In Acute Coronary Syndrome (ACS) patients, coronary plaque instability is related to abnormal abdominal fat distribution. Analyses of the abdominal fat distribution of ACS patients have demonstrated that both VAT and SAT are positively correlated with vessel and plaque volumes, but not with plaque tissue components, the fibrous and lipid content of plaque. However, considering coronary plaque characteristics, a higher VAT/SAT ratio was independently associated with a higher percentage of plaque lipid content, with a lower percentage of fibrous volumes and a thinner fibrous cap thickness, characteristics that define greater plaque rupture vulnerability and a high risk for coronary events.

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Editorial

Immigrants, Descendants and the Risk of Coronary Heart Disease

Antonio Carlos Palandri Chagas et al. João Fernando Monteiro Ferreira

Cardiovascular disease remains the leading cause of death worldwide and in all regions of Brazil. Racial, cultural, and environmental factors contribute to different prevalence rates of risk factors and presentations of the disease. Differences have been found between Whites, Hispanics, Asians, and Afro-descendants, and even within each race, due to migratory movements.^,

Changes in the socio-demographic profile of migrant populations have resulted in health transitions, considering the country of origin (some of them with a high risk for certain diseases) and changes in lifestyle and diet in the new country. Several studies have found a significant linear relationship between migration and acculturation, alcohol consumption, lipid profile, blood pressure, body mass index and physical activity.^–

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Editorial

Exercise Is Medicine! How to Safely Return to Sports after COVID-19? A Meta-Analysis and a Practical Flowchart for Cardiovascular Risk Assessment may Help you

Exercise is medicine! Although this premise is well established, how to maintain this “treatment” for various diseases during the COVID-19 pandemic? This has been a concern of all doctors in the world since exercise contributes to the control of cardiovascular diseases and other comorbidities recognized as risk factors for a worse outcome in COVID-19. Moreover, it has already been shown that higher cardiorespiratory fitness is inversely associated with the likelihood of hospitalization due to COVID-19.

In addition to the hygiene and social distancing measures necessary to prevent coronavirus infection, cardiovascular sequelae in individuals recovering from COVID-19 may contribute to the delay in resuming exercise. Cardiovascular complications, including myocarditis, are relatively common in patients affected by SARS-CoV-2. Although the occurrence of myocarditis as a consequence of COVID-19 was initially described in hospitalized patients with severe presentation of the disease, subsequent studies have reported its occurrence in individuals with mild COVID-19 and even in asymptomatic patients.

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Editorial

Cardiovascular Benefits of Plant-Based Diets

Marcella Rodrigues Guedes et al. Márcia Regina Simas Torres Klein

Increasing evidence suggests that plant-based dietary patterns, characterized by higher intake of plant foods and lower intake of animal foods, confer benefits to cardiovascular health.^– Vegetarian diets are a subset of plant-based diets that exclude some or all animal products (vegan diets).

A meta-analysis of 86 cross-sectional and 10 cohort prospective studies evaluated the association between vegetarian, vegan diets, risk factors for chronic diseases, risk of all-cause mortality, incidence, and mortality from cardio-cerebrovascular diseases. The overall analysis of cross-sectional studies revealed significantly reduced levels of body mass index, total cholesterol, LDL-cholesterol, and glucose levels in vegetarians and vegans compared with omnivores. In relation to cohort studies, the analysis showed a significantly reduced risk of incidence and/or mortality from ischemic heart disease by 25%.

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Viewpoint

Physical Activity, Obesity, and COVID-19: What can we Expect from his Relationship?

Ciro Oliveira Queiroz et al. Ariani França Conceição Paulo Rodrigo Santos Aristides Leandro Silva Alves Rogério Tosta Almeida

The COVID-19 pandemic is a public health problem, whose first cases were found in Wuhan, China, in December, 2019, and which is currently present around the world. COVID-19 is caused by the new coronavirus (SARS-CoV-2), which shows a high potential of contamination. Its transmission occurs through droplets during unprotected proximity with an infected person and contact with contaminated environmental surfaces, which are the main systemic and respiratory symptoms.^,

To date, there is no pharmacological treatment that has proven to be effective, or a vaccine for the prevention or treatment of COVID-19. Thus, a non-pharmacological strategy of public health, which has shown effectiveness in the exponential control of the disease, is social distancing, which encompasses the isolation of cases, quarantine of contacts, and the voluntary practice of not going to crowed places. These measures have demonstrated that they can reduce mortality rates during the pandemic, and they have helped in governmental decision-making.^,

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Original Article

Predictors of Hospitalization in Vitamin K Antagonist Users Presenting with Bleeding at the Emergency Department

Alan Fabiani Chiaparini et al. Paola Stefania Bohrer Rabaioli João Vitor Slaviero Cinthia Scatolin Tem-Pass … Hugo Antonio Fontana Filho Iran Castro Eduardo Dytz Almeida Tiago Luiz Luz Leiria

Abstract

Background

Vitamin K antagonists (VKA) are indicated for the prevention of thromboembolic events and reduction of mortality in patients with atrial fibrillation and patients with valvular prostheses. However, their use is associated with bleeding complications and hospitalizations. Predictors of hospital admission for bleeding in these patients are poorly known.

Objectives

To define the predictors for hospitalization of VKA users who seek emergency care due to bleeding.

Methods

Single-center, cross-sectional study, with retrospective analysis of electronic medical records from 03/01/2012 to 02/27/2017. Clinical and laboratory variables were compared between patients who were hospitalized and those who were not. A logistic regression model as used, in which the variables were included using the Backward stepwise method, with a p value of 0.05 as the input criterion, a removal value of 0.20 and a confidence interval of 95%. The p-value was considered statistically significant when <0.05.

Results

A total of 510 patients with bleeding were included, of whom 158 were hospitalized. Predictors of hospitalization were: INR at supratherapeutic levels (OR 3.45; P <0.01; 95% CI 1.58 – 7.51), gastrointestinal bleeding (OR 2.36; P <0.01; CI 95% 1.24 – 4.50), drop in hemoglobin (OR 6.93; P <0.01; 95% CI 3.67 – 13.07), heart failure (OR 1.96; P 0.01; 95% CI 1.16 – 3.30) and need for blood transfusion (OR 8.03; P <0.01; 95% CI 2.98 – 21.64).

Conclusion

Drop in hemoglobin, heart failure, INR at supratherapeutic levels, gastrointestinal bleeding and need for blood transfusion were associated with hospitalization. Identification of these factors in the initial evaluation would help to define which patients will demand more intensive care.

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Original Article

Predictive Value of Myocardial injury in Patients with COVID-19 Admitted to a Quaternary Hospital in the City of Rio de Janeiro

Antônio Sérgio Cordeiro da Rocha et al. Andre Volschan Luiz Antonio Almeida Campos Roberta Pereira dos Santos Coelho … Dominique Cardoso de Almeida Thielmann Carlos Augusto Lobbe Cotta Ferreira Alexandre Siciliano Colafranceschi

Abstract

Background

In Brazil the factors involved in the risk of death in patients with COVID-19 have not been well established.

Objective

To analyze whether elevations of high-sensitivity troponin I (hTnI) levels influence the mortality of patients with COVID-19.

Methods

Clinical and laboratory characteristics of hospitalized patients with COVID-19 were collected upon hospital admission. Univariate and binary logistic regression analyzes were performed to assess the factors that influence mortality. P-value<0.05 was considered significant.

Results

This study analyzed192 patients who received hospital admission between March 16 and June 2, 2020 and who were discharged or died by July 2, 2020. The mean age was 70±15 years, 80 (41.7%) of whom were women. In comparison to those who were discharged, the 54 (28.1%) who died were older (79±12 vs 66±15years; P=0.004), and with a higher Charlson´s index (5±2 vs 3±2; P=0.027). More patients, aged≥60years (P 1 (P=0.004), lung injury>50% in chest computed tomography (P=0.011), with previous coronary artery disease (P=0.037), hypertension (P=0.033), stroke (P=0.008), heart failure (P=0.002), lymphocytopenia (P=0.024), high D-dimer (P=0.024), high INR (P=0.003), hTnI (P<0.0001), high creatinine (P<0.0001), invasive mechanical ventilation (P<0.0001), renal replacement therapy (P<0.0001), vasoactive amine (P<0.0001), and transfer to the ICU (P=0.001), died when compared to those who were discharged. In logistic regression analysis, elevated hTnI levels (OR=9.504; 95% CI=1.281–70.528; P=0.028) upon admission, and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360–923.706; P=0.012) increased the chance of in-hospital mortality.

Conclusion

This study suggests that in COVID-19 disease, myocardial injury upon hospital admission is a harbinger of poor prognosis.

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Original Article

Better Adequacy of Food Intake According to Dietary Recommendations of National Cholesterol Education Program in Vegetarian Compared to Omnivorous Men

Luiza Antoniazzi et al. Julio Acosta-Navarro Adriana Midori Oki Maria Carlos Bonfim Maria Cristina Almeida Gaspar

Abstract

Background

The lower frequency of cardiovascular (CV) risk factors observed in vegetarians compared to omnivores may be due to more appropriate nutrient intake according to recommendations for the prevention of cardiovascular diseases.

Objective

To compare the dietary adequacy according to the recommendations of the National Cholesterol Education Program (NCEP) in apparently healthy vegetarian (VEG) and omnivorous (OMN) men.

Methods

This was a cross-sectional study, conducted with apparently healthy men (44 omnivorous and 44 vegetarians, ≥ 35 years), who were assessed for daily food consumption, anthropometric data, physical exercise status, and clinical data. Multiple logistic regression was used to test the association between the type of diet and the dietary adequacy. Significant values were considered for p<0.05.

Results

Several clinical CV risk markers were significantly lower in VEG when compared to OMN: body mass index (BMI) (23.1 vs. 27.3 kg/m2), systolic blood pressure (119.5 vs. 129.2 mmHg), and diastolic blood pressure (75.7 vs. 83.9 mmHg). VEG presented significant lower values of blood lipids and glucose. No significant difference was observed in caloric intake; however, VEG consumed significantly more carbohydrates, dietary fibers, and polyunsaturated fats. VEG presented an adequate consumption of dietary cholesterol and saturated and polyunsaturated fatty acids, regardless of caloric intake and age.

Conclusion

VEG were more likely to consume saturated fatty acids, dietary cholesterol, and fibers according to the recommendations of NCEP, factors that may contribute to lower levels of CV risk markers than OMN.

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Original Article

Ischemic Heart Disease in German Immigrants and Their Descendants in a Region of Southern Brazil: A Comparison of Initial Symptoms Reported between two Generations

Sergio Luiz Zimmermann et al. Miguel Antônio Moretti Caio de Brito Vianna Antônio de Pádua Mansur … Siegmar Starke Luiz Antônio Machado Cesar

Abstract

Background

Nothing is known about ischemic heart disease (IHD) in the Germans who emigrated to Brazil during the last century.

Objective

We sought to compare age at diagnosis and IHD manifestations between German immigrants and their first-generation descendants in the region of Blumenau, Brazil.

Methods

We reviewed medical records of hospitals in Blumenau. Comparison of the groups in the evaluation times was made by analysis of variance (ANOVA) with repeated measures, and comparison of two factors was made by two-way ANOVA. The level of significance was set at p <0.05.

Results

Study population comprised 68 patients who were born in Germany (group G) and 99 descendants (group D). Twenty-nine patients of group D had two German parents and 70 had one. Mean age at diagnosis was 66.8 ± 10.6 years, with a significant difference between the groups, four years higher in Group G than group D (69.0 ± 8.8 vs 65.4 ± 11.5 years old) (p = 0.025). There was no significant difference in risk factors or coronary angiography data between the groups. HDL cholesterol levels were significantly higher in group G than in group D (48.4 ± 11.1 mg/dL vs 43.3 ± 11.2 mg/dL, p = 0.005).

Conclusion

At the time of first IHD diagnosis, mean age of the group G was significantly higher than group D, with no differences between groups in sex, risk factors, LDL levels, or clinical and angiographic manifestations. An earlier manifestation of the disease could be part of lifestyle changes in descendants, in this population that mantained eating habits characterized by high saturated fat consumption.

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Original Article

Comparison between Bruce and Ramp Protocols for Exercise Testing in the Diagnosis of Myocardial Ischemia

Thiago Teixeira da Silveira Fagundes et al. Carolina Christianini Mizzaci Susimeire Buglia Fabricio da Costa Wohnrath … Flavia Medina João França Rica Dodo Delmar Buchler Luiz Eduardo Mastrocola Romeu Sérgio Meneghelo

Abstract

Background:

Exercise tests are an important tool in the investigation of myocardial ischemia. The ramp protocol has gained increasing importance in clinical practice because of the possibility of individualizing its exercise intensity.

Objective:

To assess and compare the sensitivity, specificity, and accuracy of Bruce and ramp protocols for exercise testing in the diagnosis of myocardial ischemia considering myocardial perfusion scintigraphy as the reference standard. Secondary objectives included the assessment of hemodynamic profiles, functional capacity, and the incidence of arrhythmias in each of the protocols.

Methods:

Participants underwent exercise testing using the ramp and Bruce protocols, and the tests’ diagnostic power was assessed. For testing the difference between data provided by both protocols, we used a paired Student’s t-test or Wilcoxon test, depending on the assumption of data normality. The level of significance adopted for all tests was 5%.

Results:

The ramp protocol showed sensitivity, specificity, and accuracy values of 55.6%, 82.4%, and 76.7%, respectively, whereas the Bruce protocol had results of 77.8%, 64.7%, and 67.4%, respectively. The maximum heart rate and double product at peak exercise were significantly higher in the Bruce protocol (p = 0.043 and p = 0.040, respectively). No differences were observed between the incidence of arrhythmias in both protocols.

Conclusion:

The Bruce protocol presented higher sensitivity for detecting ischemia on the exercise test, while the ramp protocol presented higher specificity and accuracy.

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Review Article

Effectiveness of Mindfulness Meditation Programs in the Promotion of Quality of Life in Patients with Heart Failure: A Systematic Review

Vaisnava Nogueira Cavalcante et al. Ana Carla Dantas Cavalcanti Juliana de Melo Vellozo Pereira Tinoco Lyvia da Silva Figueiredo Evandro Tinoco Mesquita

Abstract

Background:

Despite optimal medical treatment, many heart failure (HF) patients continue to show a high prevalence of symptoms, which contributes to a high morbidity and poor health-related quality of life (HRQL). Mindfulness meditation may be effective in improving the quality of life in these patients.

Objective:

A systematic review was conducted to evaluate if mindfulness meditation programs are effective in promoting and improving the quality of life in patients with heart failure.

Methods:

The PubMed (MEDLINE), Cumulative Index of Nursing and Allied Health (CINAHL), LILACS, Cochrane Library, and Scopus databases were searched between October and November of 2019. Articles were selected if they evaluated mindfulness intervention, with an experimental or quasi-experimental design, in adults with heart failure and measured health-related quality of life.

Results:

This systematic review identified 108 studies through database searches. After applying the inclusion and exclusion criteria, a total of three studies were considered qualified. These studies took place in the Netherlands, the USA, and Brazil, and occurred between 2005 and 2015. Sample sizes varied from 19 to 215, and the average range of participants within each study varied from 43.2 to 75.4 years. Compared to control programs, mindfulness-based meditation programs improved the quality of life in two studies (p= 0.041 and p=0.03).

Conclusion:

Mindfulness-based meditation programs improved the quality of life in patients with HF. Therefore, there is limited data to strengthen this recommendation to this population, and future research is warranted in order to present consistency in the intervention protocols.

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Original Article

Cardioprotective Effects of Sodium-glucose Cotransporter 2 Inhibitors Regardless of Type 2 Diabetes Mellitus: A Meta-analysis

Lucas Silva Sousa et al. Felipe de Araújo Nascimento Juliano Rocha Michelle Rocha-Parise

Abstract

Background:

Type 2 diabetes mellitus (T2DM) is an independent risk factor for cardiovascular impairment, increasing the rates of atherosclerotic and non-atherosclerotic events. Additionally, adverse kidney events are directly linked with T2DM and cardiovascular diseases. In this context, the sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated both cardioprotective and renoprotective effects in patients with or without T2DM. Therefore, the present meta-analysis aims to evaluate cardiovascular outcomes involving SGLT2i as monotherapy or other add-on antidiabetic agents (ADA) in patients with or without T2DM.

Objetive:

The present meta-analysis aims to evaluate cardiovascular outcomes involving SGLT2i as monotherapy or add-on other ADA in patients with or without T2DM.

Methods:

The entrance criteria to SGLT2i studies were: describing any data regarding cardiovascular effects; enrolling more than 1,000 participants; being approved by either the FDA or the EU, and having available access to the supplementary data. The trial had to exhibit at least one of the following results: major adverse cardiovascular events (MACE), cardiovascular death or hospitalization for heart failure, cardiovascular death, hospitalization for heart failure, renal or cardiovascular adverse events, or non-cardiovascular death. The significance level of 0.05 was adopted in the statistical analysis.

Results:

Nine trials with a total of 76,285 participants were included in the meta-analysis. SGLT2i reduced MACE (RR 0.75, 95% CI [0.55-1.01]), cardiovascular death or hospitalization for heart failure (RR 0.72, 95% CI [0.55-0.93]), cardiovascular death (RR 0.66, 95% CI [0.48-0.91]), hospitalization for heart failure (RR 0.58, 95% CI [0.46-0.73]), renal or cardiovascular adverse events (RR 0.55, 95% CI [0.39-0.78]), and non-cardiovascular death (RR 0.88, 95% CI [0.60-1.00]).

Conclusions:

Conjunction overall data suggests that these drugs can minimize the risk of cardiovascular events, thus decreasing mortality in patients, regardless of the presence of T2DM.

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Original Article

Association between Deep Subcutaneous Adipose Tissue Estimated by DAAT Index and Dietary Intake in Patients with Acute Coronary Syndrome

Elana Stein et al. Sandra Barbiero Vera Lucia Portal Victória da Luz Aline Marcadenti

Abstract

Background:

Abdominal obesity has been associated with cardiovascular disease and may be modulated by dietary intake. The deep abdominal subcutaneous adipose tissue (dSAT) is a body fat compartment that can be estimated by using mathematical formulas.

Objectives:

To evaluate the association between dSAT estimated by the Deep-Abdominal-Adipose-Tissue (DAAT) index and dietary intake in patients with acute coronary syndrome (ACS).

Methods:

This is a cross-sectional study conducted with patients ≥ 18 years of age admitted to a tertiary hospital. Sociodemographic, clinical, and anthropometric (body weight [kg], height [m], waist, hip and neck circumferences [cm]) data were evaluated. A food frequency questionnaire was applied to identify each patient’s nutrient intake. The DAAT index was calculated according to specific formulas for men and women. Possible association between food intake and the DAAT index was evaluated by multiple linear regression. The level of significance adopted was 0.05.

Results:

This study evaluated 138 patients, with a mean age of 61.2±10.8 years. Prevalence of obesity was 29.4% in men and 37.7% in women. Regarding waist circumference, 83% of the women showed values considered to be very high. The DAAT index was significantly higher in men when compared to woman (P < 0.0001) and proved to be positively correlated with proteins (r= 0.22, P= 0.01) and monounsaturated fatty acid (r= 0.18, P= 0.04) intake in the entire sample. After adjustment for sex, alcohol consumption, and levels of physical activity, the DAAT index was associated with the female sex (B= −129.84, P <0.001) and a sedentary lifestyle (B= 57.99, P <0.001).

Conclusion:

dSAT estimated by the DAAT index was not associated with dietary intake in patients with ACS.

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Original Article

Lifestyle Intervention in Reducing Cardiometabolic Risk Factors in Students with Dyslipidemia and Abdominal Obesity: A Randomized Study

Heloisa Pamplona-Cunha et al. Nilton Rosini Roberta Caetano Marcos José Machado Edson Luiz da Silva

Abstract

Background

The long incubation periods of cardiovascular diseases offer opportunities for controlling risk factors. In addition, preventive interventions in childhood are more likely to succeed because lifestyle habits become ingrained as they are repeated.

Objective

To investigate the effects of recreational physical activities, in combination or not with a qualitative nutritional counseling, in cardiometabolic risk factors of students with dyslipidemia and abdominal obesity.

Methods

Students (8-14 years old) were randomly divided into three groups (n=23 each): i ) Control; ii ) PANC, students undergoing Physical Activity and Nutritional Counseling, and iii ) PA, students submitted to Physical Activity, only. Blood samples (12-h fasting) were collected for biochemical analysis and anthropometric markers were also assessed. Two-Way RM-ANOVA and Holm-Sidak’s test, and Friedman ANOVA on Ranks and Dunn’s test were applied. P ≤ 0.05 was considered significant. Effect sizes were evaluated by Hedges’ g and Cliff’s δ for normal and non-Gaussian data, respectively.

Results

Compared to the control group and to baseline values, both interventions caused significant average reductions in total cholesterol (11%; p <0.001), LDL-c (19%; p=0.002), and non-HDL-c (19%; p=0.003). Furthermore, students in the PANC group also experienced a significant decrease in body fat compared to baseline (p=0.005) and to control (5.2%; g=0.541).

Conclusions

The proposed strategies were effective to reduce cardiometabolic risk factors in children and adolescents. The low cost of these interventions allows the implementation of health care programs in schools to improve the students’ quality of life.

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Review Article

Reperfusion Strategies in Acute Myocardial Infarction: State of the Art

Fernando Oswaldo Dias Rangel

Abstract

ST elevation myocardial infarction (STEMI) is a highly prevalent condition worldwide. Reperfusion therapy is strongly associated with the prognosis of STEMI and must be performed with a high standard of quality and without delay. A systematic review of different reperfusion strategies for STEMI was conducted, including randomized controlled trials that included major cardiovascular events (MACE), and systematic reviews in the last 5 years through the PRISMA ( Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology. The research was done in the PubMed and Cochrane Central Register of Controlled Trials databases, in addition to a few manual searches. After the exclusion criteria were applied, 90 articles were selected for this review. Despite the reestablishment of IRA patency in PCI for STEMI, microvascular lesions occur in a significant proportion of these patients, which can compromise ventricular function and clinical course. Several therapeutic strategies – intracoronary administration of nicorandil, nitrates, melatonin, antioxidant drugs (quercetin, glutathione), anti-inflammatory substances (tocilizumab [an inhibitor of interleukin 6], inclacumab, P-selectin inhibitor), immunosuppressants (cyclosporine), erythropoietin and ischemic pre- and post-conditioning and stem cell therapy – have been tested to reduce reperfusion injury, ventricular remodeling and serious cardiovascular events, with heterogeneous results: These therapies need confirmation in larger studies to be implemented in clinical practice

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Original Article

Emergency Department Visits and Deaths from Cardiovascular Diseases at a Referral Center for Cardiology During the COVID-19 Pandemic

Luis Sérgio Carvalho Luciano et al. Luiz Eduardo Koenig São Thiago Isabela de Carlos Back Leandro Waldrich … Luiza Di Bernardi de São Thiago Amabile Rodrigues Alves Beatriz Campos Comelli Mariane Janning Santos Luiz Carlos Giuliano

Abstract

Background

The COVID-19 pandemic has imposed measures of social distancing and, during this time, there has been an elevation in cardiovascular mortality rates and a decrease in the number of emergency visits.

Objectives

To assess and compare in-hospital mortality for cardiovascular diseases and emergency department visits during the COVID-19 pandemic and the same period in 2019.

Methods

Retrospective, single-center study that evaluated emergency visits and in-hospital deaths between March 16, 2020 and June 16, 2020, when the steepest fall in the number of emergency admissions for COVID-19 was registered. These data were compared with the emergency visits and in-hospital deaths between March 16 and June 16, 2019. We analyzed the total number of deaths, and cardiovascular deaths. The level of significance was set at p < 0.05.

Results

There was a 35% decrease in the number of emergency visits and an increase in the ratio of the number of deaths to the number of emergency visits in 2020. The increase in the ratio of the number of all-cause deaths to the number of emergency visits was 45.6% and the increase in the ratio of the number of cardiovascular deaths to the number of emergency visits was 62.1%. None of the patients who died in the study period in 2020 tested positive for COVID-19.

Conclusion

In-hospital mortality for cardiovascular diseases increased proportionally to the number of emergency visits during the COVID-19-imposed social distancing compared with the same period in 2019. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Original Article

Cardiovascular Risk Assessment after COVID-19 Infection before Resuming Sports Activities – Practical Flowchart and Meta-Analysis

Luís Puga et al. Paulo Dinis Rogério Teixeira Joana Maria Ribeiro … Hélder Dores Lino Gonçalves

Abstract

Background:

The risk of sports-related sudden cardiac arrest after COVID-19 infection can be a serious problem. There is an urgent need for evidence-based criteria to ensure patient safety before resuming exercise.

Objective:

To estimate the pooled prevalence of acute myocardial injury caused by COVID-19 and to provide an easy-to-use cardiovascular risk assessment toolkit prior to resuming sports activities after COVID-19 infection.

Methods:

We searched the Medline and Cochrane databases for articles on the prevalence of acute myocardial injury associated with COVID-19 infection. The pooled prevalence of acute myocardial injury was calculated for hospitalized patients treated in different settings (non-intensive care unit [ICU], ICU, overall hospitalization, and non-survivors). Statistical significance was accepted for p values <0.05. We propose a practical flowchart to assess the cardiovascular risk of individuals who recovered from COVID-19 before resuming sports activities.

Results:

A total of 20 studies (6,573 patients) were included. The overall pooled prevalence of acute myocardial injury in hospitalized patients was 21.7% (95% CI 17.3-26.5%). The non-ICU setting had the lowest prevalence (9.5%, 95% CI 1.5-23.4%), followed by the ICU setting (44.9%, 95% CI 27.7-62.8%), and the cohort of non-survivors (57.7% with 95% CI 38.5-75.7%). We provide an approach to assess cardiovascular risk based on the prevalence of acute myocardial injury in each setting.

Conclusions:

Acute myocardial injury is frequent and associated with more severe disease and hospital admissions. Cardiac involvement could be a potential trigger for exercise-induced clinical complications after COVID-19 infection. We created a toolkit to assist with clinical decision-making prior to resuming sports activities after COVID-19 infection.

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Case Report

Isolated Left Ventricular Apical Hypoplasia without Lamin A/C Gene Mutation

Paulo Henrique Manso et al. Veridiana Kiill Suazo Fernando Tadeu Vasconcelos Amaral Mauro Cruz Jurca Henrique Simão Trad

Abstract

Isolated left ventricular apical hypoplasia is a rare cardiomyopathy, with a broad range of clinical presentations. Since this entity was already described in association with osteomuscular diseases, mutation in the Lamin A/C gene has been regarded as a possible cause of this disease. This study describes the case of an asymptomatic teenager with isolated left ventricular apical hypoplasia and arthrogriposis but with no mutations in the entire Lamin A/C gene.

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Case Report

Pulmonary Embolism in Patients with Covid-19 in Direct Oral Anticoagulant

Fabio Augusto De Luca et al. Guilherme Arruda Vinicius Esteves André Feldman … Ítalo Bruno dos Santos Sousa José Célio Vieira Brandão Raquel Muarrek Garcia Olga Ferreira de Souza

Introduction

The global pandemic caused by the new coronavirus (COVID-19) has been promoting major challenges and unprecedented clinical decisions in the medical scenario. Currently, according to the World Health Organization, the disease affects over 185 countries, with over 12 million people infected and nearly 500 thousand deaths.

Among the most serious manifestations of the syndrome, the high prevalence of thromboembolic events, up to 31% of the patients hospitalized in intensive care units, according to an international series, calls attention.^– Different mechanisms of action related to the infection by SARS-CoV-2 may be related to thrombosis: excessive inflammation, tissue hypoxia, immobilization, and disseminated intravascular coagulation (DIC); however, one question remains: Is the etiology linked to some specific effect of the virus or a reflex of the severity of the case? Despite the anticoagulant therapy emerging as a major weapon in the therapeutic arsenal, data is still scarce in the literature regarding the efficacy and safety of warfarin or direct oral anticoagulants (DOAC) in this specific setting. It should be highlighted that, of the 1.5 million people currently infected in Brazil, a significant number present a history of cardiovascular disease and are presently taking anticoagulants. This class of drugs may show serious interactions with investigational therapies currently employed for COVID-19, which could increase the risk of thrombotic or hemorrhagic events. In this context, it becomes imperative to highlight that the thrombosis associated with COVID-19 and anticoagulant therapy is a unique scenario and must be investigated.

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