Gostaria de parabenizar Accarini e Godoy1, autores do artigo "Doença periodontal como potencial fator de risco para síndromes coronarianas agudas" publicado na edição de novembro de 2006 dos
Levando em consideração a associação entre DP e DAC2, e que a prevenção e o tratamento da DP podem ser realizados de modo rotineiro pelos serviços de saúde, acredito que o exame da cavidade oral deveria fazer parte da avaliação de risco cardiovascular dos pacientes de meia-idade, principalmente os de risco intermediário, nos casos em que métodos mais caros de avaliação (como, por exemplo, dosagem de proteína C-reativa ultra-sensível)3 não estejam disponíveis de forma usual na prática clínica.
Faculdade de Medicina de São José do Rio Preto
São José do Rio Preto, SP
1. Accarini R, Godoy MF. Periodontal disease as a potential risk factor for acute coronary syndromes. Arq Bras Cardiol. 2006; 87:592-6.
2. Beck JD, Eke P, Heiss G, Madianos P, Couper D, Lin D, et al. Periodontal disease and coronary heart disease: a reappraisal of the exposure. Circulation. 2005; 112 (1):19-24.
3. Cushman M, Arnold AM, Psaty B, Manolio TA, Peterson D, Stehman-Breen C, et al. C-Reactive protein and the 10-year incidence of coronary heart disease in older men and women: the cardiovascular health study. Circulation. 2005; 112:25-31.
Agradecemos os importantes comentários feitos por Martin JFV a nosso trabalho1. Ressaltamos que, apesar de coletados, os fatores de risco clássicos não foram analisados especificamente, porque o estudo era em pacientes que já se apresentavam com síndromes coronarianas agudas e, portanto, já deveriam ser portadores, em grande escala, de associações com os referidos fatores.
Em atenção à solicitação do ilustre comentarista, informamos que o índice de massa corporal, o colesterol total e suas frações (HDL, LDL e VLDL), assim como os níveis séricos de triglicérides e a glicemia em jejum foram tratados como variáveis quantitativas e comparadas com o auxílio do teste de Kruskal-Wallis, em termos de presença ou ausência de coronariopatia obstrutiva. Não foram detectadas diferenças significantes entre os grupos. A variável tabagismo foi tratada como categórica e avaliada globalmente com o teste do qui-quadrado, encontrando-se valor de p de 0,0373.
A subanálise intragrupos demonstrou diferença significante apenas entre os grupos sem doença periodontal e sem coronariopatia
Em resumo, em uma amostra selecionada de pacientes com quadro clínico de doença coronariana aguda, nos quais a presença de coronariopatia obstrutiva foi constatada por cateterismo cardíaco, os fatores de risco convencionais não foram suficientes para separar os grupos com e sem obstrução, o mesmo não ocorrendo com a presença de doença periodontal ativa, indicando que essa afecção pode ser considerada elemento isolado de risco para a ocorrência de quadros agudos de insuficiência coronariana. Dessa forma, concordamos com a sugestão de Martin relativa à inclusão do exame periodontal no rol de investigação da doença coronariana. Agradecemos mais uma vez seus comentários, que permitiram complementar os resultados publicados.
Hospital de Base da Fundação Faculdade Regional de Medicina (FUNFARME)
Faculdade de Medicina de São José do Rio Preto (FAMERP)
Curso de Pós-Graduação em Ciências da Saúde da FAMERP
São José do Rio Preto, SP
1. Accarini R, Godoy MF. Periodontal disease as a potential risk factor for acute coronary syndromes. Arq Bras Cardiol. 2006;87:592-6.
I would like to congratulate Accarini e Godoy1, authors of the article "Periodontal Disease as a Potential Risk Factor for Acute Coronary Syndromes (Arq Bras Cardiol 2006; 87:592-6), a subject still underexplored in the medical literature. I have noted the authors’ concern in classifying periodontal disease (PD) as accurately as possible, using several definitions since a universal standardization is still lacking. PD was found to be associated with obstructive coronary disease, and therefore should be regarded as a risk factor for the development of coronary artery disease (CAD). However, it would be interesting if Accarini described the presence of other risk factors for CAD in the sample studied, to assess precisely the relevance of periodontitis as a risk factor, either alone or associated with other well known risk factors.
Considering the association between PD and CAD2, and also that PD prevention and treatment may be routinely carried out by health services, I believe that oral cavity examination should be part of cardiovascular risk assessment in middle-aged patients, particularly those of intermediate risk, when more expensive methods (such as high-sensitivity CRP)3 are not usually available in the clinical practice.
Faculdade de Medicina de São José do Rio Preto
São José do Rio Preto, SP
1. Accarini R, Godoy MF. Periodontal disease as a potential risk factor for acute coronary syndromes. Arq Bras Cardiol. 2006; 87:592-6.
2. Beck JD, Eke P, Heiss G, Madianos P, Couper D, Lin D, et al. Periodontal disease and coronary heart disease: a reappraisal of the exposure. Circulation. 2005; 112 (1):19-24.
3. Cushman M, Arnold AM, Psaty B, Manolio TA, Peterson D, Stehman-Breen C, et al. C-Reactive protein and the 10-year incidence of coronary heart disease in older men and women: the cardiovascular health study. Circulation. 2005; 112:25-31.
We appreciate the important comments made by JFV Martin on our work1. We should like to point out that, although collected, the classic risk factors were not studied specifically because the study was on patients that already presented acute coronary syndromes and, therefore, would have, on a broad scale, associations with said factors.
With respect to the eminent commentator’s request, we inform that the body mass index, total cholesterol and its fractions (HDL, LDL, and VLDL), as well as serum triglyceride levels and fasting glucose, were treated as quantitative variables and compared using the Kruskal-Wallis test in terms of presence or absence of obstructive coronary artery disease. No significant differences were detected among the groups. The smoking variable was treated as a category and evaluated globally through use of the chi-square test, and a p value of 0.0373 was found.
The intragroup subanalysis showed significant difference only among the groups not having periodontal disease or coronary artery disease versus the groups having periodontal disease and coronary artery disease (p = 0.0079, two-tailed Fisher’s exact test) and between the groups having periodontal and coronary artery disease versus those being edentulous and having coronary artery disease (p = 0.0067; two-tailed Fisher’s exact test); the association of smoking with the presence of periodontal disease was always indicated. It should be emphasized that, although an association exists between periodontal disease and smoking, there was no association between the presence of obstructive coronary artery disease and smoking (p = 0.2381; two-tailed Fisher’s exact test),
In sum, in a sample of selected patients with acute coronary artery disease, in whom the presence of obstructive coronary disease was detected by cardiac catheterization, the conventional risk factors were not sufficient to separate the groups with and without obstruction. The same did not occur with the presence of active periodontal disease, indicating that this condition may be considered an isolated risk factor for syndromes. Consequently, we agree with Martin’s suggestion regarding inclusion of periodontal examination when investigating the presence of coronary artery disease. Once again we thank him for his comments, which have allowed us to complement the results published.
Hospital de Base da Fundação Faculdade Regional de Medicina (FUNFARME)
Faculdade de Medicina de São José do Rio Preto (FAMERP)
Curso de Pós-Graduação em Ciências da Saúde da FAMERP
São José do Rio Preto, SP
1. Accarini R, Godoy MF. Periodontal disease as a potential risk factor for acute coronary syndromes. Arq Bras Cardiol. 2006;87:592-6.