A Variação Anormal da Pressão Arterial Circadiana está Associada aos Escores SYNTAX em Pacientes Hospitalizados com Síndrome Coronariana Aguda

Background Blunted nocturnal blood pressure (BP) reduction, referred to as non-dipper hypertension, is a strong predictor of cardiovascular morbidity and mortality.Objectives This study aimed to investigate the relationship between non-dipper hypertension and the severity and complexity of coronary artery disease using SYNTAX score in hospitalized patients with acute coronary syndrome.Methods A total of 306 consecutive patients with acute coronary syndrome were screened. Patients who were clinically stable and admitted to the intermediate intensive care unit at least 24 hours after angiography and/or successful revascularization. After the exclusion criteria, 141 patients (34 female and 107 male; mean age 61 ± 11 years) were included. Non-dipper hypertension has been defined as a 0% to 10% decrease in average systolic BP at nighttime compared to daytime, measured at hourly intervals using the same automatic BP measuring device on bedside monitors (Vismo PVM-2701; Nihon Kohden Corp., Tokyo, Japan). SYNTAX score was calculated with an online calculator. The independent predictors of SYNTAX score were assessed using multivariable logistic regression analysis. P < 0.05 was considered statistically significant.Results The patients with non-dipper hypertension had higher SYNTAX score than the patients with dipper hypertension (11.12 ± 6.41 versus 6.74 ± 6.45, p < 0.0001). In a multivariable logistic regression model, non-dipper hypertension status (odds ratio: 5.159; 95% confidence interval: 2.246 to 11.852, p < 0.001), sex (p = 0.012) and low-density lipoprotein cholesterol (p = 0.008) emerged as independent predictors of high SYNTAX score.Conclusions The results of our study provide a possible additional mechanism linking abnormal circadian BP profile with coronary artery disease severity and complexity in patients with acute coronary syndrome.     

Associação do Genótipo e Fenótipo da Paraoxonase-1 com Angiografia Positiva para Doença Arterial Coronariana

BackgroundIt has been shown that increased serum PON1 levels are protective against several disorders. Several single nucleotide polymorphisms (SNPs) of the PON1 gene have been reported to be associated with serum enzyme protein levels and activity.ObjectiveTo investigate the association of SNPs of PON1 and serum paraoxonase activity with coronary artery disease (CAD).MethodsA total of 601 unrelated patients who underwent coronary angiography including those who had >50% stenosis (N=266) and those with <30% stenosis (N=335) were studied. The Paraoxonase gene rs662 and rs840560 SNPs were determined using the ARMS-PCR method and the rs705379 SNP was genotyped using PCR-RFLP analysis. Serum paraoxonase activity was measured using paraoxon as a substrate. A p value of p<0.05 was considered as significant.ResultsSerum paraoxonase activity was not significantly different between the study groups. After adjustment for age, sex, hypertension, diabetes mellitus and dyslipidemia, the GG genotype and co-dominant model of rs662 was positively associated with a positive angiogram (respectively, OR=2.424, 95%CI [1.123-5.233], p<0.05, OR=1.663, 95%CI [1.086-2.547]). Serum paraoxonase activity was significantly higher in the G allele and GG variant of rs662, A allele and AA variant of rs854560 and C allele and CC variant of rs705379. The haplotype analysis has shown that the ATC haplotype was significantly more prevalent among the angiogram negative group. The analysis between groups indicated that the A allele of rs662 was significantly associated with lower paraoxonase activity in the positive angiogram group (p=0.019).ConclusionsThe presence of the G allele of the rs662 single nucleotide polymorphism is independently associated to increased risk of CAD.     

A Associação de TWEAK com Calcificação da Artéria Coronária em Pacientes com Doença Renal Crônica

BackgroundThe soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) is a member of the TNF superfamily that plays a critical role in proliferation and inflammation in the arterial circulation.ObjectivesThis prospective study aimed to show the relationship between the sTWEAK levels and coronary artery calcification (CAC) in patients with chronic kidney disease (CKD).MethodsThis prospective study included 139 consecutive patients undergoing computed coronary angiography for any reason except for acute coronary syndromes from August 2020 to February 2021. A total of 12 patients were excluded from the study due to exclusion criteria. Patients were divided into two groups with regard to having a CAC score of less than 400 (n=84) and 400 or more (n=43). Significance was assumed at a 2-sided p<0.05.ResultsAs the CAC score increased, sTWEAK levels presented a statistically significant decrease, and a strong relationship between sTWEAK levels and the CAC score (r: -0.779, p<0.001) was observed. The ROC analysis revealed that the optimal cut-off level of sTWEAK for predicting the CAC score of 400 was 761 pg/mL with a sensitivity of 71% and a specificity of 73% (AUC: 0.78; 95% CI:0.70-0.85; p < 0.001)ConclusionsEven though the large-scale studies showed a positive correlation between eGFR and the sTWEAK levels, some studies found the increased sTWEAK levels to be associated with mortality and the severity of the coronary artery system in patients with CKD. Our results support our hypothesis that the sTWEAK level shows coronary calcification rather than other types of atherosclerotic plaques.     

Avaliação da Circulação Coronariana após a Cirurgia de Jatene

BackgroundCoronary artery evaluation remains after arterial switch operation a clinical challenge.ObjectiveThis study aims to correlate anatomical changes diagnosed by cardiac computed tomography (CCT) with physiological alterations on clinical evaluation to diagnose coronary obstruction in late ASO patients.MethodsThis study included 61 consecutive patients with mean age of 9.4 years who underwent ASO. The patients were submitted to echocardiography, electrocardiography, cardiopulmonary exercise test, and cardiac computed tomography to evaluate functional capacity and coronary artery anatomy.ResultsCardiac computed tomography revealed that only 3.3% of the patients had coronary stenosis. These patients were asymptomatic, and no signs of myocardial ischemia were detected by the tests.ConclusionThe incidence of coronary abnormalities in late ASO patients was 3.3% in our cohort. There is no clear guideline as to why, when, and how these patients should be screened or what to propose when a coronary obstruction is diagnosed in asymptomatic patients.     

O Prognóstico da Doença Arterial Coronariana em um Hospital Público no Brasil: Achado do Estudo ERICO

BackgroundLong-term prognosis post-acute coronary syndrome (ACS) in secondary care is not well-known. The severity of coronary artery disease (CAD) as a predictor of long-term mortality was evaluated in a community hospital in Brazil.ObjectiveWe aimed to compare short and long-term prognosis after an ACS event according to severity of obstructive disease in patients attended in a secondary community hospital from prospective CAD cohort in Brazil (the Strategy of Registry of Acute Coronary Syndrome, ERICO study).MethodsSurvival analyses were performed by Kaplan-Meier curves and Cox proportional hazard models (hazard ratios (HR) with respective 95% confidence interval (CI) to evaluate cumulative all-cause, CVD and CAD mortality according the coronary artery obstruction: no-obstruction (reference group), 1-vessel-disease, 2-vessel-disease, multivessel-disease) among 800 adults from an ERICO study during a 4-year-follow-up. HR are presented as crude and further adjusted for potential confounders from 180 days to 4-year follow-up after ACS. A p-value <0.05 was considered statistically significant.ResultsPoorer survival rates were detected among individuals with multivessel-disease (all-cause, CVD and CAD, p-log rank< 0.0001). After multivariate adjustments, multivessel-disease |(HR; 2.33 (CI 95%; 1.10-4.95)) and 1-vessel-disease obstructed (HR; 2.44 (CI 95%; 1.11-5.34)) had the highest risk for all-cause mortality compared to those with no obstruction at 4-year follow-up.ConclusionsNot only multivessel-disease, but also 1-vessel-disease patients showed a high long-term mortality risk post-ACS. These findings highlight the importance of having a better approach in the treatment and control of cardiovascular risk even in apparently low-risk individuals attended to in secondary care.     

Associação entre Ácido Úrico Sérico e Pré-Hipertensão e Hipertensão entre Adultos Chineses

BackgroundUric acid (UA), the end product of purine nucleotide metabolism, participates in the processes of metabolic and cardiovascular diseases. Experimental evidence suggests it is an important mediator in the physiological response to blood pressure increase.ObjectiveTo evaluate the association between serum UA levels and pre-hypertension and hypertension in a Chinese population.MethodsA cross-sectional study was conducted from March to September 2017, and 1,138 participants aged 35 to 75 were enrolled in this study, where 223 normotensive, 316 pre-hypertensive, and 599 hypertensive subjects were selected to evaluate the association between serum UA levels and hypertension. A p-value <0.05 was considered statistically significant.ResultsSerum UA levels were significantly higher in the pre-hypertension and hypertension group compared to the control group in the entire population (p<0.05 for all). Quantitative trait analysis indicated that serum UA levels were (2.92±0.81, 3.06±0.85, 3.22±0.98 mg/d) linearly increased in normotensive, pre-hypertensive and hypertensive females, with a p value of 0.008. Serum UA levels in the quartiles were positively correlated with DBP (p<0.05), particularly in females. After adjusting for age, gender, body mass index (BMI), glucose (GLU), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), the odds ratios (ORs) and 95% confidence intervals (CIs) of pre-hypertension from the lowest (referent) to the highest levels of serum UA were 1.718 (1.028–2.872), 1.018 (0.627–1.654) and 1.738 (1.003–3.010). Additionally, the second quartile of serum UA levels were significantly associated with hypertension, with an OR (95% CI) of 2.036 (1.256–3.298).ConclusionsThis study suggests that higher serum UA levels are positively associated with pre-hypertension and hypertension among Chinese adults.     

Associação entre a Gravidade da Doença Arterial Coronariana e Câncer de Pulmão: Um Estudo Piloto Transversal

BackgroundThe direct relationship between coronary artery disease (CAD) and lung cancer is not well known.ObjectiveTo investigate the association between the anatomical severity of CAD and lung cancer.MethodsThree-hundred study patients, including 75 recently diagnosed lung cancer patients and 225 matched non-cancer patients, underwent coronary angiography during hospitalization without previous percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The SYNTAX score (SXscore) was used to assess the severity of CAD. A high SXscore (SXhigh) grade was defined as SXscore > 15 (the highest quartile of the SXscore). The Cochran-Armitage test for trend was used to assess the distribution of patients’ SXscores. Logistic regression analysis was used to assess the association between the severity of CAD and lung cancer. P-values were set when significance level was 5%.ResultsThe distribution trend of patients’ SXscore by quartiles was different between lung cancer patients and control patients (from the lowest to the highest quartile: 20.0%, 20.0%, 24.0%, 36.0% vs. 26.7%, 26.2%, 25.8%, 21.3%, p=0.022). The SX high rate was higher in lung cancer patients than in control patients (36.0% vs. 21.3%, p=0.011).The highest quartile of the SXscore showed higher risk of lung cancer in comparison to the lowest quartile (OR: 2,250, 95%CI: 1,077 to 4,699 ; P-trend= 0.016). After adjustment, patients in the highest quartile of the SXscore had higher risk of lung cancer (OR: 2,149, 95%CI: 1,008 to 4,584; P-trend= 0.028). Patients with high SXscore (> 15) had 1,985 times more chances of having lung cancer (95%CI: 1,105–3,563, P= 0.022).ConclusionsThe anatomical severity of CAD is associated with the risk of lung cancer, which indicates that a thorough lung cancer screening may be significant among severe CAD patients.     

Impacto da Concentração de Ácido Úrico Sérico no Risco de Doença Cardiovascular: Um Estudo Coorte Realizado no Norte da China

BackgroundThe results of previous studies of the relationship between serum uric acid (SUA) and the risk of cardiovascular disease (CVD) have been inconsistent due to confounding factors caused by other known cardiovascular risk factors.ObjectivesThis study aimed to evaluate the relationship between SUA and incident CVD in middle-aged and elderly Chinese people, who were stratified according to body mass index (BMI).MethodsThis study recruited 5,721 participants of 40–75 years of age, who were free of CVD at baseline and who underwent follow-up from 2008 to 2017. Participants were categorized in SUA quintiles. Cox proportional hazard and Kaplan-Meier survival analysis were used to compare CVD incidence among the SUA groups. The correlations between SUA and CVD incidence in groups with differing BMI and waist circumference (WC) were also analyzed. A P value <0.05 was considered statistically significant.ResultsDuring a mean follow-up period of 7.6 years, CVD incidence increased with SUA (log-rank test p<0. 001). Compared with the first quintile, the adjusted hazard ratios (95% confidence interval (CI)) for the development of CVD were 1.08 (0.78–1.65), 1.17 (0.88–1.77), 1.47 (1.12–2.21), and 1.68 (1.28–2.44) for the second to fifth quintiles, respectively. This relationship was clearer in participants with normal BMI and WC. The adjusted hazard ratio for each 100 μmol/L increase in SUA was 1.13 (95% CI: 1.02–1.39) for CVD events.ConclusionsHigh SUA is an independent risk factor for CVD in middle-aged and elderly northern Chinese people. This effect is maintained even after stratification according to measures of leanness/obesity.     

Escore de Cálcio Coronário e Estratificação do Risco de Doença Arterial Coronariana em Pacientes com Acidente Vascular Encefálico Isquêmico Aterosclerótico e não-Aterosclerótico

BackgroundIschemic Stroke (IS) and Coronary Artery Disease (CAD) frequently coexist and share atherosclerotic disease risk factors. According to the American Heart Association, IS subtypes may be considered CAD risk equivalents, but the evidence for non-atherosclerotic IS is uncertain. Additionally, the Coronary Calcium Score (CCS) is an accurate marker to address CAD risk; however, CCS distribution between IS subtypes is not well characterized.ObjectivesTo compare the CCS between atherosclerotic and non-atherosclerotic IS groups; and to determine which covariates were associated with high CCS in IS.MethodsThis cross-sectional design included all patients with IS, 45 to 70 years of age at the time of the stroke, consecutively admitted to a rehabilitation hospital between August 2014 and December 2016, without prevalent CAD. All patients underwent CT scanning for CCS measurement. CCS≥100 was considered a high risk for CAD, with a significance level of p<0.05.ResultsFrom the 244 studied patients (mean age 58.4±6.8 years; 49% female), 164 (67%) had non-atherosclerotic etiology. The proportions of CCS≥100 were similar between the atherosclerotic and the non-atherosclerotic groups (33% [n=26] x 29% [n=47]; p= 0.54). Among all IS patients, only age ≥60 years was independently associated with CCS≥100 (OR 3.5; 95%CI 1.7-7.1), accounting for hypertension, dyslipidemia, diabetes, sedentarism, and family history of CAD.ConclusionAtherosclerotic IS did not present a greater risk of CAD when compared to non-atherosclerotic IS according to CCS. Only age ≥60 years, but not etiology, was independently associated with CCS≥100.     

Medição do Fluxo Sanguíneo Coronário em Angiogramas Coronários Convencionais por um Novo Método Baseado na Detecção da Densidade de Contraste. Uma Visão Fisiológica

Background TIMI flow grade and corrected TIMI frame count (CTFC) are widely used methods to evaluate angiographic coronary blood flow. Measurement of coronary blood flow (CBF) on standard coronary angiography (CAG) has aroused great interest recently, trying to combine the CTFC concept with new methods for post-angioplasty and for cardiac syndrome X assessment. Additionally, coronary slow flow it is now considered a major criterion for microvascular angina.Objective Explore a new approach of quantitative angiographic measurement of CBF based on densitometric contrast detection in CAG off-line, using an accessible software to obtain a more precise and reliable CBF assessment.Methods Thirty patients were studied and divided in 2 groups, normal coronary blood flow (NF) and slow coronary blood flow (SF), according to CTFC definition. The DM was applied to the study sample to differentiate between NF and SF. Non-parametric statistics was used to assess differences between groups at p<0.05.Results The DM normal reference value obtained for coronary blood flow was 9 [5–10] frames. NF vs SF group were compared and expressed as median [interquartile range], for the left anterior descending: 10 [7-11] vs 21 [8-33];p= 0.016; circumflex: 9 [4-13] vs 14 [11-30]; p= 0.012 and right coronary artery: 5 [3-11] vs 13 [8-26]; p=0.009.Conclusion The DM showed the feasibility of measuring coronary blood flow with precision, consistency and reproducible in a standard coronary angiogram, showing the additional capability to differentiate between NF and SF in chest pain patients with normal coronary arteries. (Arq Bras Cardiol. 2020; 115(3):503-512)     

Controle da Pressão Arterial e Fatores Associados em um Serviço Multidisciplinar de Tratamento da Hipertensão

BackgroundAlthough team-based care is recommended for patients with hypertension, results of this intervention in a real-world setting are missing in the literature.ObjectiveTo report the results of a real-world long-term team-based care for hypertensive patients we conducted this study.MethodsData of hypertensive patients attending a multidisciplinary treatment center located in the Midwest region of Brazil in June 2017 with at least two follow-up visits were retrospectively assessed. Anthropometric, blood pressure (BP), follow-up time, pharmacological treatment, diabetes and lifestyle data were collected from the last visit to the service. BP values < 140 x 90 mmHg in non-diabetics and < 130 x 80 mmHg in diabetics were considered controlled. A logistic regression model was built to identify variables independently associated to BP control. Significance level adopted p < 0.05.ResultsA total of 1,548 patients were included, with a mean follow-up time of 7.6 ± 7.1 years. Most patients were female (73.6%; n=1,139) with a mean age of 61.8 ±12.8 years. BP control rates in all the sample, and in non-diabetics and diabetics were 68%, 79%, and 37.9%, respectively. Diabetes was inversely associated with BP control (OR 0.16; 95%CI 0.12-0.20; p<0.001) while age ≥ 60 years (OR 1.48; 95%CI 1.15-1.91; p=0.003) and female sex (OR 1.38; 95%CI 1.05-1.82; p=0.020) were directly associated.ConclusionsA BP control rate around 70% was found in patients attending a multidisciplinary team care center for hypertension. Focus on patients with diabetes, younger than 60 years and males should be given to further improve these results. (Arq Bras Cardiol. 2020; 115(2):174-181)     

Comparação das Novas Equações de Martin/Hopkins e Sampson para o Cálculo do Colesterol de Lipoproteína de Baixa Densidade em Pacientes Diabéticos

BackgroundThe accurate determination of low-density lipoprotein cholesterol (LDL-C) is important to reach guideline-recommended LDL-C concentrations and to reduce adverse cardiovascular outcomes in diabetic patients. The commonly used Friedewald equation (LDL-Cf), gives inaccurate results in diabetic patients due to accompanying diabetic dyslipidemia. Recently two new equations – Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) – were developed to improve the accuracy of LDL-C estimation, but data are insufficient to suggest the superiority of one equation over the other one.ObjectiveThe present study compared the accuracy and clinical usefulness of novel Martin/Hopkins and Sampson equations in diabetic patients.MethodsThis study included 402 patients with diabetes. Patients’ cardiovascular risk and LDL-C targets were calculated per European guidelines. Calculated LDL-Cmh, LDL-Cs, and LDL-Cf concentrations were compared with direct LDL-C concentration (LDL-Cd) to test agreement between these equations and LDL-Cd. A p-value <0.05 was accepted as statistically significant.ResultsBoth LDL-Cmh and LDL-Cs had a better agreement with LDL-Cd as compared to LDL-Cf, but no statistical differences were found among novel equations for agreement with LDL-Cd (Cronbach’s alpha 0.955 for both, p=1). Likewise, LDL-Cmh and LDL-Cs showed a similar degree of agreement with LDL-Cd in determining whether a patient was in a guideline-recommended LDL-C target (96.3% for LDL-Cmh and 96.0% for LDL-Cs), which were marginally better than LDL-Cf (94.6%). In patients with a triglyceride concentration >400 mg/dl, agreement with LDL-Cd was poor, regardless of the method used.ConclusionMartin/Hopkins and Sampson’s equations show a similar accuracy for calculating LDL-C concentrations in patients with diabetes, and both equations were marginally better than the Friedewald equation.