Estratificação de Risco e Avaliação da Atividade Simpática Cardíaca Utilizando Imagem Miocárdica com [123I] MIBG na Denervação Renal

Hyperactivation of the sympathetic nervous system plays a central role in the pathophysiology of hypertension. The aim of this study was to assess cardiac sympathetic activity and investigate the role of myocardial¹²³I-labelled meta-iodo benzyl guanidine ([¹²³I] MIBG) scintigraphy in cardiovascular risk stratification of patients with resistant hypertension treated with renal denervation (RDN). Eighteen patients were included in this prospective study (mean age 56 ± 10 years old, 27.8% females). Transthoracic echocardiogram, general blood analysis and myocardial ([123I] MIBG scintigraphy were performed before and six-months after RDN. A patient was considered a responder (R) if a drop ≥ 5mmHg on mean systolic ambulatory blood pressure (BP) monitoring was observed at the six-month follow-up. 66.7% of patients were R (drop in systolic BP of 20.6 ± 14.5mmHg, vs minus 8 ± 11.6mmHg in non-responders (NR), p=0.001). Early heart-mediastinum ratio (HMR) was significantly lower at baseline in the R group (1.6 ± 0.1 vs 1.72 ± 0.1, p<0.02) but similar at six months. Considering both instants in time, the R group had lower early HMR values than the NR group (p<0.05). Both the late HMR and the washout rate were identical and no significant correlation between response to RDN or any MIBG imaging index was found. Renal denervation effectively lowered blood pressure in the majority of patients but [¹²³I] MIBG was not useful in predicting the response. However, there was evidence of sympathetic overdrive and, both early and late HMR were overall reduced, probably putting this population at a higher risk of adverse events.     

História Familiar de Hipertensão Prejudica o Balanço Autonômico,mas não a Função Endotelial em Jovens Jogadores de Futebol

BackgroundThe family history of hypertension (FHH) imposes consistent risk for diverse chronic diseases that are accompanied by hypertension. Furthermore, the heart rate variability (HRV) and flow-mediated dilation (FMD) are both related to maximal oxygen uptake (VO_2max), and are usually impaired during hypertensionObjectiveTo compare the autonomic modulation, the endothelial function (EF) and maximum oxygen uptake (VO_2max) of young athletes, separated according to their parents’ blood pressure (BP) history, in order to study the influence of their genetic background on those parameters.MethodsA total of 46 young male soccer players (18±2 years of age) were divided into four groups: 1-normotensive father and mother (FM-N); 2-only father was hypertensive (F-H); 3-only mother was hypertensive (M-H); 4-father and mother were hypertensive (FM-H). Measurements of BP, FMD, HRV and VO_2maxwere performed. The significance level adopted in the statistical analysis was 5%.ResultsThe standard deviation of normal RR intervals (SDNN; FM-N=314±185; FM-H=182.4± 57.8), the square root of the mean squared differences in successive RR intervals (RMSSD; FM-N=248±134; FM-H=87±51), the number of interval differences of successive NN intervals greater than 50ms (NN50; FM-N=367±83.4; FM-H=229±55), the ratio derived by dividing NN50 by the total number of NN intervals (pNN50; FM-N=32.4±6.2; FM-H=21.1±5.3) and the high (HF; FM-N=49±8.9; FM-H=35.3±12) and low-frequency (LF; FM-N=50.9±8.9; FM-H=64.6±12) components, in normalized units (%), were significantly lower in the FM-H group than in the FM-N group (p<0.05). On the other hand, the LF/HF ratio (ms²) was significantly higher (p<0.05). We found no significant difference between the groups in VO_2maxand FMD (p<0.05).ConclusionsIn young male soccer players, the FHH plays a potentially role in autonomic balance impairment, especially when both parents are hypertensive, but present no changes in VO_2maxand FMD. In this case, there is a decrease in the sympathetic-vagal control, which seems to precede the endothelial damage (Arq Bras Cardiol. 2020; 115(1):52-58)     

A Remodelação do Sistema Nervoso Autônomo Cardíaco pode Desempenhar um Papel na Fibrilação Atrial: Um Estudo do Sistema Nervoso Autônomo e Receptores Miocárdicos

BackgroundThe primary factors that originate and perpetuate atrial fibrillation (AF) are electrical and anatomical substrate alterations. However, the central mechanisms governing AF perpetuation have not been elucidated yet, which is reflected on the modest results of the treatment in patients with long persistent AF.ObjectiveTo evaluate if human intrinsic cardiac autonomic nervous system (ICANS) remodeling, including nervous system fibers and muscarinic and β-adrenergic receptors, play a role in permanent AF.MethodsHeart necropsy samples from thirteen patients with heart disease and permanent AF and thirteen controls without AF were used. By using immunoperoxidase and histomorphometry quantification, we identified the following: the density of all fibers of the ICANS, sympathetic and parasympathetic fibers; and the percentage of myocardium positive for β-adrenergic receptors 1, 2 and 3; G protein-coupled receptor kinase-5 (GRK-5); and muscarinic receptors M1 to M5. The results were compared using ANOVA and nested ANOVA and were adjusted according to the left atrium volume for all variables, and β-blocker use to evaluate the expression of β-receptors and GRK-5.ResultsThere was an overall increase in the density of fibers of the ICANS (p=0.006), especially in atrial sympathetic nerve fibers (p=0.017). Only M1 muscarinic receptors were increased (5.87 vs 2.35, p=0.032). For adrenergic receptors, the results were positive for increased expression of β-3 (37.41 vs 34.18, p=0.039) and GRK-5 (51.16 vs 47.66; p<0.001). β-blocker use had no impact on β-receptor expression.ConclusionIncreased ICANS innervation and remodeling receptor expression in regions prone to triggering AF may play a role in permanent AF.     

Desfechos em Pacientes com Fenômeno de No-Reflow Coronário e a Relação entre a Molécula-1 de Lesão Renal e o Fenômeno de No-Reflow Coronário

Background Coronary no-reflow phenomenon (CNP) is associated with an increased risk of major cardiovascular adverse events (MACE).Objective This study aimed to evaluate the relationship between serum Kidney Injury Molecule-1 (KIM-1) levels and CNP in patients with acute ST-segment elevation myocardial infarction (STEMI).Methods This study included a total of 160 patients (113 males and 47 females; mean age: 61.65±12.14 years) who were diagnosed with STEMI. The patients were divided into two groups, the reflow group (RG) (n=140) and the no-reflow group (NRG) (n=20). Patients were followed during one year. A p-value of <0.05 was considered significant.Results CNP was observed in 12.50% of the patients. Serum KIM-1 was significantly higher in the NRG than in the RG (20.26±7,32 vs. 13.45±6.40, p<0.001). Body mass index (BMI) was significantly higher in the NRG than in the RG (29.41 (28.48-31.23) vs. 27.56 (25.44-31.03), p=0.047). Heart rate (HR) was significantly lower in the NRG than in the RG (61.6±8.04 vs. 80.37±14.61, p<0.001). The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was significantly higher in the NRG than in the RG (3.06±2.22 vs. 2.36±2.85, p=0.016). The incidence of stroke was significantly higher in the NRG than in the RG (15% vs. 2.90%, p=0.013). The baseline KIM-1 level (OR=1.19, 95% CI:1.07 to 1.34, p=0.002) and HR (OR=0.784, 95% CI:0.69 to 0.88, p<0.001) were the independent predictors of CNP.Conclusion In conclusion, baseline serum KIM-1 concentrations and lower HR are independently associated with CNP in STEMI patients and the incidence of stroke was significantly higher in the NRG in the one-year follow-up. (Arq Bras Cardiol. 2021; 116(2):238-247)     

A Sonotrombólise Promove Melhora dos Índices de Motilidade e Perfusão do Ventrículo Esquerdo após o Infarto Agudo do Miocárdio

BackgroundIt has recently been demonstrated that the application of high-energy ultrasound and microbubbles, in a technique known as sonothrombolysis, dissolves intravascular thrombi and increases the angiographic recanalization rate in patients with ST-segment–elevation myocardial infarction (STEMI).ObjectiveTo evaluate the effects of sonothrombolysis on left ventricular wall motion and myocardial perfusion in patients with STEMI, using real-time myocardial perfusion echocardiography (RTMPE).MethodsOne hundred patients with STEMI were randomized into the following 2 groups: therapy (50 patients treated with sonothrombolysis and primary coronary angioplasty) and control (50 patients treated with primary coronary angioplasty). The patients underwent RTMPE for analysis of left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and number of segments with myocardial perfusion defects 72 hours after STEMI and at 6 months of follow-up. P < 0.05 was considered statistically significant.ResultsPatients treated with sonothrombolysis had higher LVEF than the control group at 72 hours (50% ± 10% versus 44% ± 10%; p = 0.006), and this difference was maintained at 6 months of follow-up (53% ± 10% versus 48% ± 12%; p = 0.008). The WMSI was similar in the therapy and control groups at 72 hours (1.62 ± 0.39 versus 1.75 ± 0.40; p = 0.09), but it was lower in the therapy group at 6 months (1.46 ± 0.36 versus 1.64 ± 0.44; p = 0.02). The number of segments with perfusion defects on RTMPE was similar in therapy and control group at 72 hours (5.92 ± 3.47 versus 6.94 ± 3.39; p = 0.15), but it was lower in the therapy group at 6 months (4.64 ± 3.31 versus 6.57 ± 4.29; p = 0.01).ConclusionSonothrombolysis in patients with STEMI resulted in improved wall motion and ventricular perfusion scores over time.     

Acurácia da Redução do Segmento-ST Pós-Trombólise como Preditor de Reperfusão Adequada em Estratégia Fármaco-Invasiva

Background Primary percutaneous coronary intervention is considered the “gold standard” for coronary reperfusion. However, when not available, the drug-invasive strategy is an alternative method and the electrocardiogram (ECG) has been used to identify reperfusion success.Objectives Our study aimed to assess ST-Segment changes in post-thrombolysis and their power to predict recanalization and using the angiographic scores TIMI-flow and Myocardial Blush Grade (MBG) as an ideal reperfusion criterion.Methods 2,215 patients with ST-Segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis [(Tenecteplase)-TNK] and referred to coronary angiography within 24 h post-fibrinolysis or immediately referred to rescue therapy were studied. The ECG was performed pre- and 60 min-post-TNK. The patients were categorized into 2 groups: those with ideal reperfusion (TIMI-3 and MBG-3) and those with inadequate reperfusion (TIMI and MBG <3). The ECG reperfusion criterion was defined by the reduction of the ST-Segment >50%. A p-value <0.05 was considered for the analyses, with bicaudal tests.Results The ECG reperfusion criterion showed a positive predictive value of 56%; negative predictive value of 66%; sensitivity of 79%; and specificity of 40%. There was a weak positive correlation between ST-Segment reduction and ideal reperfusion angiographic data (r = 0.21; p <0.001) and low diagnostic accuracy, with an AUC of 0.60 (95%CI: 0.57-0.62).Conclusion The ST-Segment reduction was not able to accurately identify patients with adequate angiographic reperfusion. Therefore, even patients with apparently successful reperfusion should be referred to angiography soon, to ensure adequate macro and microvascular coronary flow.     

Agrupamentos de Fatores de Risco Cardiometabólicos e sua Associação com Aterosclerose e Inflamação Crônica em Adultos e Idosos em Florianópolis,Sul do Brasil

Background The significant increase in cardiovascular diseases in developing countries alerts about their impact on underprivileged populations.Objective To identify the relationship of clusters of metabolic syndrome (MS) components with atherosclerosis and chronic inflammation among adults and elderly.Methods Cross-sectional analysis using data from two population-based cohort studies in Florianópolis, Southern Brazil (EpiFloripa Adult Cohort Study, n = 862, 39.9±11.5 years; EpiFloripa Aging Cohort Study, n = 1197, 69.7±7.1 years). Blood pressure (BP), waist circumference (WC), and lipid and glucose levels were analyzed as individual factors or as clusters (either as the number of components present in an individual or as combinations of components). Outcomes included carotid intima-media thickness (IMT), atherosclerotic plaques, and C-reactive protein (CRP) levels. Multiple linear and logistic regression analyses adjusted for confounding factors were used. The statistical significance adopted was 5%.Results Individuals with high BP, elevated WC, dyslipidemia and hyperglycemia (6.1% of the sample) showed higher IMT and CRP than those negatives for all MetS components. Elevated WC was a common determinant of systemic inflammation, while the coexistence of high BP and elevated WC (clusters of two or three factors) was associated with higher IMT (β between +3.2 and +6.1 x 10-2 mm; p value < 0.05) and CRP (_EXPβ between 2.18 and 2.77; p value < 0.05).Conclusion The coexistence of high BP and elevated WC was associated with increased IMT and CRP levels, but central obesity affected systemic inflammation either alone or in combination with other risk factors.     

Mortalidade por Insuficiência Cardíaca com Fração de Ejeção Intermediária

Background The prognostic importance of the classification ‘heart failure (HF) with mid-range ejection fraction (EF)’ remains uncertain.Objective To analyze the clinical characteristics, comorbidities, complications, and in-hospital and late mortality of patients classified as having HF with mid-range EF (HFmrEF – EF: 40%-49%), and to compare them to those of patients with HF with preserved EF (HFpEF – EF > 50%) and with HF with reduced EF (HFrEF – EF < 40%) on admission for decompensated HF.Methods Ambispective cohort of patients admitted to the cardiac intensive care unit due to decompensated HF. Clinical characteristics, comorbidities, complications, and in-hospital and late mortality were assessed. The software R was used, with a 5% significance, for the tests chi-square, analysis of variance, Cox multivariate, and Kaplan-Meier survival curve, in addition to machine-learning techniques (Elastic Net and survival tree).Results 519 individuals were included between September 2011 and June 2019 (mean age, 74.87 ± 13.56 years; 57.6% were men). The frequencies of HFpEF, HFmrEF and HFrEF were 25.4%, 27% and 47.6%, respectively. Previous infarction was more frequent in HFmrEF. The mean follow-up time was 2.94 ± 2.55 years, with no statistical difference in mortality between the groups (53.8%, 52.1%, 57.9%). In the survival curve, there was difference between neither the HFpEF and HFmrEF groups, nor the HFpEF and HFrEF groups, but between the HFmrEF and HFrEF groups. Age over 77 years, previous HF, history of readmission, dementia and need for vasopressors were associated with higher late mortality in the survival tree.Conclusion The EF was not selected as a variable associated with mortality in patients with decompensated HF.     

Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca

Background Spirometry is underused in heart failure (HF) and the extent to which each defect associates with exercise capacity and prognosis is unclear.Objective To determine the distinct relationship of continuous %predicted FVC (ppFVC) and FEV₁/FVC with: 1) maximal inspiratory pressure (MIP), left ventricular ejection fraction (LVEF), exercise performance; and 2) prognosis for the composite of cardiovascular death, heart transplantation or left ventricular assist device implant.Methods A cohort of 111 HF participants (AHA stages C/D) without diagnosed pneumopathy, spirometry, manovacuometry and maximum cardiopulmonary test. The association magnitudes were verified by linear and Cox (HR; 95% CI) regressions, age/sex adjusted. A p<0.05 was considered significant.Results Age was 57±12 years, 60% men, 64% in NYHA III. Every 10%-point increase in FEV₁/FVC [β 7% (95% CI: 3–10)] and ppFVC [4% (2-6)] associated with ventilatory reserve (VRes), however only ppFVC associated with MIP [3.8 cmH₂O (0.3-7.3)], LVEF [2.1% (0.5-3.8)] and VO₂peak [0.5 mL/kg/min (0.1–1.0)], accounting for age/sex. In 2.2 years (mean), 22 events occurred, and neither FEV₁/FVC (HR 1.44; 95% CI: 0.97–2.13) nor ppFVC (HR 1.13; 0.89–1.43) was significantly associated with the outcome. Only in the LVEF ≤50% subgroup (n=87, 20 events), FEV₁/FVC (HR 1.50; 1.01–2.23), but not ppFVC, was associated with greater risk.Conclusions In chronic HF, reduced ppFVC associated with lower MIP, LVEF, VRes and VO₂peak, but no distinct poorer prognosis over 2.2 years of follow-up. Distinctively, FEV₁/FVC was associated only with VRes, and, in participants with LVEF ≤50%, FEV₁/FVC reduction proportionally worsened prognosis. Therefore, FEV₁/FVC and ppFVC add supplementary information regarding HF phenotyping.     

Ablação por Cateter de Taquicardia Atrial Focal com Ativação Precoce Próxima ao Feixe de His,a Partir da Cúspide Aórtica não Coronária

BackgroundAtrial tachycardia (AT) ablation with earliest activation site close to the His-Bundle is a challenge due to the risk of complete AV block by its proximity to His-Purkinje system (HPS). An alternative to minimize this risk is to position the catheter on the non-coronary cusp (NCC), which is anatomically contiguous to the para-Hisian region.ObjectivesThe aim of this study was to perform a literature review and evaluate the electrophysiological characteristics, safety, and success rate of catheter-based radiofrequency (RF) delivery in the NCC for the treatment of para-Hisian AT in a case series.MethodsThis study performed a retrospective evaluation of ten patients (Age: 36±10 y-o) who had been referred for SVT ablation and presented a diagnosis of para-Hisian focal AT confirmed by classical electrophysiological maneuvers. For statistical analysis, a p-value of <0.05 was considered statistically significant.ResultsThe earliest atrial activation at the His position was 28±12ms from the P wave and at the NCC was 3±2ms earlier than His position, without evidence of His potential in all patients. RF was applied on the NCC (4-mm-tip catheter; 30W, 55ºC), and the tachycardia was interrupted in 5±3s with no increase in the PR interval or evidence of junctional rhythm. Electrophysiological tests did not reinduce tachycardia in 9/10 of patients. There were no complications in all procedures. During the 30 ± 12 months follow-up, no patient presented tachycardia recurrence.ConclusionThe percutaneous treatment of para-Hisian AT through the NCC is an effective and safe strategy, which represents an interesting option for the treatment of this complex arrhythmia. (Arq Bras Cardiol. 2021; 116(1):119-126)     

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)     

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.     

Otimização da Terapia de Reperfusão no Infarto Agudo do Miocárdio com Supradesnível do Segmento ST por Meio de Telemedicina Baseada no WhatsApp®

Background About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy.Objective The use of a telemedicine network based on WhatsApp^® could increase the percentage of patients receiving reperfusion therapy.Methods A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS−XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant.Results The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 – 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 – 0.927], p = 0.028.Conclusion The use of WhatsApp^®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.     

Relação entre Resposta Imune Inata do Receptor Toll-Like-4 (TLR-4) e o Processo Fisiopatológico da Cardiomiopatia da Obesidade

BackgroundObesity is a chronic low-grade inflammation condition related to cardiac disorders. However, the mechanism responsible for obesity-related cardiac inflammation is unclear. The toll-like receptor 4 (TLR-4) belongs to a receptor of the transmembrane family responsible for the immune response whose activation stimulates the production of proinflammatory cytokines.ObjectiveTo test whether the activation of the TLR-4 receptor participates in the obesity cardiomyopathy process, due to cytokine production through NF-ĸB activation.MethodsMale Wistar rats were randomized into two groups: the control group (C, n= 8 animals) that received standard diet/water and the obese group (OB, n= 8 animals) that were fed a high sugar-fat diet and water plus 25% of sucrose for 30 weeks. Nutritional analysis: body weight, adiposity index, food, water, and caloric intake. Obesity-related disorders analysis: plasma glucose, uric acid and triglycerides, HOMA-IR, systolic blood pressure, TNF-α in adipose tissue. Cardiac analysis included: TLR-4 and NF-ĸB protein expression, TNF-α and IL-6 levels. Comparison by unpaired Student’s t-test or Mann- Whitney test with a p-value < 0.05 as statistically significant.ResultsThe OB group showed obesity, high glucose, triglycerides, uric acid, HOMA, systolic blood pressure, and TNF-α in adipose tissue. OB group presented cardiac remodeling and diastolic dysfunction. TLR-4 and NF-ĸB expression and cytokine levels were higher in OB.ConclusionOur findings conclude that, in an obesogenic condition, the inflammation derived from cardiac TLR-4 activation can be a mechanism able to lead to remodeling and cardiac dysfunction.     

Valor Prognóstico de Rigidez Aórtica usando Ressonância Magnética Cardiovascular em Idosos com Suspeita ou Confirmação de Doença Arterial Coronariana

BackgroundAortic stiffness is established as a marker of cardiovascular disease. Cardiovascular magnetic resonance (CMR) provides a comprehensive assessment of aortic stiffness and myocardial ischemia in a single examination. However, prognostic data concerning aortic stiffness in elderly patients remain limited.ObjectiveTo determine the prognostic value of aortic stiffness using CMR-based pulse wave velocity (PWV) in elderly patients with known or suspected coronary artery disease (CAD).MethodsThis study enrolled consecutive patients aged >70 referred for adenosine stress perfusion CMR including PWV between 2010 and 2014. Patients were followed up for occurrence of major adverse cardiovascular events (MACE), including cardiac mortality, nonfatal myocardial infarction, hospitalization for heart failure, late revascularization (>180 days after CMR), and ischemic stroke. Univariable and multivariable analyses were performed to determine the predictors of MACE. A p-value of <0.05 is considered statistically significant.ResultsMean PWV was 13.98±9.00 m/s. After a median follow-up period of 59.6 months in 263 patients (55% female, 77±5 years), 61 MACE occurred. Patients with elevated PWV (>13.98 m/s) had significantly higher rates of MACE (HR 1.75; 95% CI 1.05-2.94; p=0.03) than those with non-elevated PWV (<13.98 m/s). Multivariate analysis demonstrated diastolic blood pressure, left ventricular ejection fraction (LVEF), myocardial ischemia, and elevated PWV as independent predictors for MACE (p<0.05 for all). PWV provided an incremental prognostic value over clinical data, LVEF, and ischemia (increased global chi-square=7.25, p=0.01).ConclusionAortic stiffness using CMR is a strong and independent predictor of cardiovascular events in elderly patients with known or suspected CAD.     

Impacto Atual da Circulação Extracorpórea na Cirurgia de Revascularização Miocárdica no Estado de São Paulo

BackgroundPrevious results on the use of cardiopulmonary bypass (CPB) have generated difficulties in choosing the best treatment for each patient undergoing myocardial revascularization surgery (CABG) in the current context.ObjectiveEvaluate the current impact of CPB in CABG in São Paulo State.MethodsA total of 2905 patients who underwent CABG were consecutively analyzed in 11 São Paulo State centers belonging to the São Paulo Registry of Cardiovascular Surgery (REPLICCAR) I. Perioperative and follow-up data were included online by trained specialists in each hospital. Associations of the perioperative variables with the type of procedure and with the outcomes were analyzed. The study outcomes were morbidity and operative mortality. The expected mortality was calculated using EuroSCORE II (ESII). The values of p <5% were considered significant.ResultsThere were no significant differences concerning the patients’ age between the groups (p=0.081). 72.9% of the patients were males. Of the patients, 542 underwent surgery without CPB (18.7%). Of the preoperative characteristics, patients with previous myocardial infarction (p=0.005) and ventricular dysfunction (p=0.031) underwent surgery with CPB. However, emergency or New York Heart Association (NYHA) class IV patients underwent surgery without CPB (p<0.001). The ESII value was similar in both groups (p=0.427). In CABG without CPB, the radial graft was preferred (p<0.001), and in CABG with CPB the right mammary artery was the preferred one (p<0.001). In the postoperative period, CPB use was associated with reoperation for bleeding (p=0.012).ConclusionCurrently in the REPLICCAR, reoperation for bleeding was the only outcome associated with the use of CPB in CABG. (Arq Bras Cardiol. 2020; 115(4):595-601)     

Modulação Autonômica Cardíaca é Fator Chave para Pressão Alta em Adolescentes

BackgroundThe interest regarding hypertension among children and adolescents has increased since the blood pressure rating system was updated to be compared with the adult rating system, changing the terminology from “normal high” to “prehypertension”.ObjectiveThis study aimed to analyze the association between cardiac autonomic modulation and pressure levels of adolescents.Methods203 adolescents were grouped according to systolic blood pressure (SBP) and diastolic blood pressure (DBP). One group was characterized as prehypertension, and the other as normotensive. Anthropometric, cardiovascular and sleep quality characteristics were collected. Initially, the data were submitted to the Kolmogorov-Smirnov normality test. Continuous quantitative variables were analyzed using the unpaired Student t-test. For the analysis of categorical variables, a chi-square test was used. A logistic regression model was performed. The level of significance was set at p<0.05. The data were expressed as mean ± standard deviation and confidence interval. The R software was used for data analysis. The effect size was calculated using the Cohen’s formula.ResultsThe prehypertension group showed an increase in Shannon entropy and a decrease in total variance. Also, in the logistic regression model, adolescents in this group were 1.03 times more likely to have Shannon entropy’s affected when SBP was adjusted for gender, sexual maturation, school time, age, waist circumference, and sleep quality.ConclusionOur data show that autonomic modulation may play an important role in the development of elevated blood pressure in adolescents, when controlling for other factors, such as school time and sleep quality.     

Fibrose Cardíaca e Mudanças Evolutivas na Função Ventricular Esquerda em Pacientes com Cardiopatia Chagásica Crônica

BackgroundChagas heart disease (CHD) is a slow progressing condition with fibrosis as the main histopathological finding.ObjectivesTo study if cardiac fibrosis increases over time and correlates with increase in left ventricular (LV) size and reduction of ejection fraction (EF) in chronic CHD.MethodsRetrospective study that included 20 individuals (50% men; 60±10 years) with chronic CHD who underwent two cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement with a minimum interval of four years between tests. LV volume, EF, and fibrosis mass were determined by cardiac MRI. Associations of fibrosis mass at the first cardiac MRI and changes in LV volume and EF at the second cardiac MRI were tested using logistic regression analysis. P values <0.05 were considered significant.ResultsPatients were classified as follows: A (n=13; changes typical of CHD in the electrocardiogram and normal global and segmental LV systolic function) and B1 (n=7; LV wall motion abnormality and EF≥45%). Mean time between cardiac MRI studies was 5.4±0.5 years. LV fibrosis (in %LV mass) increased from 12.6±7.9% to 18.0±14.1% between MRI studies (p=0.02). Cardiac fibrosis mass at baseline was associated with decrease in >5 absolute units in LV EF from the first to the second MRI (OR 1.48, 95% CI 1.03-2.13, p=0.03). LV fibrosis mass was larger and increased between MRI studies in the group that presented decrease in LV EF between the tests.ConclusionsEven patients at an initial stage of CHD show an increase in myocardial fibrosis over time, and the presence of LV fibrosis at baseline is associated with a decrease in LV systolic function.     

Porcine Circovirus 2 Deploys PERK Pathway and GRP78 for Its Enhanced Replication in PK-15 Cells

Porcine circovirus type 2 (PCV2) infection induces autophagy and apoptosis. These cellular responses could be connected with endoplasmic reticulum (ER) stress. It remains unknown if PCV2 induces ER stress and if autophagy or apoptosis is primary to PCV2 infection or secondary responses following ER stress. Here, we demonstrate that PCV2 triggered unfolded protein response (UPR) in PK-15 cells by activating the PERK/eIF2α pathway without concomitant activation of IRE1 or ATF6. Since ATF4 and CHOP were induced later than PERK/eIF2α, it is clear that persistent PCV2 infection could lead to selective activation of PERK via the PERK-eIF2α-ATF4-CHOP axis. Therefore, PERK activation could be part of the pro-apoptotic signaling via induced expression of CHOP by PCV2. Since PERK inhibition by GSK2606414 or RNA silencing or suppression of eIF2α dephosphorylation by salubrinal limited viral replication, we suppose that PCV2 deploys UPR to enhance its replication. Over-expression of GRP78 or treatment with tauroursodeoxycholic acid could enhance viral capsid expression and/or viral titers, indicating that these chaperones, endogenous or exogenous, could help correct folding of viral proteins. Our findings provide the first evidence that ER stress plays a role in the pathogenesis of PCV2 infection probably as part of autophagic and apoptotic responses.     

Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda

BackgroundEpicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear.ObjectivesTo measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI).MethodsPatients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EAT_LMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05.ResultsMost of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EAT_LMvolume of 2.4 cm³/m²(interquartile range [IQR] 1.6–3.2 cm³/m²), and a median amount of LA fibrosis of 8.9 g (IQR 5–15 g). The correlation between EAT_LMand LA fibrosis was statistically significant but weak (Spearman’s R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12–31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EAT_LM(HR 2.05, 95% CI 1.51–2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08–5.16, p=0.031).ConclusionThe weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.