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ISSN (Print): 2359-4802 | ISSN (Online): 2359-5647

Edition: 29.4 - 13 Article(s)


Challenges for Contemporary Medicine: Implementation of Evidence in Clinical Practice
Desafios para Medicina Contemporânea: Implementação das Evidências na Prática Clínica

André Volschan
Int J Cardiovasc Sci. 2016;29(4):250-252


Myocardial Infarction in the Daily Practice
Infarto Agudo do Miocárdio na Prática Clínica Diária

Alexandre Schaan de Quadros, Márcia Moura Schmidt, Cristina do Amaral Gazeta, Karina Pezzi Melleu, Alexandre Damiani Azmus, Júlio Vinícius Teixeira, Cláudio Vasques de Moraes, Henrique Basso Gomes, Rogério Eduardo Gomes Sarmento-Leite, Carlos Antonio Mascia Gottschall
Int J Cardiovasc Sci. 2016;29(4):253-261

+   Abstract  
BACKGROUND: Guideline recommendations for the management of patients with ST-elevation myocardial infarction (STEMI) are mainly based on data from randomized clinical trials.
OBJECTIVES: We sought to assess temporal trends in characteristics, treatment and outcomes of patients with STEMI representative of the daily practice.
METHODS: Prospective cohort study including all patients with STEMI who presented at our institution from 2010 to 2013. Clinical, angiographic, laboratory, treatment aspects and 30-day major cardiovascular events (MACEs) were assessed and compared over the years.
RESULTS: The mean TIMI risk score, and most baseline clinical and angiographic characteristics of the 1973 patients included remained stable from 2010 to 2013, except for diabetes mellitus (whose frequency increased from 21% to 28%; p < 0.01). Primary PCI was performed in 95% of cases, and the door-to-balloon time decreased from 1.27 to 1.11 hours (p < 0.01). Regarding treatment, there were significant increases in the use of 600 mg boluses of clopidogrel (75% in 2010 vs 93% in 2013; p < 0.001), upstream anticoagulant (50% vs 91%; p < 0.001) and the radial approach in pPCI (9% vs 66%; p < 0.001), and lower use of beta-blockers (72% vs 63%; p < 0.001). MACE decreased from 17.4% to 9.5% (p < 0.05). Independent predictors of MACE were baseline characteristics, the radial approach, and use of beta-blockers and upstream anticoagulant.
CONCLUSIONS: The baseline characteristics of patients with STEMI remained stable over a four-year period, except for the incidence of diabetes mellitus, which increased significantly. Medical and interventional treatments significantly changed, and short-term adverse cardiovascular outcomes significantly decreased. Predictors of better outcomes were baseline characteristics, use of beta-blockers and upstream anticoagulant, and the radial approach. (Int J Cardiovasc Sci. 2016;29(4):253-261)

Keywords: Myocardial Infarction; Delivery of Health Care; Quality of Health Care; Percutaneous Coronary Intervention.


Clinical Outcomes of Percutaneous Intervention in Triple-Vessel and Left Main Coronary Artery Diseases
Desfechos Clínicos da Intervenção Percutânea na Doença Triarterial e de Tronco da Coronária Esquerda

Samuel Cargnin Cunha, Luiz Eduardo Koenig São Thiago, Evelim de Medeiros Sartor
Int J Cardiovasc Sci. 2016;29(4):262-269

+   Abstract  
BACKGROUND: Myocardial revascularization in triple-vessel and left main coronary artery (LMCA) diseases can be performed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The SYNTAX trial demonstrated equivalent clinical results in patients with low to moderate anatomical complexity undergoing CABG or PCI.
OBJECTIVES: To evaluate the incidence of cardiovascular events and rates of new myocardial revascularization in patients with LMCA and triple-vessel lesions undergoing PCI.
METHODS: Nonrandomized, observational cohort study that evaluated patients with triple-vessel or LMCA diseases undergoing PCI with drug-eluting stent in the period from June 2013 to May 2015 at the Hospital SOS Cardio in Florianópolis. Baseline data, main anatomical features, and clinical outcomes were reported during the in-hospital phase and during a 12-month follow-up.
RESULTS: In total, 46 patients with a mean age of 69.9 years were evaluated. At baseline, 39.1% had diabetes mellitus, 19.6% were smokers, 78.3% had dyslipidemia, 10.9% had chronic renal dysfunction, and 15.2% had moderate to severe ventricular dysfunction. As regards the number of arteries affected, 24% had triple-vessel disease and 76% had lesions in the LMCA. During the in-hospital period, there was a 4.34% rate of acute myocardial infarction without ST elevation. During this period, reintervention was not required and no deaths occurred. In the 12-month follow-up, mortality from cardiovascular causes was 4.35%. The rate of new revascularization was 4.3% by CABG and 2.2% by angioplasty.
CONCLUSION: The rates of cardiovascular events were low, indicating that PCI may be an acceptable alternative in selected cases. (Int J Cardiovasc Sci. 2016;29(4):262-269)

Keywords: Myocardial Revascularization; Percutaneous Coronary Intervention; Coronary Disease; Cardiac Catheterization.


Impact of Periodontal Disease in the Lipid Profile of Patients With Chronic Coronary Artery Disease: a 3-Year, Retrospective Cohort
Impacto da Doença Periodontal no Perfil Lipídico de Pacientes com Doença Arterial Coronariana Crônica: uma Coorte Retrospectiva de 3 anos

Cassio Kampits, Cassiano K. Rösing, Marlon Munhoz Montenegro, Ingrid W. J. Ribeiro, Marco Aurelio Lumerts Saffi, Carisi A. Polanczyk, Mariana V. Furtado, Alex N. Haas
Int J Cardiovasc Sci. 2016;29(4):270-279

+   Abstract  
BACKGROUND: Inflammation has been recognized as an important risk factor for cardiovascular diseases. Periodontal disease may alter some plasma markers involved in the atherogenic process.
OBJECTIVE: To assess the association between periodontal disease and lipid levels over time in patients with chronic coronary artery disease.
METHODS: This retrospective cohort study included a sample of patients with chronic heart disease receiving care in an outpatient tertiary care for ischemic heart disease. Of 239 patients eligible for the study, we included 80 patients who had available retrospective data of lipid profile between 2009 and 2011. We performed periodontal examinations of all teeth present in 2011. Multiple models of generalized estimating equations were applied to assess the association between periodontal parameters and changes over time in the following outcomes: triglycerides, total cholesterol, LDL-cholesterol, and HDL-cholesterol levels adjusted for age, body mass index, smoking, use of oral hypoglycemic, and follow-up duration.
RESULTS: During a mean follow-up time of 713 days, there were no significant changes in the concentrations of triglycerides, total cholesterol, and LDL-cholesterol. A significant 31.6% increase in HDL-cholesterol levels was observed between 2009 and 2011. We observed a significant negative association between mean individual periodontal attachment loss and HDLcholesterol levels, indicating that the greater the attachment loss, the lower the HDL-cholesterol level over time.
CONCLUSION: Destructive periodontal disease may be related to a worse lipid control, specifically regarding HDL-cholesterol levels, in chronic cardiac patients. (Int J Cardiovasc Sci. 2016;29(4):270-279)

Keywords: Cardiovascular Diseases; Periodontal Diseases / complications; Coronary Artery Disease; Lipidis; Hyperlipidemias.


Reduction of in Long-Term Mortality Related to Higher Doses of Atorvastatin in Patients with Acute Coronary Syndromes
Redução de Mortalidade em Longo Prazo Relacionada a Doses Mais Elevadas de Atorvastatina em Pacientes com Síndrome Coronariana Aguda

Alexandre de Matos Soeiro, Aline Siqueira Bossa, Maria Cristina César, Cindel Nogueira Zullino, Tatiana de Carvalho A. Torres Leal, Bruno Biselli, Maria Carolina Feres de Almeida Soeiro, Carlos Vicente Serrano Jr., Múcio Tavares Oliveira Jr.
Int J Cardiovasc Sci. 2016;29(4):280-287

+   Abstract  
BACKGROUND: Recent experimental studies have described reduction in inflammatory markers related to higher doses of statins in patients with acute coronary syndromes (ACS). However, the clinical implication of the dose of statin in the acute phase of the ACS remains uncertain.
OBJECTIVE: To compare the outcomes in short and long terms among patients with acute coronary syndromes that received higher doses of atorvastatin versus low doses of atorvastatin started in the first 24 hours of hospital admission.
METHODS: For such, the patients were divided in two groups: group I (N = 464): atorvastatin dose: 40 mg/day. Demographic data, laboratory exams, medications used and coronary treatment adopted were obtained. Statistical analysis: The primary outcome was mortality from all causes. The comparison between groups was made by T-test and Q-square. Multivariative analysis of in-hospital outcomes were determined by logistic regression, considered significant when p < 0.05. In long-term, the mortality and combined events by the Kaplan-Meier method were assessed, with median follow-up of 8.79 months.
RESULTS: In the analysis of in-hospital outcomes, no significant differences were observed between groups I and II. In the long-term, group II presented lower mortality in comparison with group 9 (8.4% vs. 3.9%, p = 0.013).
CONCLUSIONS: Favorable and significant differences were observed in relation to long-term mortality in patients with ACS that received high doses of atorvastatin since the acute phase. (Int J Cardiovasc Sci. 2016;29(4):280-287)

Keywords: Acute Coronary Syndrome/mortality; Hidroxymethylglutaryl CoA Reductase Inhibitors; Hypertension; Cohort Studies.


Evaluation of IL-6 (-174 G/C) Polymorphism in Acute Coronary Syndrome in the Northeast of Brazil
Avaliação do Polimorfismo -174 G/C do gene IL-6 na Síndrome Coronariana Aguda no Nordeste do Brasil

Viviane do Carmo Vasconcelos de Carvalho, Lílian Caroliny Amorim Silva, Roberto Pereira Werkhauser, Sérgio Tavares Montenegro, Carlos Gustavo Regis da Silva, Adriana Vieira Gomes, Clarice Neuenschwander Lins de Morais, Silvia Maria Lucena Montenegro
Int J Cardiovasc Sci. 2016;29(4):288-294

+   Abstract  
BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of morbidity and mortality worldwide. It is a multifactorial disease caused by obstruction of the coronary arteries by atheromatous plaques and leads to heart ischemia. Several studies suggest that some genetic polymorphisms change the cytokines levels and influence ACS development.
OBJECTIVE: In this study, we evaluated the IL-6 polymorphism -174 G/C, serum levels of cytokine and its relationship with ACS and the thrombolysis in myocardial infarction (TIMI) risk score.
MATERIALS AND METHODS: A sample of 200 patients with ACS [TIMI risk - Low (70); Intermediate (89); High (41)] in Brazilian population was used. Genotyping was carried out by polymerase chain reaction, followed by DNA sequencing.
RESULTS: There was no significant differences in genotype (p = 0.53) and allele (p = 0.32) distributions between ACS patient and without ACS patients groups on IL-6 allelic polymorphism and between the three different TIMI risk score (p > 0.05). Moreover IL-6 polymorphism did not affect the cytokine levels and these levels were not related to the TIMI score.
CONCLUSIONS: With these results, we suggest that the IL-6 (-174 G/C) polymorphism, until now, is not related to ACS and did not change the levels of the cytokine in studied population. Further studies with different populations should be done to verify those results. It is important to emphasize that, since ACS is a multifactorial disease, other risk factors and other pro-inflammatory cytokines should be assessed to better understand this pathology. (Int J Cardiovasc Sci. 2016;29(4):288-294)

Keywords: Acute Coronary Syndrome; Myocardial Ischemia; Polymorphism, Genetic; Interleukin-6.


Inflammation Markers, Microalbuminuria and Blood Pressure Control in Primary Health Care
Marcadores de Inflamação, Microalbuminúria e Controle de Pressão Arterial em Cuidados de Saúde Primários

Guilherme Brasil Grezzana; Bruna Eibel; Airton Tetelbom Stein; Lúcia Campos Pellanda
Int J Cardiovasc Sci. 2016;29(4):295-302

+   Abstract  
BACKGROUND: Systemic arterial hypertension (SAH) is an important cause of cardiovascular morbidity and mortality. In spite of the effectiveness of the treatment, a high number of patients do not obtain blood pressure (BP) control, a fact that implies the need for investigating the role of other additional factors, such as inflammation markers and microalbuminuria, especially in health care environments.
OBJECTIVES: To evaluate the association between serum fibrinogen levels, ultra-sensitive C-reactive protein (CRP) and microalbuminuria, with blood pressure (BP) averages evaluated by 24-hour ambulatory blood pressure monitoring (ABPM) in hypertensive patients in primary health care setting.
METHODS: A cross-sectional study with hypertensive patients who were seen in primary health care centers was performed. A BP evaluation was carried out by the primary care doctor, and this procedure was followed by a reference test 24-hour ABPM, performed by an independent professional. Moreover, the peripheral blood collect was performed for future biochemical markers analysis.
RESULTS: 143 patients were included. There was a trend for association between the independent variable (altered BP by 24-hour ABPM) and the dependent variable (CRP), there was an association between the values > 3 mg/dL and altered 24-hour ABPM. The prevalence ratio (PR) was of 1.36 (CI 95% 0.90 - 2.06); p=0.18. Regarding microalbuminuria and fibrinogen findings, a 1.03 (CI 95% 0.41 - 2.57) PR was seen; p=1 and 1.19 (CI 95% 0.96 - 1.46) PR; p=0.019, respectively, and both were not significant for altered BP by 24-hour ABPM.
CONCLUSIONS: It is a trend for association between CRP with BP evaluated by 24-hour ABPM in the primary care setting. (Int J Cardiovasc Sci. 2016;29(4):295-302)

Keywords: Biomarkers; Inflammation; C-Reactive Protein; Albuminuria; Blood Pressure Monitoring, Ambulatory.


The MacNew Questionnaire: A Tool to Predict Unplanned Rehospitalization after Coronary Revascularization
Questionário MacNew: Uma Ferramenta Preditora de Reinternação Hospitalar Não Planejada após Revascularização Coronariana

Renato De Vecchis; Carmelina Ariano
Int J Cardiovasc Sci. 2016;29(4):303-313

+   Abstract  
BACKGROUND: The MacNew questionnaire is a neurobehavioral tool that is easily implementable and immediately usable. This self-reported questionnaire allows physicians to gather helpful information to optimize the patients' therapy and lifestyle.
OBJECTIVE: In this retrospective study, we aimed to assess whether relatively high scores in the MacNew questionnaire in patients undergoing percutaneous or surgical revascularization would be associated with a decreased risk of unscheduled rehospitalization during follow-up.
METHODS: We examined retrospectively the medical charts of 210 patients to gather information using the Italian version of the MacNew questionnaire. This questionnaire is routinely administered during hospitalization in patients recovering from percutaneous or surgical coronary revascularization in our institutions. All patients undergoing this psychological test were followed up for 3 years.
RESULTS: On univariate analysis, increased global score results (above the median obtained in the entire cohort) was associated with a significantly decreased risk of rehospitalization (hazard ratio [HR] 0.0903, 95% confidence interval [95%CI] 0.0324-0.2518, p < 0.0001). In a multivariate Cox proportional hazard regression model adjusted for age, gender, and myocardial infarction as triggering event, the association between increased MacNew scores and risk of rehospitalization remained significant (HR 0.0885, 95%CI 0.0317-0.2472, p < 0.0001).
CONCLUSIONS: A relatively elevated MacNew global score was associated with a significantly decreased risk of unscheduled rehospitalization over 3 years after coronary revascularization. (Int J Cardiovasc Sci. 2016;29(4):303-313)

Keywords: Surveys and Questionnaires; Myocardial Revascularization / psychology; Patient Readmission; Quality of Life.



Percutaneous Coronary Intervention with Bioresorbable Vascular Scaffolds
Intervenção Coronariana Percutânea com Suportes Vasculares Biorreabsorvíveis

Márcio Macri Dias, Márcio José Montenegro da Costa, Bernardo Amorim, Esmeralci Ferreira
Int J Cardiovasc Sci. 2016;29(4):314-319

+   Abstract  
Percutaneous coronary intervention (PCI) was the first revolution in interventional cardiology. Coronary stents solved the acute occlusion of the vessel, sealing dissections and preventing negative remodeling. Excessive intimal hyperplasia was reduced with drug-eluting stents (DES) mainly in diabetics, small vessels and long lesions. However, the mechanical effect of stent metal hinders the positive remodeling of the vessel wall, good endothelial function and vascular reactivity. Bioresorbable vascular scaffolds (BVS) provide good initial stability in the vascular structure and complete resorption of the material over time, resulting in better physiological adaptation of the artery. Recent studies show that these devices are safe. Despite some limitations in indication, evidence now offer unique options in the treatment of coronary artery disease (CAD) with the expansion of BVS use in daily practice, which is the reason for this review.

Keywords: Myocardial revascularization; Angioplasty; Angina pectoris.


C-Reactive Protein in Oral Contraceptive Users: Related Factors and Cardiovascular Risk
Proteína C Reativa em Usuárias de Contraceptivo Oral: Fatores Relacionados e Risco Cardiovascular

Alan Carlos Nery dos Santos, Jefferson Petto, Francisco Tiago Oliveira de Oliveira, Diego Passos Diogo, Ana Marice Teixeira Ladeia
Int J Cardiovasc Sci. 2016;29(4):320-325

+   Abstract  
Studies show an association between the use of combined oral contraceptive (COC) and the elevation of C-reactive protein (CRP). However, it is unclear whether this increase represents cardiovascular risk, and what are the mechanisms involved in this association. Thus, our study aimed to review works that investigated the CRP levels in COC users, as well as describe the factors involved in this elevation. We considered eligible the studies indexed in EBSCO, EUROPUBMED, LILACS, PubMed and MEDLINE databases that evaluated the CRP of low-dose COC users, published between 2004 and 2015. The electronic search consisted of crossing the descriptors: Contraceptives, Oral, Combined; C-Reactive Protein and Inflammation, which resulted in 136 studies, of which 11 were eligible. They showed elevated CRP, even after ten days of use of COC. The most common CRP values were between 1-3 mg / L and > 3 mg / L, and in some studies values were greater than 10 mg / L. This indicates increased risk of future cardiovascular and metabolic events in this population. On the other hand, the main factors and mechanisms involved in the increase of this protein were hormonal, and, mainly, estrogenic and androgenic, and changes in function and levels of estrogen receptor β, high levels of cortisol and insulin resistance were documented. Other findings also indicate elevation of TNF-α, DNA hypomethylation in macrophages and alterations in the hepatic production of CRP. Finally, the COC represents, as does obesity, 20% of the variation of CRP of women of reproductive age.

Keywords: C-Reactive Protein; Women; Contraceptives, Oral, Combined; Risk Factors; Cardiovascular Diseases; Premenopause.



Understanding Meta-Epidemiological Studies
Compreendendo os Estudos de Meta-Epidemiologia

Leonardo Silva Roever Borges
Int J Cardiovasc Sci. 2016;29(4):326-328

+   Abstract  
The concept of meta-epidemiology has been introduced because of the methodological limitations of the systematic review of clinical trials of intervention. Meta-epidemiology has moved from a statistical method to a new methodology to close gaps between evidence and practice, controlling the potential biases in quantitative systematic review and drawing appropriate evidence to establish evidence-based guidelines. Network metaepidemiology has been suggested to overcome some limitations of meta-epidemiology. This review aims to clarify the concept and major methods to conduct a metaepidemiological study.

Keywords: Evidence-Based Practice / statistics & numeric data; Evidence-Based Medicine; Epidemiology.



Management of Pregnant Woman with Marfan Syndrome and Mechanical Aortic Valved Conduit
Acompanhamento de Gestante Portadora de Síndrome de Marfan com Tubo Valvado Metálico Aórtico

Roberto Ramos Barbosa, Afonso Dalmazio Souza Mario, Osmar Araujo Calil, Tiago de Melo Jacques, Renato Giestas Serpa, Luiz Fernando Machado Barbosa
Int J Cardiovasc Sci. 2016;29(4):329-332

+   Abstract  
We report a case of a 29-year-old patient with Marfan Syndrome and a mechanical aortic valved conduit graft that was referred to cardiologist at seven weeks pregnant. Echocardiogram: aortic root diameter 35 mm, normally functioning mechanical aortic valve graft. She had a specialized cardiologist follow up. The patient was submitted to cesarean at 38 weeks pregnant, with general anesthesia, antibiotic prophylaxis for endocarditis, cardiac monitoring on the surgical center and stayed in the Coronary Care Unit for 24 hours. Pregnancy and puerperium evolved without hemorrhagic events. The clinical and obstetric follow up of pregnant women with Marfan Syndrome is challenging, and the condition of the previously implanted mechanical heart valve enhances the risk for those patients.

Keywords: Marfan Syndrome; Aortic Aneurysm; Thoracic; Pregnancy; High-Risk; Heart Valve Prosthesis Implantation.


Saved by the X-ray
Salva pela Radiografia

Ricardo Manuel Costa Rodrigues, Nuno Santos, Susana Gomes, Décio Pereira
Int J Cardiovasc Sci. 2016;29(4):333-335

+   Abstract  
In the emergency department setting, it is often difficult to provide proper diagnosis and potentially fatal diseases may appear in atypical forms. Clinical suspicion and complementary laboratory tests are important to define severe conditions. We report the case of a 36-year-old female patient with family and personal history of syncope. The patient was admitted in the emergency department with atypical symptoms of malaise, difficulty to say words and understand others and extreme fatigue. Chest X-ray clarified the case as it revealed a long-term monitoring device implanted years before and revealed an episode of torsades de pointes.

Keywords: Long QT syndrome; Electrocardiography, ambulatory; Torsades de pointes.