Antonio de Padua Mansur

Additional reduction in blood pressure after cholesterol-lowering treatment by statins (lovastatin or pravastatin) in hypercholesterolemic patients using angiotensin-converting enzyme inhibitors (enalapril or lisinopril)

Blood pressure (BP) reduction was compared between patients receiving angiotensin-converting enzyme inhibitors alone and patients receiving these medications plus statins after 3 months of dietary intervention. Although BP was similarly reduced at week 4, the statin-treated group had a greater reduction in BP and total cholesterol levels at week 16, suggesting a synergistic effect between cholesterol lowering with statins and angiotensin-converting enzyme inhibitor treatment for hypertensive patients.

Effect of Spironolactone on ventricular arrhythmias in congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy

Epidemiologic studies have shown an important increase in the high mortality of patients with congestive heart failure (CHF) despite optimal medical management. Ventricular arrhythmia was recognized as the most common cause of death in this population. Electrolyte imbalance, myocardial fibrosis, left ventricular dysfunction, and inappropriate neurohumoral activation are presumed responsible for sudden cardiac death. In this study, we focused on the deleterious effects of the overproduction of aldosterone that occurs in patients with CHF. Secondary hyperaldersteronism can be part of several factors thought to be responsible for sudden cardiac death. We randomized 35 patients (32 men, aged 48 +/- 9 years) with systolic dysfunction (ejection fraction 33 +/- 5%) and New York Heart Association class III CHF secondary to dilated or ischemic cardiomyopathy into 2 groups. The treatment group received spironolactone, an aldosterone receptor antagonist, along with standard medical management using furosemide, angiotensin-converting enzyme inhibitors, and digoxin. The control group received only the standard medical treatment. Holter monitoring was used to assess the severity of ventricular arrhythmia. After 20 weeks, patients who received spironolactone had a reduced hourly frequency of ventricular premature complexes (VPCs) (65 +/- 18 VPCs/hour at week 0 and 17 +/- 9 VPCs/hour at week 16) and episodes of nonsustained ventricular tachycardia (VT) (3.0 +/- 0.8 episodes of VT/24-hour period at week 0, and 0.6 +/- 0.3 VT/24-hour period at week 16). During monitored treadmill exercise, a significant improvement in ventricular arrhythmia was found in the group receiving spironolactone (39 +/- 10 VPCs at week 0, and 6 +/- 2 VPCs at week 16). These findings suggest that aldosterone may contribute to the incidence of ventricular arrhythmia in patients with CHF, and spironolactone helps reduce this complication.

Mortalidade por doenças cardiovasculares no Brasil e na região metropolitana de São Paulo: atualização 2011

BACKGROUND Cardiovascular diseases (CVD) are the leading causes of death in our population. There was a progressive decrease in mortality due to CVD up to 2005. OBJECTIVE To update the trends in mortality from cardiovascular diseases in Brazil and in the metropolitan region of São Paulo (MRSP) from 1990 to 2009. METHODS Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk of death was adjusted by the direct method, having as reference the world population in 2000. RESULTS There was a progressive decrease in the risk of death from ischemic heart disease (IHD) and stroke in Brazil and in the MRSP. From 1990 to 2009, there was a decrease in mortality from IHD and stroke in men and women in Brazil and in the MRSP. There was a greater reduction in mortality from IHD in men in the MRSP than in Brazil (36.24% vs. 23.35%, p <0.001) and in women in the MRSP (44.55% vs. 29.5%; p <0.001). The highest reduction in stroke mortality was observed in men in the MRSP, when compared to Brazil (42.43% vs. 34.9%, p = 0.036) and an equal reduction in women in the MRSP and in Brazil (42.98% vs. 36.15%, p = 0.082). The decrease in mortality was significant for all age groups. CONCLUSION We observed a progressive decrease in mortality from CVD, IHD and stroke in Brazil and in the MRSP. In spite of this decrease, we still have high rates of mortality from these diseases.

Stroke and Ischemic Heart Disease Mortality Trends in Brazil from 1979 to 1996

Stroke and ischemic heart disease (IHD) mortality rates were analyzed in Brazilian subjects older than 30 years of age from 1979 to 1996. Population estimates were based on census surveys. Mortality data were obtained from the Ministry of Health. For stroke, the age-adjusted death rate (ADR) dropped from 200 to 164 and from 168 to 130 deaths/100,000 population in men and women, respectively (p < 0.001), in the interval study. For IHD, the ADR dropped from 194 to 164 and from 119 to 105 deaths/100,000 population in men and women, respectively (p < 0.001), in the same time period. Mortality from stroke and IHD combined was greater in men for all age groups (p < 0.001). Stroke was the most frequent cause of death in both women and men except for men aged between 40 and 69 years, in whom IHD was more common. Stroke and IHD were the main causes of death in the Brazilian population.

Apolipoproteins AI, B, and E polymorphisms in severe aortic valve stenosis

Hypercholesterolemia has been related to aortic valve stenosis (AS). Polymorphisms of apolipoproteins (apo) AI, B, and E are associated with variable levels of plasma lipids, but the association between these polymorphisms and AS is unknown. In a case–control study of groups matched by age, sex, comparable body mass index, hypertension, triglycerides, high‐density lipoprotein (HDL) cholesterol, and low‐density lipoprotein (LDL) cholesterol, we analyzed the distribution of apo AI A/G mutation, apo B signal peptide insertion/deletion, apo B XbaI restriction fragment length, and apo E polymorphisms in 62 non‐diabetic patients with severe aortic valve stenosis and 62 control subjects. All patients underwent echocardiographic analysis. Univariate analysis showed a higher prevalence of the XbaI X+/X+ genotype (p=0.007) of apo B and the apo E2 allele (p=0.034) in patients with severe AS. Apo polymorphisms were not associated with lipid levels, left ventricular mass, or the aortic gradient.

Análise de séries temporais da mortalidade por doenças isquêmicas do coração e cerebrovasculares, nas cinco regiões do Brasil, no período de 1981 a 2001

OBJECTIVE The aim of this study was to evaluate the trends of ischemic and cerebrovascular death risk in the five regions--Midwest, Northeast, North, Southeast and South--of Brazil from 1981 to 2001. METHODS Data on mortality due to cerebrovascular and coronary heart diseases in the five regions of Brazil were obtained from the Brazilian Ministry of Health. The data source was the SIM--Sistema de Informações sobre Mortalidade (System of Information on Mortality), from the Department of Health Information Analysis. The population estimates were obtained from the IBGE (Brazilian Institute of Geography and Statistics) census of 1991 and 2000, and population estimates of 1996, all from DATASUS. The codes used in this study were International Classification of Diseases ICD-9 430-438 and ICD-10 I60-I69 for cerebrovascular diseases and ICD-9 410-414 and ICD-10 I21-I25 for ischemic disease. Statistical analysis was carried out by adjusted linear models. RESULTS There was a decline trend in death rates due to cerebrovascular disease at all age ranges and in both sexes in the South, Southwest, and Midwest regions. Additionally, death rates due to ischemic heart disease declined in the South and Southwest regions. There was a stabilization of the death risk in the Midwest and an increase in the Northeast region. CONCLUSION The risk of death due to cerebrovascular and ischemic heart diseases declined in the Southwest and South, which are the more developed regions of Brazil, whereas the risk increased in the less developed ones, mainly in the Northeast region.

Transição epidemiológica da mortalidade por doenças circulatórias no Brasil

FUNDAMENTO: As doencas circulatorias (DC) sao as principais causas de morte no Brasil, com predominio das doencas cerebrovasculares (DCbV). Nos paises desenvolvidos, predominam as doencas isquemicas do coracao (DIC). OBJETIVO: Analisar a relacao entre DCbV/DIC em homens e mulheres a partir de 30 anos. METODOS: As estimativas da populacao e os dados de mortalidade para DC, DIC e DCbV foram obtidos do Ministerio da Saude para o periodo entre 1980 e 2005. O risco de morte por DIC e DCbV por 100.000 habitantes e a relacao entre DCbV/DIC foram analisados nas faixas etarias decenais a partir de 30 anos. O risco de morte foi ajustado pelo metodo direto, usando como populacao padrao a populacao mundial de 1960. RESULTADOS: Observou-se aumento exponencial do risco de morte por DIC e DCbV, com o aumento da faixa etaria. DCbV foi a principal causa de morte no Brasil ate 1996, quando passou a predominar a DIC. Foi observada reducao de 33,25% no risco de morte por DC na populacao brasileira. Na regiao metropolitana de Sao Paulo, houve uma diminuicao de 45,44%, entre 1980 e 2005. A relacao DCbV/DIC foi maior nas mulheres mais jovens: de 2,53 em 1980 e 2,04 em 2005 para a populacao brasileira, e de 2,76 em 1980 e 1,96 em 2005 na regiao metropolitana de Sao Paulo, com decrescimo nas faixas etarias subsequentes. Nos homens, a relacao DCbV/DIC foi proximo de <1 para todas as faixas etarias. CONCLUSAO: Observou-se, no Brasil, uma transicao do risco de morte por DC, com predominio atual das DIC.BACKGROUND Circulatory diseases (CD) are the major cause of death in Brazil, being cerebrovascular diseases (CVD) predominant. In developed countries ischemic heart diseases (IHD) predominate. OBJECTIVE The objective of the present study was to investigate the ratio between cerebrovascular diseases/ischemic heart diseases (CVD/IHD) in males and females who were 30 years of age and older. METHODS Population estimates and mortality data for CD, IHD and CVD were provided by the Ministry of Health for the period between 1980 and 2005. The risk of death from IHD and CVD per 100,000 Brazilians and CVD/IHD ratio were analyzed in 10-year age ranges as of 30 years of age. The risk of death was adjusted by direct method by using 1960 world population as the standard population. RESULTS It was observed that the risk of death from IHD and CVD increased exponentially as age advanced. CVD was the major cause of death in Brazil until 1996, when IHD took the lead. In the period between 1980 and 2005 a 33.25% reduction in death risk from CD was observed in the Brazilian population. In that same period, the metropolitan area of the capital city of São Paulo reported a 45.44% reduction. The CVD/IHD ratio was shown to be higher among younger women - from 2.53 in 1980 down to 2.04 in 2005 in the Brazilian population, and from 2.76 in 1980 down to 1.96 in the metropolitan area of the capital city of São Paulo, with decreasing figures for subsequent age ranges. Among males, the CVD/IHD ratio was close to < 1 in all age ranges. CONCLUSION A transition in death risk from CD could be observed in Brazil, with current predominance of IHD.

Triglyceride and lipoprotein (a) are markers of coronary artery disease severity among postmenopausal women

OBJECTIVE After menopause, some women manifest coronary artery disease (CAD) with highly variable angiographic severity. For these women, postmenopausal appearing of some CAD risk factors may have differently influenced the CAD risk and severity. In this study, we attempt to unravel differences in the frequency or intensity of CAD risk factors among postmenopausal women with different angiographic severity. METHODS We studied 182 postmenopausal women (64+/-6 years) who underwent coronary angiography to investigate thoracic pain. Subjects with no detectable coronary lesions at angiography were recruited to the non-obstructive group and patients with CAD were grouped in one-vessel or multi-vessel groups. We compared clinical variables as the body mass index (BMI), age at menopause, age, hypertension, diabetes and cigarette smoking, and lipid measurements as plasma levels of total cholesterol, triglyceride, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, apolipoprotein (apo) A1, apo B and lipoprotein(a) (Lp(a)). RESULTS Comparing to the non-obstructive group, Lp(a) was twofold higher in the one-vessel group and threefold higher in the multi-vessel group and triglycerides were 34% higher in the one-vessel group and 50% higher in the multi-vessel group. No further difference was found among the three groups. After multivariate logistic regression analysis, triglyceride (odds ratio: 1.01; P=0.0013) and Lp(a) (odds ratio: 1.006; P<0.0001) were independently indicative of the presence of obstructive CAD. CONCLUSIONS We found that both Lp(a) and triglycerides constitute useful markers of CAD severity among postmenopausal women.

Tendência do risco de morte por doenças circulatórias, cerebrovasculares e isquêmicas do coração em treze Estados do Brasil, de 1980 a 1998

OBJECTIVE Analyze the trends in the risk of death from circulatory diseases (CD) in thirteen states in Brazil between 1980 and 1998. METHODS Data on mortality from CD, ischemic heart diseases (IHD), and cerebrovascular diseases (CVD) in thirteen states were obtained from the Ministry of Health data base. Populational estimates from 1980 to 1998 were calculated through interpolation, using the Lagrange method, based on data from the 1970, 1980, 1991 censuses, and 1996 populational count. The trends were analyzed by multiple linear regression model. RESULTS Mortality due to CD showed a trend towards decrease in most states. In Pernambuco state males presented increase in all age ranges, whereas in Goiás increase was shown from 40 years of age on, and in Bahia and Mato Grosso, from 50 years of age. Females showed increase starting at 30 in Mato Grosso, at 40 in Pernambuco, and in Goiás, in the age ranging from 30 to 49 years of age. In Goiás, increase was discreet in all other age ranges. As for IHD, mortality increase was reported in all age ranges in Mato Grosso and Pernambuco; in Bahia, Goiás and Pará, from 40 on. As for CVD, mortality increase was reported in all age ranges in Mato Grosso and Pernambuco; and from 40 on in Bahia and Goiás. CONCLUSION Significant increase in the risk of death from circulatory diseases could be observed in less developed states in Brazil.

Angiotensin-converting enzyme and apolipoprotein B polymorphisms in coronary artery disease

The association between angiotensin-converting enzyme (ACE) as well as apolipoprotein B polymorphisms and dyslipidemia and coronary artery disease (CAD) is controversial. We assessed the distribution of ACE insertion and/or deletion, apolipoprotein B signal peptide insertion and/or deletion, and apolipoprotein B XbaI restriction fragment length polymorphisms in 388 nondiabetic patients. We studied 112 patients with angiographically defined asymptomatic CAD or with stable functional classes I and II angina and 139 patients with acute myocardial infarction who were age matched to 137 control subjects. Univariate analysis showed higher prevalence of Xba50% reduction of lumen diameter. Overall, multivariable regression disclosed traditional risk factors and elevated levels of apolipoprotein B for men and reduced levels of apolipoprotein AI for women as independent variables for CAD. After adjustment for the most important subset of risk factors (age, hypertension, hypercholesterolemia, and smoking), apolipoprotein B XbaI polymorphism was disclosed as an independent variable for CAD. Apolipoprotein B XbaI was also selected as an independent variable for acute myocardial infarction after adjusting for age, hypertension, hypercholesterolemia, and smoking. Thus, in addition to traditional coronary risk factors, apolipoproteins B and AI, and apolipoprotein B XbaI polymorphism could be considered predictors of CAD.