António Pires

Childhood adiposity: being male is a potential cardiovascular risk factor.

AbstractAs the earliest atherosclerotic lesions begin during childhood, our aim was to correlate gender-related adiposity to classical cardiovascular risk factors in a group of children.An observational and transversal analysis was carried out in a cohort consisting of 161 children of both sexes, aged 6 to 17xa0years of age. Waist circumference was correlated to leptin, high-sensitivity C-reactive protein, systolic and diastolic blood pressure, plasma lipids, homeostasis model assessment-insulin resistance, and the left ventricular mass index. After adjusting for age, waist circumference in boys, compared to girls, correlated more strongly and directly to systolic (ru2009=u20090.538; pu2009<u20090.001) and diastolic blood pressure (ρu2009=u20090.401; pu2009<u20090.01), ApoB/ApoA ratio (ρu2009=u20090.515; pu2009<u20090.01), high-density lipoprotein cholesterol (ru2009=u2009−0.441; pu2009<u20090.001), low-density lipoprotein cholesterol (ρu2009=u20090.280; pu2009<u20090.01), triglycerides (ρu2009=u20090.420; pu2009<u20090.001), homeostasis model assessment-insulin resistance (ρu2009=u20090.463; pu2009<u20090.001), and the left ventricular mass index (ρu2009=u20090.286; pu2009<u20090.01). A similar pattern was observed regarding the correlations between leptin, high-sensitivity C-reactive protein, and the above parameters (except between high-sensitivity C-reactive protein and diastolic blood pressure), and also, particularly in boys.n Conclusion: Although increased childhood adiposity is related to a more adverse metabolic and clinical profile in both genders, males appear to have a potentially greater cardiovascular risk.What is Known:•Obesity is characterized by a chronic low-grade inflammatory process.What is New:•Increased adiposity is related to a more pronounced pro-inflammatory response in boys.•Childhood male adiposity is a potentially greater cardiovascular risk factor.•Arterial hypertension, insulin resistance, and dyslipidemia is more strongly correlated to waist circumference in boys.

Pro-inflammatory triggers in childhood obesity: Correlation between leptin, adiponectin and high-sensitivity C-reactive protein in a group of obese Portuguese children

INTRODUCTIONnPediatric obesity is increasingly prevalent in the Portuguese population. Adipocyte dysfunction results in the expression of pro-inflammatory mediators that are responsible for the low-grade inflammatory process that characterizes obesity.nnnOBJECTIVESnThe aim of this study was to investigate the relationship between markers of adiposity, inflammation and adipokines in a Portuguese obese pediatric population.nnnMETHODSnOne hundred and twenty children of both sexes, aged 6-17 years, were included in this study. The control group consisted of 41 healthy normal-weight children. The variables analyzed were age, gender, body mass index, waist circumference, fat mass percentage, high-sensitivity C-reactive protein (hs-CRP), leptin and adiponectin.nnnRESULTSnThere were significant differences between controls and obese children for all parameters analyzed. In the obese group, after controlling for age and gender, hs-CRP (p=0.041), adiponectin (p=0.019) and leptin (p<0.001) still showed significant statistical differences. A direct correlation was found between hs-CRP, leptin, body mass index and waist circumference, the strongest being with leptin (r=0.568; p<0.001). This trend remained statistically significant, regardless of gender or pubertal age.nnnCONCLUSIONSnConsidering the role of leptin, adiponectin and hs-CRP in the genesis of endothelial dysfunction, they may be used in clinical practice for risk stratification, as well as in the assessment of weight control programs.

Insulin resistance, dyslipidemia and cardiovascular changes in a group of obese children.

Introduction Obesity-related comorbidities are present in young obese children, providing a platform for early adult cardiovascular disorders. Objectives To compare and correlate markers of adiposity to metabolic disturbances, vascular and cardiac morphology in a European pediatric obese cohort. Methods We carried out an observational and transversal analysis in a cohort consisting of 121 obese children of both sexes, between the ages of 6 and 17 years. The control group consisted of 40 children with normal body mass index within the same age range. Markers of adiposity, plasma lipids and lipoproteins, homeostasis model assessment-insulin resistance, common carotid artery intima-media thickness and left ventricular diameters were analyzed. Results There were statistically significant differences between the control and obese groups for the variables analyzed, all higher in the obese group, except for age, high-density lipoprotein cholesterol and adiponectin, higher in the control group. In the obese group, body mass index was directly correlated to left ventricular mass (r=0.542; p=0.001), the homeostasis model assessment-insulin resistance (r=0.378; p=<0.001) and mean common carotid artery intima-media thickness (r=0.378; p=<0.001). In that same group, insulin resistance was present in 38.1%, 12.5% had a combined dyslipidemic pattern, and eccentric hypertrophy was the most common left ventricular geometric pattern. Conclusions These results suggest that these markers may be used in clinical practice to stratify cardiovascular risk, as well as to assess the impact of weight control programs.

Dyslipidemia and cardiovascular changes in children.

Purpose of review In this review, we firstly highlight the role of dyslipidemia as a trigger in the initiation and progression of endothelial dysfunction, considered the earliest atherosclerotic lesion and patent in children with risk factors. In this context, we also revise methods that reflect the impact of endothelial dysfunction not only on arterial stiffness but also on cardiovascular morphology, namely, the common carotid intima-media thickness and the ventricular geometry. Recent findings In view of its atherogenic burden, the most widely studied lipoprotein has been low density lipoprotein cholesterol. However, the smaller, denser, low density lipoprotein cholesterol particles, the nonhigh density lipoprotein cholesterol fraction, appear to be more atherogenic and a more sensitive cardiovascular risk marker. Studies have shown that in children, atherogenic lipids have also been linked to cardiovascular morphological changes, such as the common carotid intima-media thickness and the ventricular geometry, both independent cardiovascular risk markers. Summary In infancy, atherosclerosis is a preclinical disorder in which dyslipidemia plays a crucial role. Due to its impact on cardiovascular structures, potentially reversible during childhood, dyslipidemia ought to be managed aggressively to prevent further disease progression that will ultimately culminate in cardiac disease, a leading cause of mortality in adults.

Circulating endothelial progenitor cells in obese children and adolescents

Objective nThis study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity.OBJECTIVEnThis study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity.nnnMETHODSnObservational and transversal study, including 120 children and adolescents with primary obesity of both sexes, aged 6-17 years, who were recruited at this Cardiovascular Risk Clinic. The control group was made up of 41 children and adolescents with normal body mass index. The variables analyzed were: age, gender, body mass index, systolic and diastolic blood pressure, high-sensitivity C-reactive protein, lipid profile, leptin, adiponectin, homeostasis model assessment-insulin resistance, monocyte chemoattractant protein-1, E-selectin, asymmetric dimethylarginine and circulating progenitor endothelial cell count.nnnRESULTSnInsulin resistance was correlated to asymmetric dimethylarginine (ρ=0.340; p=0.003), which was directly, but weakly correlated to E-selectin (ρ=0.252; p=0.046). High sensitivity C-reactive protein was not found to be correlated to markers of endothelial activation. Systolic blood pressure was directly correlated to body mass index (ρ=0.471; p<0.001) and the homeostasis model assessment-insulin resistance (ρ=0.230; p=0.012), and inversely correlated to adiponectin (ρ=-0.331; p<0.001) and high-density lipoprotein cholesterol (ρ=-0.319; p<0.001). Circulating endothelial progenitor cell count was directly, but weakly correlated, to body mass index (r=0.211; p=0.016), leptin (ρ=0.245; p=0.006), triglyceride levels (r=0.241; p=0.031), and E-selectin (ρ=0.297; p=0.004).nnnCONCLUSIONnCirculating endothelial progenitor cell count is elevated in obese children and adolescents with evidence of endothelial activation, suggesting that, during infancy, endothelial repairing mechanisms are present in the context of endothelial activation.

Coronary and systemic aneurysms in an infant with Kawasaki disease.

Kawasaki disease is an immune-mediated vasculitis of unknown etiology. Among untreated patients, the incidence of coronary aneurysm reaches 25%, declining to 5% even among those treated appropriately [1]. The incidence of iliac artery aneurysms varies from 0.6% to 2.5% [2]. The aneurysms tend to regress with medical therapy but are more prone than other systemic aneurysms to the development of stenotic lesions [3]. In this case, Dacron graft replacement is required [2]. We describe the case of a previously well 6-month-old infant admitted to our intensive care unit with cardiac failure after a 10-day history of unremitting fever of unknown origin and a fading macular papular rash. No other clinical signs were apparent. An echocardiogram showed a moderate pericardial effusion, diminished left ventricular contractility, and moderate to large aneurysms in both coronary arteries. The largest aneurysm (9 mm) was in the right coronary artery. Immunoglobulin (2 g/kg) and acetyl salicylic acid (100 mg/kg/day) were started, and 4 days after admission the infant required resuscitation for cardiac arrest. At the time, the electrocardiogram showed evidence of posteroinferior ischemia, and a repeat echocardiogram showed the presence of thrombi in the coronary aneurysms. He was managed with thrombolytic therapy (alteplase 0.3 mg/kg/h for 6 h) and repeat immunoglobulin (2 g/kg), with reestablishment of flow in the obstructed aneurismal coronary arteries and subsequent clinical improvement. The infant was clinically well 1 month after discharge, with no further cardiac events reported. However, followup echocardiography showed no regression of the coronary aneurysms. Cardiac catheterization performed to define the coronary lesions showed rosary-like dilations of the right (Fig. 1) and left coronary arteries as well as sac-like aneurysms of both internal iliac arteries (Fig. 2). No other cardiac anomalies were found, and left ventricular function was preserved.

Original articleCirculating endothelial progenitor cells in obese children and adolescentsCélulas progenitoras endoteliais circulantes em crianças e adolescentes obesos

Objective nThis study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity.OBJECTIVEnThis study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity.nnnMETHODSnObservational and transversal study, including 120 children and adolescents with primary obesity of both sexes, aged 6-17 years, who were recruited at this Cardiovascular Risk Clinic. The control group was made up of 41 children and adolescents with normal body mass index. The variables analyzed were: age, gender, body mass index, systolic and diastolic blood pressure, high-sensitivity C-reactive protein, lipid profile, leptin, adiponectin, homeostasis model assessment-insulin resistance, monocyte chemoattractant protein-1, E-selectin, asymmetric dimethylarginine and circulating progenitor endothelial cell count.nnnRESULTSnInsulin resistance was correlated to asymmetric dimethylarginine (ρ=0.340; p=0.003), which was directly, but weakly correlated to E-selectin (ρ=0.252; p=0.046). High sensitivity C-reactive protein was not found to be correlated to markers of endothelial activation. Systolic blood pressure was directly correlated to body mass index (ρ=0.471; p<0.001) and the homeostasis model assessment-insulin resistance (ρ=0.230; p=0.012), and inversely correlated to adiponectin (ρ=-0.331; p<0.001) and high-density lipoprotein cholesterol (ρ=-0.319; p<0.001). Circulating endothelial progenitor cell count was directly, but weakly correlated, to body mass index (r=0.211; p=0.016), leptin (ρ=0.245; p=0.006), triglyceride levels (r=0.241; p=0.031), and E-selectin (ρ=0.297; p=0.004).nnnCONCLUSIONnCirculating endothelial progenitor cell count is elevated in obese children and adolescents with evidence of endothelial activation, suggesting that, during infancy, endothelial repairing mechanisms are present in the context of endothelial activation.

Right Subclavian Artery Aneurysm in an Adolescent With a Bicuspid Aortic Valve

Bicuspic aortic valve is the most common congenital cardiac anomaly (Fedak et al. 106:900–904, 2002), and it is associated with other structural anomalies of the aorta, such as coarctation, suggesting a common embryologic developmental mechanism (Mergan et al. 104:118–119, 2004). In more than a half of patients, it is associated with progressive dilation and aneurysm formation of the aorta (Warnes 89:965–966, 2003) despite normally functioning bicuspid aortic valves. In this context, aneurysms of the right subclavian artery are extremely rare, and even more so when associated with a right-sided aortic arch that has a left aberrant subclavian artery with a Kommerell diverticulum, as found in the reported case. These aneurysms represent a significant risk for thromboembolism and rupture, and elective surgical management should be advised, even for asymptomatic cases.

Total anomalous pulmonary venous return.

TAPVR typically presents in early infancy due to excessive pulmonary blood flow and mild cyanosis. Presentation is earlier when there is obstruction to pulmonary venous flow where neonates present with severe cyanosis and cardiogenic shock, surgical repair must be planned immediately. Mixing of well oxygenated blood through the anomalous connection of pulmonary veins with the systemic blood in the right atrium results in similar oxygen saturation in all cardiac chambers and arteries, therefore pre and post ductal oxygen saturations are equal. Increased blood flow across the right heart causes delay in closure of the pulmonary valve, presenting as fixed splitting of second heart sound as well as systolic flow murmur over the pulmonic region. Supra-cardiac drainage of anomalous pulmonary veins to the superior vena cava result in figure-eight or snow man appearance of the cardiac silhouette on CXR.

Importância da monitorização ambulatória da pressão arterial no diagnóstico e prognóstico da hipertensão arterial em idade pediátrica

The prevalence of high blood pressure (BP) at pediatric age has increased progressively, one of the causes of which is obesity. However, the dominant etiology in this age group is renal and/or cardiovascular pathology. Ambulatory blood pressure monitoring (ABPM) is the method of choice for the diagnosis of hypertension, especially in children at high cardiovascular risk. Its use is limited to children from five years of age. Choosing appropriate cuff size is key to obtaining correct blood pressure. The main indication for ABPM is to confirm the diagnosis of hypertension. It also allows the diagnosis of white coat hypertension (which may represent an intermediate stage between the normotensive phase and hypertension), or masked hypertension, associated with progression to sustained hypertension and left ventricular hypertrophy (LVH). Children with isolated nocturnal hypertension should be considered as having masked hypertension. BP load is defined as the percentage of valid measurements above the 95th percentile for age, gender, and height. Values above 25-30% are pathological and those above 50% are predictive of LVH. ABPM correlates with target organ damage, particularly LVH and renal damage. It is useful in the differentiation of secondary hypertension, since these children show higher BP load and less nocturnal dipping, and confirmation of response to therapy. Thus ABPM allows the diagnosis and classification of hypertension, provides cardiovascular prognostic information and identifies patients with intermediate phenotypes of hypertension.