Aristarco Gonçalves de Siqueira-Filho

Prevalence and Prognostic Value of Perfusion Defects Detected by Stress Technetium-99m Sestamibi Myocardial Perfusion Single-Photon Emission Computed Tomography in Asymptomatic Patients With Diabetes Mellitus and No Known Coronary Artery Disease

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in diabetics. Early diagnosis of CAD and identification of high-risk subgroups, followed by appropriate therapy, may therefore enhance survival. This study sought to determine the value of stress myocardial perfusion single-photon emission computed tomography (SPECT) with technetium-99m sestamibi to detect perfusion defects and predict cardiac events in asymptomatic diabetics. One hundred eighty asymptomatic diabetics without known CAD who underwent 2-day stress technetium-99m sestamibi SPECT were followed up for 36 +/- 18 months. End points were defined as hard (myocardial infarction or cardiac death) or total events (myocardial infarction, cardiac death, or late revascularization). Logistic regression analysis evaluated clinical variables, type of stress, exercise treadmill test (ETT), and SPECT as predictors of end points. Perfusion defects were found in 26% of patients (15% reversible, 6% mixed, and 5% fixed). Clinical or ETT variables were not associated with perfusion defect type or with hard events. However, male gender predicted total events (chi-square 3.3; p = 0.01). An abnormal SPECT significantly increased the risk of hard events (chi-square 5.4; p = 0.001) and total events (chi-square 7.4; p = 0.0001). Extensive defects determined the highest risk of total events (chi-square 18.8; p = 0.0001). Event rates increased according to SPECT: 2% of hard events per year and 5% of total events per year in patients with normal SPECT versus 9% per year and 38% per year, respectively, in those with abnormal SPECT. Importantly, a normal SPECT identified a relatively low-risk subgroup of patients. Thus, stress technetium-99m sestamibi SPECT was useful in evaluating asymptomatic diabetics for the presence of CAD, and effectively risk-stratified this population.

Clinical determinants of increased QT dispersion in patients with diabetes mellitus

AIMS To compare QT dispersion measurements in diabetic patients to control subjects and assess any associations between QT dispersion and diabetic clinical characteristics. METHODS A total of 512 diabetics and 50 age and gender matched controls were studied. QT interval was measured manually in 12-lead conventional electrocardiograms, and QT dispersion (QTd), heart rate-corrected QT dispersion (QTcd), number of leads-adjusted QT dispersion (adjuQTd) and adjacent QT dispersion (adjaQTd) were calculated. Demographic, clinical, laboratory and electrocardiographic data were recorded. RESULTS Diabetics showed increased QT dispersion compared to controls (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001), even those with recent diagnosis (less than 2 years) and without arterial hypertension, ECG abnormalities or chronic degenerative complications (QTd: P=0.01, QTcd: P<0.001, adjuQTd: P=0.04). Left ventricular hypertrophy (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001, adjaQTd: P<0.001) and conduction disturbances (QTd: P=0.002, QTcd: P=0.003, adjuQTd: P=0.003) were the electrocardiographic findings associated with increased QT dispersion in bivariate analysis. Clinical variables were the presence of arterial hypertension (QTd: P=0.004, QTcd: P=0.01, adjuQTd: P<0.001), even without left ventricular hypertrophy (QTd: P=0.01, QTcd: P=0.03, adjuQTd: P=0.003), and the presence of diabetic cardiovascular complications (QTd: P=0.02, QTcd: P=0.01, adjuQTd: P=0.008, adjaQTd: P=0.03). No association between QT dispersion and the presence of diabetic microvascular complications, glycaemic control, age and gender, or cardiovascular drugs was observed. Multivariate regressive statistical analysis confirmed the associations noted in bivariate analysis. CONCLUSIONS Diabetic patients have increased QT dispersion compared to non-diabetics even those without arterial hypertension and cardiovascular complications and with recent diagnosis. The presence of arterial hypertension, diabetic cardiovascular complications and electrocardiographic abnormalities of left ventricular hypertrophy and conduction disturbances were associated to increased QT dispersion in diabetes mellitus.

The effects of early administration of atropine during dobutamine stress echocardiography: advantages and disadvantages of early dobutamine-atropine protocol.

BackgroundThe conventional dobutamine protocol for the investigation of induced myocardial ischemia is well established. Our objective was to evaluate the effects of early administration of atropine during the dobutamine stress echocardiogram, as compared to its conventional use.MethodsOne hundred and twenty-one patients were referred to the dobutamine stress echocardiogram, for the investigation of myocardial ischemia and the administration of atropine was randomized into three groups (A, B, C at 10, 20 and 40 mcg/kg/min of dobutamine, respectively).ResultsThe mean level of the double product was significantly lower in the group C patients when compared to group B patients (p = 0.002). The mean test time (12.8 ± 3.1 and 18.7 ± 3.4 p= 0.0001) and the mean total dose of dobutamine (14 × 18 × 25 mg p = 0.008) were significantly higher in group C patients than in group A & B patients. The mean test time was reduced in 6 minutes (31%) with the early administration of atropine in relation to the standard protocol. The atropine dose used in the different groups was similar. Complications were uniform in all cases.ConclusionThe early administration of atropine during the dobutamine-atropine stress echocardiography significantly reduces duration of the test and the dose of amine without increasing the number of complications, the total dose of atropine or the number of diagnostic tests.

Comparison of the inoue and single balloon techniques during long term percutaneous balloon mitral valvoplasty follow-up: analysis of risk factors for death and major events

OBJECTIVE To analyze the long term evolution of patients undergoing percutaneous balloon mitral valvoplasty comparing the Inoue and Balt single balloon methods, and to identify predictors of death and major events (death, repeat balloon mitral valvoplasty or mitral valve surgery). METHODS The follow-up for the single and Inoue balloon groups were 54 +/- 31 (1 to 126) months and 34 +/- 26 (2 to 105) months, respectively (p < 0.0001). The Balt single balloon was used in 254 (84.1%) patients and the Inoue balloon in 48 (15.9%). RESULTS The following data were found for the Inoue and single balloon groups, respectively: age, 36.9 +/- 10.4 (19 to 63) years and 38.0 +/- 12.6 (13 to 83) years (p = 0.5769); echocardiographic score, 7.5 +/- 1.3 points and 7.2 +/- 1.5 points (p = 0.1307); female gender, 72.9% and 87.4% (p = 0.0097); atrial fibrillation, 10.4% and 16.1% (p = 0.4275); mortality during follow-up, 2.1% and 4.3% (0.6984); and major events, 8.3% and 17.7% (p = 0.1642). Univariate and Kaplan-Meier curve analyses revealed no differences between the Inoue and Balt single balloon techniques in relation to survival and major event free survival. In the multivariate analysis, age > 50 years and an echocardiographic score > 8 were independent predictors of death; and an echocardiographic score > 8 and post operative mitral valve area < 1.50 cm(2) were predictors for major events. CONCLUSION No differences were found in the long term evolution of patients undergoing the Inoue versus the single balloon technique. Predictors of death and/or major events were: age > 50 years, echocardiographic score > 8 and mitral valve area < 1.50 cm(2) after the procedure.

Complications related to carotid sinus massage in 502 ambulatory patients

BACKGROUND The carotid sinus massage (CSM) is a simple and low-cost technique with many indications. OBJECTIVE To determine the safety of CSM in outpatients with high prevalence of atherosclerotic disease and cardiopathy. METHODS A transversal study. INCLUSION CRITERIA Outpatients aged >or= 50 years, referred for ECG. EXCLUSION CRITERIA Individuals that refused to participate in a study on the prevalence of the cardioinhibitory response to CSM, patients with dementia, patients with pacemakers, individuals with carotid murmur or history of stroke or AMI in the last three months. The CSM was carried out in the supine position during 10 seconds. The occurrence of sustained arrhythmias or the occurence of neurological deficit during the CSM or in the first 24 hours after its end were considered complications of the CSM. RESULTS 562 patients were randomly selected from a total of 1,686 individuals that met the inclusion criteria. Sixty individuals met the exclusion criteria. The remaining 502 patients (52% males, 69% with cardiopathies and 50% with atherosclerotic disease) were submitted to 1,053 CSM. Two patients presented complications (0.4%; 95%CI:0%-0.9%). A 71-yr-old man developed left arm monoparesis with complete regression within 30 minutes. Another 56-yr-old man presented left homonymous hemianopsia, with regression after 7 days. CONCLUSION The incidence of CSM-related complications was small, particularly when considering that the population submitted to the maneuver was elderly, with high incidence of structural heart disease and atherosclerotic disease.FUNDAMENTO: A massagem do seio carotideo (MSC) e uma tecnica simples, de baixo custo e com muitas indicacoes. OBJETIVO: Determinar a seguranca da MSC em pacientes ambulatoriais com alta prevalencia de doenca aterosclerotica e de cardiopatia. METODOS: Estudo transversal. Criterios de inclusao: pacientes ambulatoriais com idade > 50 anos, encaminhados para realizacao de eletrocardiograma (ECG). Criterios de exclusao: individuos que nao aceitaram participar de um estudo sobre a prevalencia da resposta cardioinibitoria a MSC, pacientes com demencia, portadores de marca-passo, individuos com sopro carotideo ou com historia de AVC ou IAM nos ultimos 3 meses. A MSC foi realizada na posicao supina durante 10 segundos. Foram consideradas complicacoes da MSC a ocorrencia de arritmias sustentadas e o aparecimento de deficit neurologico durante a MSC ou nas primeiras 24 horas apos o seu termino. RESULTADOS: Foram selecionados aleatoriamente 562 pacientes de um total de 1.686 individuos com criterios de inclusao. Sessenta individuos apresentaram criterios de exclusao. Os 502 pacientes restantes (52% homens, idade media de 65 anos, 69% cardiopatas e 50% com doenca aterosclerotica) foram submetidos a 1.053 MSC. Dois pacientes apresentaram complicacoes (0,4%; IC95%:0%-0,9%). Um homem de 71 anos apresentou monoparesia do braco esquerdo com regressao completa em 30 minutos. Outro homem, de 56 anos, apresentou hemianopsia homonima a esquerda que regrediu em 7 dias. CONCLUSAO: A incidencia de complicacoes relacionadas a MSC foi pequena, particularmente quando se considerou que a populacao submetida a manobra era idosa e com alta prevalencia de cardiopatia estrutural e de doenca aterosclerotica.

Prevalência e preditores da resposta cardioinibitória à massagem do seio carotídeo em 502 pacientes ambulatoriais

BACKGROUND: Cardioinhibitory response (CIR) is defined as asystole >3 seconds in response to 5-10 seconds of carotid sinus massage (CSM). Pacemaker implantation is indicated for patients with unexplained syncope episodes and CIR. OBJECTIVE: To determine the prevalence and predictors of CIR in patients with a high prevalence of cardiovascular disease, and assess the clinical significance of CIR in patients with a history of unexplained syncope or falls. METHODS: Cross-section design study. Outpatients, aged >50 years, referred to the electrocardiography sector of a tertiary hospital. Those with dementia, carotid bruit, and history of myocardial infarction, stroke or transient ischemic attack in the preceding 3 months were excluded. CSM was performed by a single investigator, with the patients in the supine position. CSM was applied on the right side and then on the left side during 10 seconds each time. RESULTS: 502 patients underwent CSM. CIR was present in 52 patients (10.4%; 95% CI: 7.7%-13%). Independent predictors of CIR were male gender (OR: 2.61%; CI 95%: 1.3%-5.1%), structural heart disease (OR: 3.28%; CI 95%: 1.3%-7.9%) and baseline heart rate (P 50 years. In males and in patients with structural heart disease CIR was more common. In women and patients with no apparent structural heart disease, the presence of CIR was a highly specific finding in the evaluation of syncope or falls.

The effects of beta-blockers on dobutamine-atropine stress echocardiography: early protocol versus standard protocol

BackgroundTo study the effects of Beta-blockers during Dobutamine Stress Echocardiography (DSE) comparing the hemodynamic benefits of an early administration of atropine in patients taking or not Beta-blockers.MethodsOne hundred and twenty-one patients were submitted to dobutamine stress echocardiography for the investigation of myocardial ischemia. The administration of atropine was randomized into two groups: A or B (early protocol when atropine was administered at 10 and 20 mcg/kg/min of dobutamine, respectively) and C (standard protocol with atropine at 40 mcg/kg/min of dobutamine). Analysis of the effects of Beta-blockers was done regarding the behavior pattern of heart rate and blood pressure, test time, number of conclusive and inconclusive (negative sub-maximum test) results, total doses of atropine and dobutamine, and general complications.ResultsBeta-blocked patients who received early atropine (Group A&B) had a significantly lower double product (p = 0.008), a higher mean test time (p = 0.010) and required a higher dose of atropine (p = 0.0005) when compared to the patients in this group who were not Beta-blocked. The same findings occurred in the standard protocol (Group C), however the early administration of atropine reduced test time both in the presence and absence of this therapy (p = 0.0001). The patients with Beta-blockers in Group A&B had a lower rate of inconclusive tests (26%) compared to those in Group C (40%). Complications were similar in both groups.ConclusionThe chronotropic response during dobutamine stress echocardiography was significantly reduced with the use of Beta-blockers. The early administration of atropine optimized the hemodynamic response, reduced test time in patients with or without Beta-blockers and reduced the number of inconclusive tests in the early protocol.

Incidencia de complicaciones relacionadas al masaje del seno carotídeo en 502 pacientes ambulatorios

BACKGROUND The carotid sinus massage (CSM) is a simple and low-cost technique with many indications. OBJECTIVE To determine the safety of CSM in outpatients with high prevalence of atherosclerotic disease and cardiopathy. METHODS A transversal study. INCLUSION CRITERIA Outpatients aged >or= 50 years, referred for ECG. EXCLUSION CRITERIA Individuals that refused to participate in a study on the prevalence of the cardioinhibitory response to CSM, patients with dementia, patients with pacemakers, individuals with carotid murmur or history of stroke or AMI in the last three months. The CSM was carried out in the supine position during 10 seconds. The occurrence of sustained arrhythmias or the occurence of neurological deficit during the CSM or in the first 24 hours after its end were considered complications of the CSM. RESULTS 562 patients were randomly selected from a total of 1,686 individuals that met the inclusion criteria. Sixty individuals met the exclusion criteria. The remaining 502 patients (52% males, 69% with cardiopathies and 50% with atherosclerotic disease) were submitted to 1,053 CSM. Two patients presented complications (0.4%; 95%CI:0%-0.9%). A 71-yr-old man developed left arm monoparesis with complete regression within 30 minutes. Another 56-yr-old man presented left homonymous hemianopsia, with regression after 7 days. CONCLUSION The incidence of CSM-related complications was small, particularly when considering that the population submitted to the maneuver was elderly, with high incidence of structural heart disease and atherosclerotic disease.FUNDAMENTO: A massagem do seio carotideo (MSC) e uma tecnica simples, de baixo custo e com muitas indicacoes. OBJETIVO: Determinar a seguranca da MSC em pacientes ambulatoriais com alta prevalencia de doenca aterosclerotica e de cardiopatia. METODOS: Estudo transversal. Criterios de inclusao: pacientes ambulatoriais com idade > 50 anos, encaminhados para realizacao de eletrocardiograma (ECG). Criterios de exclusao: individuos que nao aceitaram participar de um estudo sobre a prevalencia da resposta cardioinibitoria a MSC, pacientes com demencia, portadores de marca-passo, individuos com sopro carotideo ou com historia de AVC ou IAM nos ultimos 3 meses. A MSC foi realizada na posicao supina durante 10 segundos. Foram consideradas complicacoes da MSC a ocorrencia de arritmias sustentadas e o aparecimento de deficit neurologico durante a MSC ou nas primeiras 24 horas apos o seu termino. RESULTADOS: Foram selecionados aleatoriamente 562 pacientes de um total de 1.686 individuos com criterios de inclusao. Sessenta individuos apresentaram criterios de exclusao. Os 502 pacientes restantes (52% homens, idade media de 65 anos, 69% cardiopatas e 50% com doenca aterosclerotica) foram submetidos a 1.053 MSC. Dois pacientes apresentaram complicacoes (0,4%; IC95%:0%-0,9%). Um homem de 71 anos apresentou monoparesia do braco esquerdo com regressao completa em 30 minutos. Outro homem, de 56 anos, apresentou hemianopsia homonima a esquerda que regrediu em 7 dias. CONCLUSAO: A incidencia de complicacoes relacionadas a MSC foi pequena, particularmente quando se considerou que a populacao submetida a manobra era idosa e com alta prevalencia de cardiopatia estrutural e de doenca aterosclerotica.

Analysis of the Economic Impact of Cardiovascular Diseases in the Last Five Years in Brazil

Background There is growing concern about the economic impact of cardiovascular diseases (CVD) in Brazil and worldwide. Objective To estimate the economic impact of CVD in Brazil in the last five years. Methods The information to estimate CVD costs was taken from national databases, adding the direct costs with hospitalizations, outpatient visits and benefits granted by social security. Indirect costs were added to the calculation, such as loss of income caused by CVD morbidity or mortality. Results CVD mortality accounts for 28% of all deaths in Brazil in the last five years and for 38% of deaths in the productive age range (18 to 65 years). The estimated costs of CVD were R

Influence of the tilt angle of Percutaneous Aortic Prosthesis on Velocity and Shear Stress Fields

37.1 billion in 2015, a 17% increase in the period from 2010 to 2015. The estimated costs of premature death due to CVD represent 61% of the total cost of CVD, Direct costs with hospitalizations and consultations were 22%, and costs related to the loss of productivity related to the disease were 15% of the total. Health expenditures in Brazil are estimated at 9.5% of GDP and the average cost of CVD was estimated at 0.7% of GDP. Conclusion CVD costs have increased significantly in the last five years. It is estimated that CVD costs increase as the Brazilian population ages and the prevalence of CVD increases.