Beatriz Moreira Ayub Ferreira

The Effects of Glibenclamide, a KATP Channel Blocker, on the Warm-Up Phenomenon

Background: The warm‐up phenomenon observed after the second of two sequential exercise tests is characterized by an increased time to ischemia and ischemic threshold, and the latter is related to ischemic preconditioning. Previous studies have demonstrated that a single dose of glibenclamide, a cardiac ATP‐sensitive K (KATP) channel blocker, prevents ischemic preconditioning. This study aimed to investigate the effects of chronic treatment with glibenclamide during two sequential exercise tests.

Electrocardiographic score: application in exercise test for the assessment of ischemic preconditioning

FUNDAMENTO: O tempo para 1,0 mm de depressao do segmento ST (T-1,0 mm), adotado para caracterizar o precondicionamento isquemico (PCI) em testes ergometricos sequenciais, e consistente e reprodutivel, porem, possui varias limitacoes. OBJETIVO: Aplicar um escore eletrocardiografico de isquemia miocardica em testes ergometricos sequenciais, comparando-o com o classico indice T-1,0 mm. METODOS: Avaliamos 61 pacientes, com idade media de 62,2 ± 7,5 anos, sendo 86,9% homens. Foram analisados 151 exames, sendo 116 de pacientes que completaram duas fases de avaliacao. A primeira fase compreendia dois testes ergometricos sequenciais para documentacao do PCI e a segunda fase, apos uma semana, mais dois testes sob efeito de repaglinida. Dois observadores aplicaram o escore de forma cega. RESULTADOS: Observou-se concordância perfeita inter e intraobservador (Kendall Tau-b = 0,96, p < 0,0001, Kendall Tau-b = 0,98,p < 0,0001, respectivamente). Os valores de sensibilidade, especificidade, valor preditivo negativo, valor preditivo positivo e acuracia foram de 72,41%, 89,29%, 75,8%, 87,5% e 81,0%, respectivamente. CONCLUSAO: O escore de isquemia e um metodo consistente e reprodutivel para documentacao do PCI, representando uma alternativa factivel ao indice T-1,0 mm.BACKGROUND the time for 1.0 mm ST-segment depression (T-1.0mm) adopted to characterize ischemic preconditioning (IPC) in sequential exercise tests is consistent and reproducible; however, it has several limitations. OBJECTIVE to apply an electrocardiographic score of myocardial ischemia in sequential exercise tests, comparing it to the conventional T-1.0 mm index. METHODS sixty one patients with mean age of 62.2 ± 7.5 years were evaluated; 86.9% were males. A total of 151 tests were analyzed, 116 of which were from patients who completed two assessment phases. The first phase comprised two sequential exercise tests for the documentation of IPC; the second phase, initiated one week later, comprised two more tests carried out under the effect of repaglinide. Two observers who were blind to the tests applied the score. RESULTS Perfect inter and intraobserver agreement was found (Kendall tau-b = 0.96, p < 0.0001, and Kendall tau-b = 0.98, p < 0.0001, respectively). Values of sensitivity and specificity, negative predictive value, positive predictive value and accuracy were 72.41%, 89.29%, 75.8%, 87.5% and 81.0%, respectively. CONCLUSION the ischemic score is a consistent and reproducible method for the documentation of IPC, and is a feasible alternative to T-1.0 mm.

Escore eletrocardiográfico: aplicação em ergometria para avaliação do precondicionamento isquêmico

FUNDAMENTO: O tempo para 1,0 mm de depressao do segmento ST (T-1,0 mm), adotado para caracterizar o precondicionamento isquemico (PCI) em testes ergometricos sequenciais, e consistente e reprodutivel, porem, possui varias limitacoes. OBJETIVO: Aplicar um escore eletrocardiografico de isquemia miocardica em testes ergometricos sequenciais, comparando-o com o classico indice T-1,0 mm. METODOS: Avaliamos 61 pacientes, com idade media de 62,2 ± 7,5 anos, sendo 86,9% homens. Foram analisados 151 exames, sendo 116 de pacientes que completaram duas fases de avaliacao. A primeira fase compreendia dois testes ergometricos sequenciais para documentacao do PCI e a segunda fase, apos uma semana, mais dois testes sob efeito de repaglinida. Dois observadores aplicaram o escore de forma cega. RESULTADOS: Observou-se concordância perfeita inter e intraobservador (Kendall Tau-b = 0,96, p < 0,0001, Kendall Tau-b = 0,98,p < 0,0001, respectivamente). Os valores de sensibilidade, especificidade, valor preditivo negativo, valor preditivo positivo e acuracia foram de 72,41%, 89,29%, 75,8%, 87,5% e 81,0%, respectivamente. CONCLUSAO: O escore de isquemia e um metodo consistente e reprodutivel para documentacao do PCI, representando uma alternativa factivel ao indice T-1,0 mm.BACKGROUND the time for 1.0 mm ST-segment depression (T-1.0mm) adopted to characterize ischemic preconditioning (IPC) in sequential exercise tests is consistent and reproducible; however, it has several limitations. OBJECTIVE to apply an electrocardiographic score of myocardial ischemia in sequential exercise tests, comparing it to the conventional T-1.0 mm index. METHODS sixty one patients with mean age of 62.2 ± 7.5 years were evaluated; 86.9% were males. A total of 151 tests were analyzed, 116 of which were from patients who completed two assessment phases. The first phase comprised two sequential exercise tests for the documentation of IPC; the second phase, initiated one week later, comprised two more tests carried out under the effect of repaglinide. Two observers who were blind to the tests applied the score. RESULTS Perfect inter and intraobserver agreement was found (Kendall tau-b = 0.96, p < 0.0001, and Kendall tau-b = 0.98, p < 0.0001, respectively). Values of sensitivity and specificity, negative predictive value, positive predictive value and accuracy were 72.41%, 89.29%, 75.8%, 87.5% and 81.0%, respectively. CONCLUSION the ischemic score is a consistent and reproducible method for the documentation of IPC, and is a feasible alternative to T-1.0 mm.

2017 Guidelines for Arterial Hypertension Management in Primary Health Care in Portuguese Language Countries

Arq Bras Cardiol. 2017; 109(5):389-396 2017 Guidelines for Arterial Hypertension Management in Primary Health Care in Portuguese Language Countries Gláucia Maria Moraes de Oliveira,1 Miguel Mendes,2 Marcus Vinícius Bolívar Malachias,3,4 João Morais,5 Osni Moreira Filho,6 Armando Serra Coelho,7 Daniel Pires Capingana,8 Vanda Azevedo,9 Irenita Soares,9 Alda Menete,10,11 Beatriz Ferreira,10,11 Miryan Bandeira dos Prazeres Cassandra Soares,12 Mário Fernandes13 Universidade Federal do Rio de Janeiro (UFRJ),1 Rio de Janeiro, RJ Brazil; Centro Hospitalar de Lisboa Ocidental, E.P.E. Hospital de Santa Cruz,2 Carnaxide Portugal; Faculdade Ciências Médicas de Minas Gerais;3 Fundação Educacional Lucas Machado (FCMMG/FELUMA),4 Belo Horizonte, MG Brazil; Centro Hospitalar de Leiria Hospital de Santo André,5 Leiria Portugal; Pontifícia Universidade Católica do Paraná,6 Curitiba, PR Brazil; Clínica Santos Dumont,7 Lisboa Portugal; Instituto Superior de Ciências de Saúde do Cuando Cubango de Angola8 Angola; Colégio da Especialidade de Cardiologia da Ordem dos Médicos de Cabo Verde9 Cabo Verde; Instituto do Coração de Moçambique10 Moçambique; Colégio da Especialidade de Cardiologia da Ordem dos Médicos de Moçambique11 Moçambique; Hospital Dr. Ayres de Menezes,12 São Tomé São Tomé e Príncipe; Hospital Américo Boavida,13 Luanda Angola

Avaliação prognóstica da doença coronária estável através de um novo escore

FUNDAMENTO: A necessidade de melhorar a acuracia do teste de esforco, determinou o desenvolvimento de escores, cuja aplicabilidade ja foi amplamente reconhecida. OBJETIVO: Avaliacao prognostica do coronariopata estavel atraves de um novo escore simplificado. METODOS: Um novo escore foi aplicado em 372 coronariopatas multiarteriais e funcao ventricular preservada, 71,8% homens, idade media 59,5 (± 9,07) anos, randomizados para angioplastia, revascularizacao cirurgica e tratamento clinico, acompanhados por 5 anos. Obito cardiovascular foi o desfecho primario. Infarto do miocardio nao-fatal, obito e re-intervencao formaram o desfecho combinado secundario. O escore baseou-se numa equacao previamente validada resultante da soma de 1 ponto para: sexo masculino, historia de infarto, angina, diabete, uso de insulina e ainda 1 ponto para cada decada de vida a partir dos 40 anos. Teste positivo adicionou 1 ponto. RESULTADOS: Ocorreram 36 obitos (10 no grupo angioplastia, 15 no grupo revascularizacao e 11 no grupo clinico), p = 0,61. Observou-se 93 eventos combinados: 37 no grupo angioplastia, 23 no grupo revascularizacao e 33 no grupo clinico (p = 0,058). 247 pacientes apresentaram escore clinico > 5 pontos e 216 > 6 pontos. O valor de corte > 5 ou > 6 pontos identificou maior risco, com p = 0,015 e p = 0,012, respectivamente. A curva de sobrevida mostrou uma incidencia de obito apos a randomizacao diferente naqueles com escore > 6 pontos (p = 0,07), e uma incidencia de eventos combinados diferente entre pacientes com escore 6 pontos (p = 0,02). CONCLUSAO: O novo escore demonstrou consistencia na avaliacao prognostica do coronariopata estavel multiarterial.BACKGROUND The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE Prognostic evaluation of stable coronary disease through a new simplified score. METHODS A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8% male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score ≥ 5 points and 216 ≥ 6 points. The cutoff point ≥ 5 or ≥ 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and ≥ 6 points (p = 0.02). CONCLUSION The new score was consistent for multiarterial stable coronary disease risk stratification.

New prognostic score for stable coronary disease evaluation

FUNDAMENTO: A necessidade de melhorar a acuracia do teste de esforco, determinou o desenvolvimento de escores, cuja aplicabilidade ja foi amplamente reconhecida. OBJETIVO: Avaliacao prognostica do coronariopata estavel atraves de um novo escore simplificado. METODOS: Um novo escore foi aplicado em 372 coronariopatas multiarteriais e funcao ventricular preservada, 71,8% homens, idade media 59,5 (± 9,07) anos, randomizados para angioplastia, revascularizacao cirurgica e tratamento clinico, acompanhados por 5 anos. Obito cardiovascular foi o desfecho primario. Infarto do miocardio nao-fatal, obito e re-intervencao formaram o desfecho combinado secundario. O escore baseou-se numa equacao previamente validada resultante da soma de 1 ponto para: sexo masculino, historia de infarto, angina, diabete, uso de insulina e ainda 1 ponto para cada decada de vida a partir dos 40 anos. Teste positivo adicionou 1 ponto. RESULTADOS: Ocorreram 36 obitos (10 no grupo angioplastia, 15 no grupo revascularizacao e 11 no grupo clinico), p = 0,61. Observou-se 93 eventos combinados: 37 no grupo angioplastia, 23 no grupo revascularizacao e 33 no grupo clinico (p = 0,058). 247 pacientes apresentaram escore clinico > 5 pontos e 216 > 6 pontos. O valor de corte > 5 ou > 6 pontos identificou maior risco, com p = 0,015 e p = 0,012, respectivamente. A curva de sobrevida mostrou uma incidencia de obito apos a randomizacao diferente naqueles com escore > 6 pontos (p = 0,07), e uma incidencia de eventos combinados diferente entre pacientes com escore 6 pontos (p = 0,02). CONCLUSAO: O novo escore demonstrou consistencia na avaliacao prognostica do coronariopata estavel multiarterial.BACKGROUND The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE Prognostic evaluation of stable coronary disease through a new simplified score. METHODS A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8% male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score ≥ 5 points and 216 ≥ 6 points. The cutoff point ≥ 5 or ≥ 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and ≥ 6 points (p = 0.02). CONCLUSION The new score was consistent for multiarterial stable coronary disease risk stratification.

Evaluación pronóstica de la enfermedad coronaria estable a través de un nuevo score

FUNDAMENTO: A necessidade de melhorar a acuracia do teste de esforco, determinou o desenvolvimento de escores, cuja aplicabilidade ja foi amplamente reconhecida. OBJETIVO: Avaliacao prognostica do coronariopata estavel atraves de um novo escore simplificado. METODOS: Um novo escore foi aplicado em 372 coronariopatas multiarteriais e funcao ventricular preservada, 71,8% homens, idade media 59,5 (± 9,07) anos, randomizados para angioplastia, revascularizacao cirurgica e tratamento clinico, acompanhados por 5 anos. Obito cardiovascular foi o desfecho primario. Infarto do miocardio nao-fatal, obito e re-intervencao formaram o desfecho combinado secundario. O escore baseou-se numa equacao previamente validada resultante da soma de 1 ponto para: sexo masculino, historia de infarto, angina, diabete, uso de insulina e ainda 1 ponto para cada decada de vida a partir dos 40 anos. Teste positivo adicionou 1 ponto. RESULTADOS: Ocorreram 36 obitos (10 no grupo angioplastia, 15 no grupo revascularizacao e 11 no grupo clinico), p = 0,61. Observou-se 93 eventos combinados: 37 no grupo angioplastia, 23 no grupo revascularizacao e 33 no grupo clinico (p = 0,058). 247 pacientes apresentaram escore clinico > 5 pontos e 216 > 6 pontos. O valor de corte > 5 ou > 6 pontos identificou maior risco, com p = 0,015 e p = 0,012, respectivamente. A curva de sobrevida mostrou uma incidencia de obito apos a randomizacao diferente naqueles com escore > 6 pontos (p = 0,07), e uma incidencia de eventos combinados diferente entre pacientes com escore 6 pontos (p = 0,02). CONCLUSAO: O novo escore demonstrou consistencia na avaliacao prognostica do coronariopata estavel multiarterial.BACKGROUND The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE Prognostic evaluation of stable coronary disease through a new simplified score. METHODS A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8% male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score ≥ 5 points and 216 ≥ 6 points. The cutoff point ≥ 5 or ≥ 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and ≥ 6 points (p = 0.02). CONCLUSION The new score was consistent for multiarterial stable coronary disease risk stratification.

Escore electrocardiográfico: aplicación en ergometría para evaluación del preacondicionamiento isquémico

FUNDAMENTO: O tempo para 1,0 mm de depressao do segmento ST (T-1,0 mm), adotado para caracterizar o precondicionamento isquemico (PCI) em testes ergometricos sequenciais, e consistente e reprodutivel, porem, possui varias limitacoes. OBJETIVO: Aplicar um escore eletrocardiografico de isquemia miocardica em testes ergometricos sequenciais, comparando-o com o classico indice T-1,0 mm. METODOS: Avaliamos 61 pacientes, com idade media de 62,2 ± 7,5 anos, sendo 86,9% homens. Foram analisados 151 exames, sendo 116 de pacientes que completaram duas fases de avaliacao. A primeira fase compreendia dois testes ergometricos sequenciais para documentacao do PCI e a segunda fase, apos uma semana, mais dois testes sob efeito de repaglinida. Dois observadores aplicaram o escore de forma cega. RESULTADOS: Observou-se concordância perfeita inter e intraobservador (Kendall Tau-b = 0,96, p < 0,0001, Kendall Tau-b = 0,98,p < 0,0001, respectivamente). Os valores de sensibilidade, especificidade, valor preditivo negativo, valor preditivo positivo e acuracia foram de 72,41%, 89,29%, 75,8%, 87,5% e 81,0%, respectivamente. CONCLUSAO: O escore de isquemia e um metodo consistente e reprodutivel para documentacao do PCI, representando uma alternativa factivel ao indice T-1,0 mm.BACKGROUND the time for 1.0 mm ST-segment depression (T-1.0mm) adopted to characterize ischemic preconditioning (IPC) in sequential exercise tests is consistent and reproducible; however, it has several limitations. OBJECTIVE to apply an electrocardiographic score of myocardial ischemia in sequential exercise tests, comparing it to the conventional T-1.0 mm index. METHODS sixty one patients with mean age of 62.2 ± 7.5 years were evaluated; 86.9% were males. A total of 151 tests were analyzed, 116 of which were from patients who completed two assessment phases. The first phase comprised two sequential exercise tests for the documentation of IPC; the second phase, initiated one week later, comprised two more tests carried out under the effect of repaglinide. Two observers who were blind to the tests applied the score. RESULTS Perfect inter and intraobserver agreement was found (Kendall tau-b = 0.96, p < 0.0001, and Kendall tau-b = 0.98, p < 0.0001, respectively). Values of sensitivity and specificity, negative predictive value, positive predictive value and accuracy were 72.41%, 89.29%, 75.8%, 87.5% and 81.0%, respectively. CONCLUSION the ischemic score is a consistent and reproducible method for the documentation of IPC, and is a feasible alternative to T-1.0 mm.

The heart rate recovery may be influenced by the ischemic preconditioning

Introduction: The warm-up phenomenon, observed after the second of two sequential exercise tests, is characterized by an increased of both time to lschemia and ischemic threshold, and the last one is probably related to a ischemic preconditioning. In the other hand, the heart-rate recovery immediately after exercise, which may be a reflection of decreased vagal activity. is a powerful predictor of overall mortality. This study aimed to Investigate the effects of ischemic preconditioning on the heart-rate recovery during the first minute after graded exercise. Methods: Twenty patients with chronic stable angina pectoris were enrolled and all were off treatment. They underwent two consecutive treadmill exercise tests according to the Bruce protocol with recovery period behveen the tests of 30 min to re-establish baseline conditions. The value for the recovery of heart rate was defined as the reduction in the heart rate from the peak exercise to the rate one minute after the cessation of exercise. Results: The hearl rate and the rate-pressure product at l.Omm ST-segment depression significantly increased during the second exercise test compared to the first (121.3 + 16.5 vs.127.3 + 15.3 beatslmin, pcO.001, and 216.7 + 43.1 vs. 232.1 + 43.0 beats.mmHg.l@/min, pcO.001): the time to 1.0 mm ST-segment depression d&g the second exercise test was greater than that during the first test, too (225.0 -+ 112.5 vs. 267.02 122.3 s, p=O.OOG).The median heati rate recovery increased significantly during the second test compared to the first (254213.5 vs. 29.4 + 15.0 beatslmin, p=O.O2). Conclusion: The main findings of this study are an improvement of the ischemic threshold in the second test probably related to ischemlc preconditioning and an improvement of the heart-rate recovery. Although there isn’t a clear explanation of this relation, it is clear that ischemic preconditioning represents a powerful protective phenomenon and the better heart rate recovery in the second compared to the first test may be a expression of this phenomenon.