Bráulio Luna Filho

Qualidade de vida de pacientes hipertensos em tratamento ambulatorial

BACKGROUND: The main cause of mortality in braziliam population is the cardiovascular disease and arterial hypertension (AH) the most prevalent one. The antihypertensive treatment is effective however it is not well known how affects the quality of life (QOL) in patients afterwards. OBJECTIVE: To comparatively assess the QOL in patients submitted to an antihypertensive treatment. METHODS: One-hundred patients with AH were studied of which 46 had complied with a standard treatment regimen (group A) and 54 (group B control) were about to start the same regimen. We collected clinical and sociodemographic data and questions focusing sexuality, self-perception of QOL, number and types of medication taken and their influence on sex life. The questionnaire SF-36 was also administered. The data were analyzed using the tests chi-square, Students t, Pearson correlation and Tukey. RESULTS: No differences were detected between group A and B in any of the SF-36 domains. There was an association between the question on self-perception of QOL and the SF-36 domains, emotional aspects excepted. As regards sexuality, there was difference in the quality of sex life between the groups, which was less satisfactory for group A. CONCLUSION: When the SF-36 was administered no changes in QOL were detected between the groups because it is an asymptomatic chronic disease. The SF-36 did not properly assess emotional aspects in our case series of hypertensive patients that had high behavior variability. Group A showed lower quality sex life; however, this was not related to the number and type of medication used.

Correlation of electrocardiographic left ventricular hypertrophy criteria with left ventricular mass by echocardiogram in obese hypertensive patients

INTRODUCTION Left ventricular hypertrophy (LVH) and obesity are important cardiovascular risk factors. This study evaluates the influence of obesity on the diagnostic performance of the most used electrocardiographic criteria for LVH in hypertensive patients. METHODS One thousand two hundred four outpatients from the Hypertensive Unit of the Hospital São Paulo, São Paulo, SP, Brazil, were studied. All underwent 12-lead electrocardiogram and echocardiogram. The most known electrocardiographic criteria for LVH were assessed and compared with the left ventricular mass index obtained by echocardiogram in obese and nonobese groups of hypertensive patients. RESULTS The populations mean age was 57.4 +/- 4.7 years; 351 were men (29.1%) and 853 women (70.8%). Cornell voltage, Cornell duration, Sokolow-Lyon voltage, Romhilt-Estes criteria, and R wave in aVL 11 mm or higher showed a positive correlation with left ventricular mass index (P < .05). Notwithstanding, there were no changes regarding specificity for obese or nonobese characteristics. However, sensitivity had a statistically significant decrease in obese patients in regard to Sokolow-Lyon voltage and Romhilt-Estes criteria and strain pattern (P < .05). CONCLUSION Cornell voltage and Cornell duration criteria, Perugia score, R wave in aVL, and QTc variable had no significant changes in diagnostic sensitivity in the obese patients.

Massa ventricular e critérios eletrocardiográficos de hipertrofia: avaliação de um novo escore

BACKGROUND The left ventricular hypertrophy (LVH) is an important and independent cardiovascular risk factor. There is a scarcity of studies in Brazil designed to test the efficacy of the electrocardiogram (ECG) in the diagnosis of this important pathological process. OBJECTIVE To evaluate a new electrocardiographic score for the diagnosis of LVH by ECG: the sum of the highest amplitude of the S wave and the highest amplitude of the R wave on the horizontal plane, multiplied by the result of the QRS duration [(S+R) X QRS)] and comparing it with the classic electrocardiographic criteria. METHODS The echocardiograms and ECG of 1,204 hypertensive patients receiving outpatient care were evaluated. The left ventricular mass index (LVMI) was assessed by the echocardiogram, with a diagnosis of LVH when the LVMI was > or = 96 g/m(2) for women and > or = 116 g/m(2) for men. Four classic criteria of LVH were analyzed at the ECG, in addition to the new score to be tested. RESULTS In general, the studied ECG-LVH criteria showed significant statistical correlation to the echocardiographic LVMI. The (R+S) X QRS index, using 2.80 mm.s as the cutoff value, provided test accuracy regarding sensibility and specificity of 35.2% and 88.71%, respectively, representing the best correlation to LVMI (r=0.564) when compared to the other indexes: Romhilt-Estes (r=0.464); Sokolow-Lyon (r=0.419); Cornell voltage (r=0.377); Cornell product r=0.444). CONCLUSION All the electrocardiographic criteria used for the assessment of the LV mass presented low sensitivity. The new score presented the best correlation with LVMI when compared to the other indexes.

Electrocardiography in the diagnosis of ventricular hypertrophy in patients with chronic renal disease.

BACKGROUND Left ventricular hypertrophy (LVH) is an independent predictor of cardiovascular risk, and its characterization and prevalence in chronic renal disease (CRD) should be further studied. OBJECTIVE To establish the diagnosis of LVH in patients with stage-5 CRD using six different electrocardiographic criteria, and to correlate them with left ventricular mass index (LVMI) as obtained by echocardiography. METHODS Cross-sectional study including 100 patients (58 men and 42 women, mean age 46.2 + or - 14.0 years) with CRD of all causes undergoing hemodialysis (HD) for at least six months. Electrocardiography (ECG) and echocardiography were performed in all patients, always up to one hour after the end of the HD sessions. RESULTS LVH was detected in 83 patients (83%), of whom 56 (67.4%) had the concentric pattern and 27 (32.6%) the eccentric pattern of LVH. Diagnostic sensitivity, specificity and accuracy of all the electrocardiographic methods studied were higher than 50%. Using Pearsons linear correlation for LVMI, only the Sokolow-Lyon voltage criterion did not show a > or = 0.50 coefficient. Calculation of the likelihood ratio, in turn, showed that ECG has a discriminatory power for the diagnosis of LVH in the population studied, with emphasis on the Cornell-product and Romhilt-Estes criteria. No correlation was observed between LVMI and QTc and QTc dispersion. CONCLUSION ECG is a useful, efficient, and highly reproducible method for the diagnosis of LVH in HD patients. In this population, the Cornell-product proved to be the most reliable criterion for the detection of LVH.FUNDAMENTO: La hipertrofia ventricular izquierda (HVI) es un factor predictor independiente de riesgo cardiovascular y su caracterizacion y prevalencia en la enfermedad renal cronica (ERC) carecen de mejor estudio. OBJETIVO: Establecer el diagnostico de HVI en pacientes con ERC en estadio 5 por seis diferentes criterios electrocardiograficos, correlacionandolos al indice de masa del ventriculo izquierdo (IMVI) que se obtuvo mediante el ecocardiograma. METODOS: Estudio transversal que incluyo a 100 pacientes (58 varones y 42 mujeres, edad de 46,2 ± 14,0 anos) con ERC de todas las etiologias, desde hace al menos 6 meses en hemodialisis (HD). Se obtuvieron electrocardiograma (ECG) y ecocardiograma de los pacientes, siempre hasta una hora tras el termino de las sesiones de HD. RESULTADOS: La HVI se detecto en 83 pacientes (83%), de los que 56 (67,4%) presentaban el estandar concentrico y 27 (32,6%) el estandar excentrico de HVI. Todos los metodos electrocardiograficos estudiados tuvieron sensibilidad, especificidad y exactitud diagnosticas superiores al 50%. Mediante la correlacion lineal de Pearson con el IMVI, solamente el criterio de Sokolow-Lyon voltaje no presento coeficiente > 0,50. Sin embargo, el calculo de la razon de verosimilitud evidencio que el ECG tiene poder discriminatorio para diagnostico de HVI en la poblacion estudiada, con enfasis para los criterios de Producto de Cornell y Romhilt-Estes. No hubo correlacion entre IMVI con el QTc y su dispersion. CONCLUSION: El ECG es un metodo util, eficaz y de alta reproductibilidad en el diagnostico de HVI de los pacientes en HD. En esa poblacion, el criterio de Producto de Cornell fue mas fiable para la deteccion de HVI.

Duchenne muscular dystrophy: electrocardiographic analysis of 131 patients

FUNDAMENTO: E conhecido o envolvimento cardiaco em pacientes com distrofia muscular de Duchenne (DMD). O eletrocardiograma (ECG) apresenta algumas alteracoes tipicas na DMD, fato que o torna um exame util no diagnostico da lesao cardiaca nessa patologia. OBJETIVO: Avaliar as alteracoes eletrocardiograficas em pacientes portadores de DMD, correlacionando-as com a idade da populacao estudada. METODOS: Foram analisados os ECG de 131 pacientes com diagnostico de DMD. Avaliaram-se diversas variaveis eletrocardiograficas, sendo os pacientes separados em dois grupos: aqueles com e sem alteracoes, por variavel estudada. Fez-se a correlacao desses dois grupos com a idade dos pacientes. Foram utilizados os criterios de Garson para estabelecer os parâmetros eletrocardiograficos de normalidade. RESULTADOS: O ECG estava anormal em 78,6% dos pacientes. Todos apresentavam ritmo sinusal. Foram os seguintes os percentuais encontrados para as principais variaveis estudadas: PR curto = 18,3%, ondas R anormais em V1 = 29,7%, ondas Q anormais em V6 = 21,3%, alteracoes da repolarizacao ventricular = 54,9%, ondas QS anormais em paredes inferior e/ou lateral alta = 37,4%, disturbios de conducao pelo ramo direito = 55,7%, intervalo QTC prolongado = 35,8% e alargamento do QRS = 23,6%. O teste t nao pareado foi utilizado para se estabelecer a correlacao da idade com as variaveis eletrocardiograficas estudadas nos dois grupos e, apenas a variavel alteracao da repolarizacao mostrou diferenca estatisticamente significante. CONCLUSAO: As alteracoes eletrocardiograficas na DMD sao frequentes, revelando comprometimento cardiaco precoce. Apenas a variavel alteracao da repolarizacao ventricular foi mais frequente, porem em faixa etaria menor (p < 0,05).BACKGROUND Cardiac involvement is known to occur in patients with Duchenne muscular dystrophy (DMD). The electrocardiogram (ECG) shows some typical changes in DMD, which makes it a useful test for the diagnosis of cardiac lesion in this disease. OBJECTIVE To evaluate the electrocardiographic changes in patients with DMD and to correlate these changes with the age of the population studied. METHODS ECG of 131 patients diagnosed with DMD were examined. Several electrocardiographic variables were analyzed, and the patients were divided into two groups - one with and one without changes, for each variable studied. The correlation between the two groups and the age of the patients was analyzed. Garsons criteria were used to establish the electrocardiographic parameters of normality. RESULTS ECG was abnormal in 78.6% of the patients. All showed normal sinus rhythm. The following percentages were found for the main variables studied: short PR interval = 18.3%; abnormal R waves in V1 = 29.7%; abnormal Q waves in V6 = 21.3%; abnormal ventricular repolarization = 54.9%; abnormal QS waves in inferior and/or upper lateral wall = 37.4%; conduction disturbances in right bundle branch = 55.7%; prolonged QT C interval = 35.8%, and wide QRS = 23.6%. Unpaired t test was used to establish the correlation between age and the electrocardiographic variables studied in the two groups. Statistically significant differences were found only for the abnormal repolarization variable. CONCLUSION Electrocardiographic abnormalities are common in DMD, revealing early cardiac involvement. Only the abnormal ventricular repolarization variable was more frequent, however at a lower age range (p < 0.05).

Teste de respiração lenta aumenta a suspeita da hipertensão do avental branco no consultório

BACKGROUND: It would be useful to have a clinical test that increases the suspicion of white coat hypertension (WCH) during the medical consultation. OBJECTIVE: To evaluate the Slow Breathing Test (SBT) when differentiating hypertension from WCH. METHODS: 101 hypertensive patients selected at triage had their medication withdrawn for 2-3 weeks. The blood pressure (BP) was measured before and after the SBT at two consultations at the office. The test consisted in breathing for 1 minute at the frequency of one respiratory cycle every 10 seconds. Two diagnostic criteria were compared: 1 - decrease in diastolic BP >10% in at least one visit or 2- decrease in BP to normal levels (<140/90 mm Hg) in at least one visit. The ambulatory blood pressure monitoring (ABPM) was performed while blinded to the clinical measurements. RESULTS: 71 women and 30 men, with a mean age of 51+10 years, with mean pre and post-test BP of 152+17/ 99+11 and 140+18/ 91+11 mm Hg were assessed. Nine patients had normal clinical and ambulatory measurements. Of the 92 patients, 28 (30%) were classified as having WCH; 15 had a positive test for Criterion 1 and 21 for the Criterion 2. Among 64 (70%) hypertensive individuals, 14 tested positive for Criterion 1 and 12 for Criterion 2. Sensitivity and specificity (95% CI): 0.54 (0.36-0.71) and 0.78 (0.67-0.87) for Criterion 1; 0.75 (0.57-0.87) and 0.81 (0.70-0.89) for Criterion 2. CONCLUSION: The SBT showed an increase in the clinical suspicion of WCH in two visits when using the BP normalization criterion. This finding suggests that the test can help in the optimization of ABPM requests for suspected cases.

O eletrocardiograma no diagnóstico da hipertrofia ventricular de pacientes com doença renal crônica

BACKGROUND Left ventricular hypertrophy (LVH) is an independent predictor of cardiovascular risk, and its characterization and prevalence in chronic renal disease (CRD) should be further studied. OBJECTIVE To establish the diagnosis of LVH in patients with stage-5 CRD using six different electrocardiographic criteria, and to correlate them with left ventricular mass index (LVMI) as obtained by echocardiography. METHODS Cross-sectional study including 100 patients (58 men and 42 women, mean age 46.2 + or - 14.0 years) with CRD of all causes undergoing hemodialysis (HD) for at least six months. Electrocardiography (ECG) and echocardiography were performed in all patients, always up to one hour after the end of the HD sessions. RESULTS LVH was detected in 83 patients (83%), of whom 56 (67.4%) had the concentric pattern and 27 (32.6%) the eccentric pattern of LVH. Diagnostic sensitivity, specificity and accuracy of all the electrocardiographic methods studied were higher than 50%. Using Pearsons linear correlation for LVMI, only the Sokolow-Lyon voltage criterion did not show a > or = 0.50 coefficient. Calculation of the likelihood ratio, in turn, showed that ECG has a discriminatory power for the diagnosis of LVH in the population studied, with emphasis on the Cornell-product and Romhilt-Estes criteria. No correlation was observed between LVMI and QTc and QTc dispersion. CONCLUSION ECG is a useful, efficient, and highly reproducible method for the diagnosis of LVH in HD patients. In this population, the Cornell-product proved to be the most reliable criterion for the detection of LVH.FUNDAMENTO: La hipertrofia ventricular izquierda (HVI) es un factor predictor independiente de riesgo cardiovascular y su caracterizacion y prevalencia en la enfermedad renal cronica (ERC) carecen de mejor estudio. OBJETIVO: Establecer el diagnostico de HVI en pacientes con ERC en estadio 5 por seis diferentes criterios electrocardiograficos, correlacionandolos al indice de masa del ventriculo izquierdo (IMVI) que se obtuvo mediante el ecocardiograma. METODOS: Estudio transversal que incluyo a 100 pacientes (58 varones y 42 mujeres, edad de 46,2 ± 14,0 anos) con ERC de todas las etiologias, desde hace al menos 6 meses en hemodialisis (HD). Se obtuvieron electrocardiograma (ECG) y ecocardiograma de los pacientes, siempre hasta una hora tras el termino de las sesiones de HD. RESULTADOS: La HVI se detecto en 83 pacientes (83%), de los que 56 (67,4%) presentaban el estandar concentrico y 27 (32,6%) el estandar excentrico de HVI. Todos los metodos electrocardiograficos estudiados tuvieron sensibilidad, especificidad y exactitud diagnosticas superiores al 50%. Mediante la correlacion lineal de Pearson con el IMVI, solamente el criterio de Sokolow-Lyon voltaje no presento coeficiente > 0,50. Sin embargo, el calculo de la razon de verosimilitud evidencio que el ECG tiene poder discriminatorio para diagnostico de HVI en la poblacion estudiada, con enfasis para los criterios de Producto de Cornell y Romhilt-Estes. No hubo correlacion entre IMVI con el QTc y su dispersion. CONCLUSION: El ECG es un metodo util, eficaz y de alta reproductibilidad en el diagnostico de HVI de los pacientes en HD. En esa poblacion, el criterio de Producto de Cornell fue mas fiable para la deteccion de HVI.

Sensibilidade do eletrocardiograma na hipertrofia ventricular de acordo com gênero e massa cardíaca

BACKGROUND: Several factors are known to interfere with electrocardiogram (ECG) sensitivity when diagnosing Left Ventricular Hypertrophy (LVH), with gender and cardiac mass being two of the most important ones OBJECTIVE: To evaluate the influence of gender on the sensitivity of some of the criteria used to detect LVH, according to the progression of ventricular hypertrophy degree. METHODS: According to gender and the degree of LVH at the echocardiogram, the patients were divided in three groups: mild, moderate and severe LVH. ECG sensitivity to detect LVH was assessed between men and women, according to the LVH degree. RESULTS: Of the 874 patients, 265 were males (30.3%) and 609, females (69.7%). The [(S + R) X QRS], Sokolow-Lyon, Romhilt-Estes, Perugia and strain criteria showed high discriminatory power in the diagnosis of LVH between men and women in the three groups with LVH, with a superior performance in the male population and highlighting the importance of the [(S + R) X QRS] and Perugia scores. Conclusion: The diagnostic sensitivity of the ECG increases with the cardiac mass. The examination is more sensitive in men, highlighting the importance of the [(S + R) X QRS] and Perugia scores. CONCLUSION: The diagnostic sensitivity of the ECG increases with the cardiac mass. The examination is more sensitive in men, highlighting the importance of the [(S + R) X QRS] and Perugia scores.

O eletrocardiograma de alta resolução da ativação atrial em pacientes com ou sem fibrilação atrial paroxística

OBJECTIVE: To analyze the parameters of the time domain P-wave signal-averaged electrocardiogram (P-SAECG) and compare them with the P-wave duration on the conventional electrocardiogram (P on ECG) as well as the left atrium diameter (LAD) and left ventricular ejection fraction (EF) obtained on the echocardiogram in order to evaluate patients with paroxysmal atrial fibrillation (PAF). METHODS: One hundred and eighty-one patients were included in the study: 117 with confirmed PAF and 64 without PAF. The P-SAECG parameters used were: the filtered P-wave duration (FPD), the root mean square (RMS) voltages in the last 40, 30 and 20 ms of the filtered P-wave (RMS 40, RMS 30 and RMS 20), the root mean square voltage of the filtered P-wave potentials (RMS P), the integral of the potentials during the filtered P-wave (Integral P) and the filtered P-wave late potential durations below 3 µV (PL<3). RESULTS: The parameters that presented significant statistical differences between the groups were: FPD, RMS 40, 30 and 20, PL<3, P on ECG and LAD. The ROC curve calculations demonstrated the best cut-off points and performance estimates for each parameter: sensitivity, specificity, area under the curve and p-value (p). CONCLUSION: The time domain P-SAECG proved to be a superior method to identify patients with paroxysmal atrial fibrillation than the conventional electrocardiogram and echocardiogram.

Enalaprilato na prevenção da hipertrofia ventricular esquerda induzida pelo isoproterenol

OBJETIVO: Avaliar se o enalaprilato, droga inibidora da enzima de conversao da angiotensina I, previne a hipertrofia ventricular esquerda (HVE) induzida pelo isoproterenol. METODOS: Foram divididos em 4 grupos, 72 ratos Wistar-EPM: CON controle; ENA, tratados com enalaprilato (1mg/kg via subcutânea (sc) por 8 dias); ISO, tratados com isoproterenol (0,3mg/kg via sc/8 dias) e ENA+ISO, tratados simultaneamente com ambas as drogas. Em 10 animais de cada grupo foram determinadas a frequencia cardiaca (FC) e a pressao arterial (PA) e verificado o peso de ventriculo esquerdo (VE). Em 8 animais de cada grupo, fragmento do VE foi corado com hematoxilina-eosina e picro-sirius e preparado para estudo morfometrico e ultra-estrutural, respectivamente, com microscopio de luz e eletronico. RESULTADOS: Nos grupos estudados (CON, ENA, ISO e ISO+ENA) nao ocorreram variacoes na PA. Os grupos ISO e ISO+ENA exibiram aumentos significantes na FC. O grupo ISO apresentou aumento significativo do peso do VE (PU= 0,821g e PS= 0,204g), quando comparado ao grupo CON. O grupo ENA nao exibiu modificacao de peso do VE quando comparado ao grupo CON (PU= 0,590g e PS= 0,139g). No grupo ENA+ISO (PU= 0,737g e PS= 0,177g) constatou-se diferenca de peso ao ser comparado aos grupos ISO e CON. A analise morfometrica e ultra-estrutural mostraram que o ISO induziu hipertrofia dos cardiomiocitos e aumento do tecido conjuntivo com deposito de fibras colagenas do tipo I. O enalaprilato associado com isoproterenol atenuou importantemente aquela manifestacao. CONCLUSAO: O enalaprilato inibiu a acao do isoproterenol sobre os cardiomiocitos, evitando parcialmente, na dose utilizada, a HVE e diminuindo tambem a quantidade de fibras colagenas.PURPOSE To evaluate whether the enalaprilat, angiotensin I enzyme conversion inhibitor, could prevent the left ventricular hypertrophy (LVH) induced by isoproterenol. METHODS Seventy two adult Wistar-EPM rats were divided into four groups: CON, control; ENA, treated with enalaprilat (1 mg/kg via subcutaneous (s.c.) for 8 days); ISO, treated with isoproterenol (0.3 mg via s.c. for 8 days) e ENA + ISO, treated with both drugs simultaneously. Each group had the arterial blood pressure, cardiac rate and the left ventricle (LV) weight determined in 10 animals. In 8 animals from each group a small sample was taken from the LV and stained with hematoxyline-eosine and picrosirius for morphometric and ultra-structural studies with optic and transmission electronic microscopy. RESULTS The ISO group showed that the LV weight increased 47% in comparison with control. On the other hand the ENA + ISO group showed only 22.1% increase (p < or = 0.05). The morphometric and ultra-structural analyses revealed that isoproterenol induced cardiomyocite hypertrophy and augmented the content of the type I collagen in the cardiac interstitium. CONCLUSION Enalaprilat inhibited the isoproterenol action on the cardiomyocite, avoiding partially the LVH and decreasing the content of collagen fibers.