Carlos Alexandre Wainrober Segre

White-coat hypertension and normotension in the League of Hypertension of the Hospital das Clínicas, FMUSP: prevalence, clinical and demographic characteristics

OBJECTIVE To assess the prevalence of white-coat normortension, white-coat hypertension, and white-coat effect. METHODS We assessed 670 medical records of patients from the League of Hypertension of the Hospital das Clínicas of the Medical School of the University of S o Paulo. White-coat hypertension (blood pressure at the medical office: mean of 3 measurements with the oscillometric device > or = 140 or > or = 90 mmHg, or both, and ambulatory blood pressure monitoring mean during wakefulness < 135/85) and white-coat normotension (office blood pressure < 140/90 and blood pressure during wakefulness on ambulatory blood pressure monitoring > or = 135/85) were analyzed in 183 patients taking no medication. The white-coat effect (difference between office and ambulatory blood pressure > 20 mmHg for systolic and 10 mmHg for diastolic) was analyzed in 487 patients on treatment, 374 of whom underwent multivariate analysis to identify the variables that better explain the white-coat effect. RESULTS Prevalence of white-coat normotension was 12%, prevalence of white-coat hypertension was 20%, and prevalence of the white-coat effect was 27%. A significant correlation (p<0.05) was observed between white-coat hypertension and familial history of hypertension, and between the white-coat effect and sex, severity of the office diastolic blood pressure, and thickness of left ventricular posterior wall. CONCLUSION White-coat hypertension, white-coat normotension, and white-coat effect should be considered in the diagnosis of hypertension.

Monitorização residencial da pressão arterial e monitorização ambulatorial da pressão arterial versus medida de pressão arterial no consultório

PURPOSE To compare both home blood pressure measurement (HBPM) and ambulatory blood pressure monitoring (ABPM) with office blood pressure measurement (OBP); and also to compare the correlation between HBPM and OBP with LVMI (left ventricular mass index). METHODS Protocol 1--68 hypertensive patients (58 +/- 12 years, 37 females): a) self recorded blood pressure at home in the 7 days; b) recorded the ABPM during 24 hours; and c) the physician recorded blood pressure in the office. Protocol 2-41 hypertensive patients underwent the HBPM, OBP, and BI-dimensional echocardiogram. RESULTS Protocol 1--OBP (153 +/- 24/96 +/- 13 mmHg) was higher (p < 0.05) than HBPM (133 +/- 18/84 +/- 12 mmHg) and ABPM (137 +/- 17/87 +/- 12 mmHg); Protocol 2--LVMI correlated better with HBPM (r = 0.39/0.49, p < 0.05, systolic and diastolic, respectively) than OBP (r = 0.02/ 0.22, p > 0.05, systolic and diastolic, respectively). CONCLUSION This study showed that HBPM has a better correlation with LVMI than OBP.

How to avoid discontinuation of antihypertensive treatment: The experience in São Paulo, Brazil

OBJECTIVES: To evaluate the importance of providing guidelines to patients via active telephone calls for blood pressure control and for preventing the discontinuation of treatment among hypertensive patients. INTRODUCTION: Many reasons exist for non-adherence to medical regimens, and one of the strategies employed to improve treatment compliance is the use of active telephone calls. METHODS: Hypertensive patients (n = 354) who could receive telephone calls to remind them of their medical appointments and receive instruction about hypertension were distributed into two groups: a) “uncomplicated” – hypertensive patients with no other concurrent diseases and b) “complicated” - severe hypertensive patients (mean diastolic ≥110 mmHg with or without medication) or patients with comorbidities. All patients, except those excluded (n = 44), were open-block randomized to follow two treatment regimens (“traditional” or “current”) and to receive or not receive telephone calls (“phone calls” and “no phone calls” groups, respectively). RESULTS: Significantly fewer patients in the “phone calls” group discontinued treatment compared to those in the “no phone calls” group (4 vs. 30; p<0.0094). There was no difference in the percentage of patients with controlled blood pressure in the “phone calls” group and “no phone calls” group or in the “traditional” and “current” groups. The percentage of patients with controlled blood pressure (<140/90 mmHg) was increased at the end of the treatment (74%), reaching 80% in the “uncomplicated” group and 67% in the “complicated” group (p<0.000001). CONCLUSION: Guidance to patients via active telephone calls is an efficient strategy for preventing the discontinuation of antihypertensive treatment.

Hypotheses, rationale, design, and methods for prognostic evaluation of cardiac biomarker elevation after percutaneous and surgical revascularization in the absence of manifest myocardial infarction. A comparative analysis of biomarkers and cardiac magnetic resonance. The MASS-V Trial

BackgroundAlthough the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis.Methods/DesignThe study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR.DiscussionThe MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.

Cardiovascular risks of androgen deprivation therapy

O adenocarcinoma de prostata e o câncer mais comum no sexo masculino apos o câncer de pele. Entre as varias formas de tratamento do câncer de prostata, a terapia de bloqueio androgenico e uma modalidade consagrada nos pacientes com doenca metastatica ou localmente avancada, que provavelmente resulta em aumento de sobrevida. No entanto, o bloqueio androgenico e causador de uma serie de consequencias adversas. Complicacoes como osteoporose, disfuncao sexual, ginecomastia, anemia e alteracoes na composicao corporal sao bem conhecidas. Recentemente, uma serie de complicacoes metabolicas foi descrita como aumento da circunferencia abdominal, resistencia a insulina, hiperglicemia, diabete, dislipidemia e sindrome metabolica com consequente aumento do risco de eventos coronarianos e mortalidade cardiovascular nessa populacao especifica. Este artigo de atualizacao apresenta uma revisao bibliografica realizada no MEDLINE de toda literatura publicada em ingles no periodo de 1966 ate junho de 2009, com as seguintes palavras-chave: androgen deprivation therapy, androgen supression therapy, hormone treatment, prostate cancer, metabolic syndrome e cardiovascular disease, no intuito de analisar quais seriam os reais riscos cardiovasculares da terapia de deprivacao androgenica, tambem chamada bloqueio androgenico, nos pacientes com câncer de prostata.Prostate adenocarcinoma is the most common cancer type in the male sex after skin cancer. Among the several types of treatment for prostate cancer, the androgen deprivation therapy has been highly recommended in patients with metastatic or locally advanced disease, which probably results in increased survival. However, the androgen deprivation is the cause of several adverse effects. Complications such as osteoporosis, sexual dysfunction, gynecomastia, anemia and body composition alterations are well-known effects of the therapy. Recently, a number of metabolic complications have been described, such as increase in the abdominal circumference, insulin resistance, hyperglycemia, diabetes, dyslipidemia and metabolic syndrome, with a consequent increase in the risk of coronary events and cardiovascular mortality in this specific population. This update article presents a literature review carried out at MEDLINE database of all literature published in English from 1966 to June 2009, using the following key words: androgen deprivation therapy, androgen suppression therapy, hormone treatment, prostate cancer, metabolic syndrome and cardiovascular disease, with the objective of analyzing which would be the actual cardiovascular risks of androgen deprivation therapy, also called androgen suppression, in patients with prostate cancer.

Riscos cardiovasculares do bloqueio androgênico

O adenocarcinoma de prostata e o câncer mais comum no sexo masculino apos o câncer de pele. Entre as varias formas de tratamento do câncer de prostata, a terapia de bloqueio androgenico e uma modalidade consagrada nos pacientes com doenca metastatica ou localmente avancada, que provavelmente resulta em aumento de sobrevida. No entanto, o bloqueio androgenico e causador de uma serie de consequencias adversas. Complicacoes como osteoporose, disfuncao sexual, ginecomastia, anemia e alteracoes na composicao corporal sao bem conhecidas. Recentemente, uma serie de complicacoes metabolicas foi descrita como aumento da circunferencia abdominal, resistencia a insulina, hiperglicemia, diabete, dislipidemia e sindrome metabolica com consequente aumento do risco de eventos coronarianos e mortalidade cardiovascular nessa populacao especifica. Este artigo de atualizacao apresenta uma revisao bibliografica realizada no MEDLINE de toda literatura publicada em ingles no periodo de 1966 ate junho de 2009, com as seguintes palavras-chave: androgen deprivation therapy, androgen supression therapy, hormone treatment, prostate cancer, metabolic syndrome e cardiovascular disease, no intuito de analisar quais seriam os reais riscos cardiovasculares da terapia de deprivacao androgenica, tambem chamada bloqueio androgenico, nos pacientes com câncer de prostata.Prostate adenocarcinoma is the most common cancer type in the male sex after skin cancer. Among the several types of treatment for prostate cancer, the androgen deprivation therapy has been highly recommended in patients with metastatic or locally advanced disease, which probably results in increased survival. However, the androgen deprivation is the cause of several adverse effects. Complications such as osteoporosis, sexual dysfunction, gynecomastia, anemia and body composition alterations are well-known effects of the therapy. Recently, a number of metabolic complications have been described, such as increase in the abdominal circumference, insulin resistance, hyperglycemia, diabetes, dyslipidemia and metabolic syndrome, with a consequent increase in the risk of coronary events and cardiovascular mortality in this specific population. This update article presents a literature review carried out at MEDLINE database of all literature published in English from 1966 to June 2009, using the following key words: androgen deprivation therapy, androgen suppression therapy, hormone treatment, prostate cancer, metabolic syndrome and cardiovascular disease, with the objective of analyzing which would be the actual cardiovascular risks of androgen deprivation therapy, also called androgen suppression, in patients with prostate cancer.

[Case 06/2005--progressive heart failure in a 65 year-old man with permanent cardiac pacemaker].

Há quinze anos apresentou vários episódios de síncope em um mesmo dia. As síncopes não foram precedidas de palpitações e tiveram duração de aproximadamente um minuto. Não procurou atendimento médico na ocasião. Tempos depois, apresentou cansaço desencadeado por esforços habituais e edema de membros inferiores. Procurou avaliação médica e foi informado ser portador de cardiopatia da doença de Chagas.

Significant elevation of biomarkers of myocardial necrosis after coronary artery bypass grafting without myocardial infarction established assessed by cardiac magnetic resonance

Abstract The release of myocardial necrosis biomarkers after off-pump coronary artery bypass grafting (OPCAB) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related myocardial infarction (MI) (type 5) has been controversial. This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective OPCAB in patients without evidence of a new MI on cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE). Patients with normal baseline cardiac biomarkers referred for elective OPCAB were prospectively included. CMR with LGE was performed in all patients before and after interventions. Measurements of troponin I (cTnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with new LGE on the postprocedure CMR were excluded. All of the 53 patients without CMR evidence of a procedure-related MI after OPCAB exhibited a cTnI elevation peak above the 99th percentile. In 48 (91%), the peak value was >10 times this threshold. However, 41 (77%) had a CK-MB peak above the limit of the 99th percentile, and this peak was >10 times the 99th percentile in only 7 patients (13%). The median peak release of cTnI was 0.290 (0.8–3.7) ng/mL, which is 50-fold higher than the 99th percentile. In contrast with CK-MB, considerable cTnI release often occurs after an elective OPCAB procedure, despite the absence of new LGE on CMR.

Abnormal elevation of myocardial necrosis biomarkers after coronary artery bypass grafting without established myocardial infarction assessed by cardiac magnetic resonance

BackgroundThe diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis.MethodsIn this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance.ResultsOf 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile.ConclusionIn this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction.Clinical trial registrationhttp://www.isrctn.com/ISRCTN09454308. Registered 08 May 2012.

478 EDUCATIONAL INTERVENTION INFLUENCE IN THE BLOOD PRESSURE CONTROL IN HYPERTENSIVE PATIENTS: RANDOMIZED CONTROLLED TRIAL

Background and Objectives: The blood pressure (BP) control may be influenced by the lack of knowledge about the disease and this can be minimized with educational interventions. Thus, the aim is to analyze the BP control by Ambulatory Blood Pressure Monitoring (ABPM) and office blood pressure (OBP) in hypertensive patients, who received educational interventions. Design and Methods: Randomized controlled trial with 485 hypertensive patients randomized to participate (intervention group = 239) or not (control group = 246) of an education program for 12 months that included active telephone calls, meetings with the multidisciplinary team and to receive educational brochures. Both groups have monthly medical visits, home blood pressure measurement and donation of medications. The BP was assessed by office measurement, using oscillometric equipment and 24-hour ABPM. Values of p⩽0.05 were accepted. Results: The average age was 52.4 ± 10.9 years old. The majority was females (68%), white (56%) and elementary education (58%). At the end of the study, the OBP reduced significantly (p < 0.05) in both “intervention” (from 159.3 ± 19.2/97.3 ± 16.5 mmHg to 126.9 ± 16.6/73.2 ± 11.9 mmHg) and “control” groups (from 159.2 ± 18.9/96.7 ± 16.4 mmHg to 129.5 ± 18.2/75.9 ± 13.9 mmHg) with consequently increased control, 22.2% to 76.2% and 23.2% to 71.1%, respectively. The BP measured by ABPM was similar to the OBP. The 24-hour ABPM reduced in the “intervention” group from 147.3 ± 15.9/91.7 ± 10.3 mmHg to 126 ± 12.4/78.5 ± 8.7 mmHg. The “control” group reduced from 149 ± 17.7/92.9 ± 12 to 128.7 ± 13.6/79.8 ± 9.6. Conclusions: BP control increased significantly at the end of the study in both groups, probably due to the medication donation and monthly medical visits (unusual aspects in Brazil)