Eduardo Cantoni Rosa

Obesidade visceral, hipertensão arterial e risco cárdio-renal: uma revisão

Great part of obesity adversity is due to its cardiovascular/coronary risk, particularly present in obese with visceral adiposity distribution. Visceral fat deposition is known to be associated with a greater prevalence of metabolic, neurohormonal, inflammatory and hemodynamic disorders, which together will be implicated in microvascular and target organ involvement, particularly to the cardio-renal axis. In this aspect, beyond its classical association with coronary disease, visceral obesity has been associated with left ventricular hypertrophy and microalbuminuria, which are known cardiac and nephrologic risk factors. So, therapeutic tools for obese patients, specially for those with hypertension, must accomplish the risk stratification based on body fat distribution, which will allow a more adequate therapy in terms of risk factors control as well as target organ damage monitoring.

Obesidade, hipertensão arterial e suas influências sobre a massa e função do ventrículo esquerdo

In order to evaluate the influences of obesity and hypertension on left ventricular mass (LVM), we studied 121 women stratified into 4 groups: normotensive non-obeses (n = 25), hypertensive non-obeses (n = 30), normotensive obeses (n = 24) and hypertensive obeses (n = 42) according to their anthropometric and echocardiographic parameters and ambulatory blood pressure monitoring (ABPM). Hypertensive obeses showed higher LVM than the other groups - normotensive non-obeses, hypertensive non-obeses and normotensive obeses (167 ± 38.8 vs. 113 ± 26.4; vs. 133 ± 26.5; vs. 132 ± 29.2g; respectively, p < 0.05) ond higher diameter of left atrium (LA) as compared to the non-obese groups with or without hypertension (36 ± 4.3 vs. 33 ±5.1; vs. 35 ± 3.9mm; p < 0.05, respectively). Normotensive obese patients showed similar LVM to the hypertensive non-obeses (133 ± 26.5 vs. 132 ± 29.5g; NS) and increased LA as compared to the normotensive non-obeses (35 ± 3.9 vs. 31 ± 4.6mm; p < 0.05). A correlation between the waist circumference and waist-to-hip ratio with the blood pressure levels obtained by the ABPM, as well as between these measurements with the echocardiographic parameters, which reflect cardiac mass; body mass index only showed to be correlated to the LA diameter. The adjustment of LVM by the height instead of body surface resulted in an increase on the prevalence of LV hypertrophy among obese patients (10.6 vs. 36.7%, p < 0.01), but not among non-obeses. Lack of nocturnal blood pressure fall assessed by ABPM (non-dipper) was more prevalent among obese patients with or without hypertension; however, non-dipper hypertensive obese patients did not differ from the dippers according to the LVM. Our data demonstrate that obesity associated to hypertension provoke a more pronounced increase in LVM as compared to the condition separately. We also conclude that obese patients showed increased frequency of abnormal 24-hr blood pressure profile, characterized by decreased tensional drop during sleep.

Left Ventricular Hypertrophy Evaluation in Obese Hypertensive Patients: Effect of Left Ventricular Mass Index Criteria

PURPOSE To evaluate left ventricular mass (LVM) index in hypertensive and normotensive obese individuals. METHODS Using M mode echocardiography, 544 essential hypertensive and 106 normotensive patients were evaluated, and LVM was indexed for body surface area (LVM/BSA) and for height2 (LVM/h2). The 2 indexes were then compared in both populations, in subgroups stratified according to body mass index (BMI): <27; 27-30; >/= 30kg/m2. RESULTS The BSA index does not allow identification of significant differences between BMI subgroups. Indexing by height2 provides significantly increased values for high BMI subgroups in normotensive and hypertensive populations. CONCLUSION Left ventricular hypertrophy (LVH) has been underestimated in the obese with the use of LVM/BSA because this index considers obesity as a physiological variable. Indexing by height2 allows differences between BMI subgroups to become apparent and seems to be more appropriate for detecting LVH in obese populations.

Rhabdomyolysis Due to Hyperosmolarity Leading to Acute Renal Failure

Authors present the case of a 37-year-old man admitted to the emergency room of Universidade Federal de São Paulo-Escola Paulista de Medicina, with hyperosmolar coma, following progressive muscle discomfort and loss of renal function, with further need of dialysis therapy. Initial laboratory evaluation showed marked hyperglycemia, hypernatremia, hyperosmolarity, and high levels of creatinine. In the evolution he presented an elevation of creatino-phosphokinase levels in parallel with increasing levels of urea and creatinine. Urinalyses showed progressive increase in proteinuria and hematuria. A muscle biopsy was performed and confirmed the presence of muscular necrosis. The purpose of this paper is to emphasize hyperosmolarity as a newly described cause of rhabdomyolysis. The authors point out its multifactorial physiopathology and also stress the relatively common occurrence of acute renal failure (ARF) following an episode of rhabdomyolysis, and the poor prognosis that this complication represents.

Left Ventricular Diastolic Function in Essential Hypertensive Patients. Influence of Age and Left Ventricular Geometry

PURPOSE To evaluate diastolic dysfunction (DD) in essential hypertension and the influence of age and cardiac geometry on this parameter. METHODS Four hundred sixty essential hypertensive patients (HT) underwent Doppler echocardiography to obtain E/A wave ratio (E/A), atrial deceleration time (ADT), and isovolumetric relaxation time (IRT). All patients were grouped according to cardiac geometric patterns (NG - normal geometry; CR - concentric remodeling; CH- concentric hypertrophy; EH - eccentric hypertrophy) and to age (<40; 40 - 60; >60 years). One hundred six normotensives (NT) persons were also evaluated. RESULTS A worsening of diastolic function in the HT compared with the NT, including HT with NG (E/A: NT - 1.38+/-0.03 vs HT - 1.27+/-0.02, p<0.01), was observed. A higher prevalence of DD occurred parallel to age and cardiac geometry also in the prehypertrophic groups (CR). Multiple regression analysis identified age as the most important predictor of DD (r2=0.30, p<0.01). CONCLUSION DD was prevalent in this hypertensive population, being highly affected by age and less by heart structural parameters. DD is observed in incipient stages of hypertensive heart disease, and thus its early detection may help in the risk stratification of hypertensive patients.

Blood pressure and cardiorenal responses to antihypertensive therapy in obese women

OBJECTIVE Blood pressure (BP) and target organ responses to antihypertensive drugs are not well established in hypertensive obese patients. This study is aimed at evaluating the effects of obesity and adiposity distribution patterns on these responses. METHODS 49 hypertensive obese women were designated to different groups according to waist to hip ratio measurements--37 with troncular and 12 with peripheral obesity. Patients were treated for 24-weeks on a stepwise regimen with cilazapril alone or a cilazapril/hydrochlorothiazide/amlodipine combination therapy to achieve a BP lower than 140/90 mmHg. Ambulatory blood pressure monitoring (ABPM), echocardiography, and albuminuria were assessed before and after the intervention. RESULTS After 24 weeks, weight loss was less than 2% in both groups. ABPM targets were achieved in 81.5% of patients upon a combination of 2(26.5%) or 3(55.1%) drugs. Similar reductions in daytime-SBP/DBP: -22.5/-14.1(troncular obesity)/-23.6/-14.9 mmHg (peripheral obesity) were obtained. Decrease in nocturnal-SBP was greater in troncular obesity patients. Upon BP control, microalbuminuria was markedly decreased, while only slight decrease in left ventricular mass was observed for both groups. CONCLUSIONS In the absence of weight loss, most patients required combined antihypertensive therapy to control their BP, regardless of their body fat distribution pattern. Optimal target BP and normal albuminuria were achieved in the group as a whole and in both obese patient groups, while benefits to cardiac structure were of a smaller magnitude.

Avaliação clínica e laboratorial e estratificação de risco

AVALIACAO CLINICA E LABORATORIAL OBJETIVOS Os principais objetivos da avaliacao clinica e laboratorial estao apresentados na Tabela 1. Para atingir tais objetivos e fundamental considerar os aspectos apresentados a seguir, levando-se em conta que o tempo necessario para a avaliacao inicial de um paciente com suspeita de hipertensao arterial e de, pelo menos, 30 minutos.1 AVALIACAO CLINICA Deve-se obter historia clinica completa, com especial atencao aos dados relevantes referentes ao tempo e tratamento previo de hipertensao, fatores de risco, indicios [...]