Emmanuelle Tenório Albuquerque Madruga Godoi

Envolvimento macrovascular e esclerose sistêmica

Este artigo tem como objetivo revisar os aspectos descritos na literatura sobre o acometimento da macrovasculatura na esclerose sistemica e avaliar a ocorrencia e distribuicao das alteracoes macrovasculares nos pacientes com esclerose sistemica atraves do eco-Doppler e do indice tornozelo-braco, alem da associacao desses achados com as caracteristicas demograficas, forma clinica, tempo de evolucao da doenca, fenomeno de Raynaud (FR), alteracoes digitais, ulceracoes de membros, reabsorcao de falange, amputacao, bem como fatores de risco e antecedentes da doenca ateromatosa. O estudo foi prospectivo, do tipo serie de casos, constituido de 20 pacientes, sendo 19 do sexo feminino, com idade media de 46,30 anos. Todos os pacientes tinham fenomeno de Raynaud objetivo, 85% a forma clinica difusa, 55% alteracao de polpa digital, 15% ulcera atual de membros, 25% reabsorcao de falange, nenhuma amputacao e 70% de um a quatro fatores de risco. Foram estudadas pelo eco-Doppler as arterias aorta e carotida, dos membros inferiores e superiores, para a avaliacao de espessamento do complexo intimo-medial e presenca de placas e aneurismas. Nas arterias dos membros inferiores, foi tambem realizado o indice tornozelo-braco. O indice tornozelo-braco foi normal em todos os pacientes; entretanto, 12 (60%) destes apresentaram doenca macrovascular pelo eco-Doppler, sendo nove (45%) na aorta, seis (30%) nas carotidas, uma (5%) nas arterias dos membros superiores e sete (35%) nas dos membros inferiores. Observou-se associacao entre doenca macrovascular e alteracoes de polpas digitais (p = 0,0045). A doenca macrovascular foi identificada em 60% dos pacientes atraves do eco-Doppler, mas nao pelo indice tornozelo-braco, que foi normal em todos. Verificou-se associacao significante da doenca macrovascular com as alteracoes atuais de polpas digitais, o que nao ocorreu com as demais variaveis estudadas.

Estudo da macrovasculatura por ultra-sonografia Doppler na esclerose sistêmica

OBJECTIVE: To assess the occurrence and distribution of the macrovascular alterations in a population with Systemic Sclerosis (SS) by means of Doppler ultrasound (Doppler US) and ankle-arm index (AAI). To investigate the assotiation of these findings with both demographic and clinical characteristics in the patients as well as with risk factors and antecedents of atheromatous disease. METHODS: Prospective study, of the series of cases type, comprising 20 patients, 19 of whom were women with a median age of 46.30 years. Eighty-five percent were of the diffuse form. All the patients had the Raynauds phenomenon, 55% presented alteration of digital pulps, 15% current limb ulcers and 25% phalanx resorption. There were no amputations and 70% presented from 1 to 4 risk factors for atherosclerosis. The aorta, carotids as well as upper (ULs) and lower (LLs) limbs arteries were evaluated by Doppler US to assess thickening of the medio-intimal complex (MIC), presence of plaques and aneurisms. In the arteries of the LLs, AAI was also undertaken. RESULTS: AAI was normal in all patients, 12 patients (60%) presented macrovascular disease (MVD) comprising 9 (45%) of these in the aorta, 7 (35%) in LLs arteries , 6 (30%) in the carotids and 1 (5%) in ULs arteries. MVD and alterations of digital pulps were positivily associated (p = 0.0045). CONCLUSIONS: Doppler US identified MVD in 60% of our SS patients. No patients had abnormal AAI. MDV was positivily associated with digital pulps alterations. The macrovascular alterations found are not necessarily associated with systemic sclerosis, and may be due to atherosclerosis process.

Impact of pelvic magnetic resonance imaging findings in the indication of uterine artery embolization in the treatment of myoma

OBJECTIVES To assess the impact of pelvic magnetic resonance imaging (MRI) findings in the indication for uterine-artery embolization in women with fibroids, as well as the correlation between MRI and ultrasound (US) examinations for diagnosing adenomyosis. MATERIAL AND METHODS A retrospective observational study was performed through the analysis of the medical records of 263 women referred for uterine-artery embolization as treatment for fibroids after undergoing US and MRI examinations. To compare uterine volume and fibroid measurement in US and MRI, the Wilcoxon test was used; for the number of fibroids, the McNemar test was used. The kappa coefficient was used to evaluate the correlation between US and MRI findings for diagnosing adenomyosis. RESULTS The mean age of patients was 37.9 ± 6.8 years and 191 (72.6%) were nulliparous. Forty-three patients with adenomyosis associated with fibroid were diagnosed by MRI; US indicated the presence of adenomyosis in 12 (4.56%) women. There was agreement between MRI and US in the diagnosis of adenomyosis in 218/263 (82.9%) patients (p < 0.05). In the US examination, the mean uterine volume was lower (389 ± 340.8 cm³) than that observed in MRI (472.2 ± 415.9 cm³; p < 0.001). Regarding the number of fibroids, MRI showed a greater number of patients with multiple fibroids (68.8% vs. 57.4%, MRI and US, respectively; p < 0.001). CONCLUSIONS In women with fibroids referred for uterine-artery embolization, MRI findings led to the revision of the initial diagnosis in 17.1% cases. US showed a lower sensitivity for diagnosing adenomyosis than MRI.

Intima-Media Thickness in the Carotid and Femoral Arteries for Detection of Arteriosclerosis in Human Immunodeficiency Virus-Positive Individuals

Background The prevalence of atherosclerosis is higher in HIV-positive people, who also experience it earlier than the general population. Objectives To assess and compare the prevalence of atherosclerosis evaluated by the intima-media thickness of carotid and femoral arteries, and by the ankle-brachial pressure index (ABPI) in HIV patients treated or not treated with protease inhibitors (PIs) and controls. Methods Eighty HIV+ subjects (40 using PIs and 40 not using PIs) and 65 controls were included in the study. Atherosclerosis was diagnosed by (carotid and femoral) ITM measurement and ABPI. Classical risk factors for atherosclerosis and HIV were compared between the groups by statistical tests. A p ≤ 0.05 was considered significant. Results An IMT > P75 or the presence of plaque was higher in the HIV+ than in the control group (37.5% vs 19%, p = 0.04). Comparative analysis showed a significant difference (p=0.014) in carotid IMT between HIV+ with PIs (0.71 ± 0.28 mm), without PIs 0.63 ± 0.11 mm and, and controls (0.59 ± 0.11 mm). There was no significant difference in femoral IMT between the groups or in ABPI between HIV+ subjects and controls. However, a significant difference (p=0.015) was found between HIV+ patients not treated with PIs (1.17 [1.08 - 1.23]), and controls 1.08 [1.07 - 1.17]). Conclusion In HIV patients, atherosclerosis is more prevalent and seems to occur earlier with particular characteristics compared with HIV-negative subjects.

Efeito da terapia antirretroviral e dos níveis de carga viral no complexo médio-intimal e no índice tornozelo-braço em pacientes infectados pelo HIV

OBJECTIVES: To precociously identify the prevalence of atherosclerosis caused by thickening of the intima-media complex of the common carotid arteries and of the ankle brachial index. These measurements were associated with the classical risk factors of atherosclerosis and the specific factors of those infected by HIV (duration of disease, length of treatment, kind of treatment, kind of antiretroviral therapy used, CD4 and viral load). METHODS: Seventy cases infected by HIV were assessed by automatic measurement of the intima-media complex in the carotids and of the ankle brachial index. The classical risk factors of atherosclerosis (age, gender, systemic arterial hypertension, smoking, hypercholesterolemia, hypertriglyceridemia, obesity, and family history of cardiovascular events), anthropometric measurements and the variables related to HIV were taken into consideration. The adopted level of significance was 5%. RESULTS: The mean time of HIV diagnosis was 104.9 months, mean duration of treatment was 97.9 months. As regard to the type of treatment, 47 (67.1%) used protease inhibitor for more than six months and 36 (51.4%) are using it recently. The ankle brachial index was increased in one patient (0.7%), and the intima-media complex was not thickened in any individual. There was no significant association of the measurement of the intima-media complex of the right common carotid with any of the variables analyzed. CONCLUSIONS: Young individuals under the use of antiretroviral therapy for five years or more did not show increase in thickness of the intima-media complex or increase in the ankle brachial index, and there was no difference in the intima-media complex thickness associated with the therapeutical scheme of antiretroviral used or the viral load level.Objectives: To precociously identify the prevalence of atherosclerosis caused by thickening of the intima-media complex of the common carotid arteries and of the ankle brachial index. These measurements were associated with the classical risk factors of atherosclerosis and the specific factors of those infected by HIV (duration of disease, length of treatment, kind of treatment, kind of antiretroviral therapy used, CD4 and viral load). Methods: Seventy cases infected by HIV were assessed by automatic measurement of the intima-media complex in the carotids and of the ankle brachial index. The classical risk factors of atherosclerosis (age, gender, systemic arterial hypertension, smoking, hypercholesterolemia, hypertriglyceridemia, obesity, and family history of cardiovascular events), anthropometric measurements and the variables related to HIV were taken into consideration. The adopted level of significance was 5%. Trabalho realizado no Programa de Prevencao, Controle e Tratamento da AIDS do Hospital das Clinicas da Universidade Federal de Pernambuco (UFPE) – Recife (PE), Brasil. 1 Doutoranda em Cirurgia pelo Centro de Ciencias da Saude (CCS) da UFPE – Recife (PE), Brasil; Especialista em Angiologia pela Sociedade Brasileira de Angiologia e Cirurgia Vascular; Especialista em USG Doppler pelo Colegio Brasileiro de Radiologia e pela Universidade Paul Sabatier – Toulouse, Franca. 2 Professor Titular de Cirurgia Pediatrica do Departamento de Cirurgia do CCS-UFPE – Recife (PE), Brasil. 3 Professora-associada do Departamento de Medicina Clinica do CCS-UFPE – Recife (PE), Brasil. 4 Professora Adjunta do Departamento de Medicina Clinica do CCS-UFPE – Recife (PE), Brasil. 5 Professora-assistente da Universidade de Pernambuco (UPE); Doutoranda do Programa de Pos-Graduacao em Medicina Tropical da UFPE – Recife (PE), Brasil. 6 Cardiologista; Especialista em Epidemiologia pela Fundacao Oswaldo Cruz (Fiocruz); Doutoranda do Programa de Medicina Tropical – Recife (PE), Brasil. 7 Aluna da Graduacao do Curso de Medicina da UFPE – Recife (PE), Brasil. 8 Estatistica; Especialista em Epidemiologia pela Faculdade de Saude Publica da Universidade de Sao Paulo (FSP-USP) – Sao Paulo (SP), Brasil. Fonte de financiamento: nenhuma. Conflito de interesse: nada a declarar. Submetido em: 25.03.11. Aceito em: 11.01.12. J Vasc Bras. 2012;11(2):123-131. Terapia antirretroviral e complexo medio-intimal Godoi ETAM et al. J Vasc Bras 2012, Vol. 11, No 2 124

Aterosclerose em indivíduos infectados com o HIV

Objective: To compare the measurements of the ankle-arm index and the intima-media complex of the femoral and subclavian carotids in patients with HIV on antiretroviral therapy in relation to the Control Group. Methods: Seventy patients with HIV who had been on antiretroviral therapy for at least five years and 70 individuals who are not infected with HIV, paired by gender and age, aged until 50 years, were assessed by the measurement of the ankle-arm index and the intima-media complex of the common, internal, femoral and right subclavian carotids. In common carotids, the manual and automatic measurement of the intima-media complex were perform, and the automatic measurement of the common carotid was considered as the gold standard, regarding the thick intimamedia complex when it is >0.8 mm. The group homogeneity was analyzed at a 5% significance level, and automatic and manual measurements were compared; for the carotids, Bland-Altman graphs were used. Results: A patient from the case group (0.7%) presented an increased ankle-arm index (>1.3 bilaterally with no signs of calcification), and no changes were observed in the control group. The automatic average of the intima-media complex in common carotids was not thick in any individual. There was no significant different between the groups as to the ankle-arm index, the intima-media complex and the presence of atheromatous Tese de doutorado desenvolvida no Hospital das Clinicas da Universidade Federal de Pernambuco (UFPE) e no Hospital Agamenon Magalhaes, pelo programa de Pos-Graduacao em Cirurgia do Centro de Ciencias da Saude da UFPE, apresentada em 04.03.2010. Orientador: Prof. Dr. Carlos teixeira Brandt e Profa. Dra. Heloisa Ramos Lacerda de Melo Banca examinadora: Prof. Dr. Alvaro Antonio Bandeira Ferraz, Prof. Dr. Jose Lamartine de Andrade Aguiar, Prof. Dr. Silvio da Silva Caldas Neto, Prof. Dr. Silvio Romero de Barros Marques e Prof. Dr. Luiz Claudio Arraes de Alencar * Doutorado em Cirurgia pela Universidade Federal de Pernambuco (UFPE); Especialista em Angiologia pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV); Especialista em Ultrassonografia Doppler pelo Colegio Brasileiro de Radiologia (CBR) e pela Universidade Paul Sabatier-Toulouse – Franca; Socia Titular da SBACV e Membro Coligado do CBR. Conflitos de interesse: nada a declarar. Submetido em: 25.03.11. Aceito em 31.08.11. J Vasc Bras. 2011;10(4):336-337. Aterosclerose em individuos infectados com o HIV Godoi ETAM J Vasc Bras 2011, Vol. 10, No 4 337 plaques. Mean age was 40.5 years in the case group, and 40.8 years in the control group. Both groups were similar as to smoking and systemic arterial hypertension. Cholesterol and triglycerides were higher in the case group, but the body mass index and the abdominal circumference had a higher normality percentage in this group. When comparing the automatic average right common carotid (RCC) with other locations (subclavian origin, medium segment and common femoral), the difference was statistically and clinically significant in the origin of the right subclavian (RCC=0.51 versus 0.91 mm; p<0.001). Conclusion: People who have HIV do not present a higher risk for atherosclerosis than the control population, considering the classic risk factors of atherosclerosis and the specific characteristics of the HIV. By comparing the automatic average of RCC with other locations, the difference was statistically and clinically significant in the origin of the right subclaian.