Fernando Henpin Yue Cesena

Short-term red wine consumption promotes differential effects on plasma levels of high-density lipoprotein cholesterol, sympathetic activity, and endothelial function in hypercholesterolemic, hypertensive, and healthy subjects

OBJECTIVES: To compare the metabolic, hemodynamic, autonomic, and endothelial responses to short-term red wine consumption in subjects with hypercholesterolemia or arterial hypertension, and healthy controls. METHODS: Subjects with hypercholesterolemia (n=10) or arterial hypertension (n=9), or healthy controls (n=7) were given red wine (250 mL/night) for 15 days. Analyses were performed before and after red wine intake. RESULTS: Red wine significantly increased the plasma levels of HDL-cholesterol in the controls, but not in the other groups. The effects on hemodynamic measurements were mild, non-significantly more prominent in healthy subjects, and exhibited high interindividual variability. Across all participants, mean blood pressure decreased 7 mmHg (p <0.01) and systemic vascular resistance decreased 7% (p = 0.05). Heart rate and cardiac output did not significantly change in any group. Red wine enhanced muscle sympathetic fibular nerve activity in hypercholesterolemic and hypertensive patients, but not in controls. At baseline, brachial artery flow-mediated dilation was impaired in patients with hypercholesterolemia and arterial hypertension; red wine restored the dilation in the hypercholesterolemic group but not in the hypertensive group. CONCLUSIONS: Red wine elicits different metabolic, autonomic, and endothelial responses among individuals with hypercholesterolemia or arterial hypertension and healthy controls. Our findings highlight the need to consider patient characteristics when evaluating the response to red wine.

Malignant hypertension and hypertensive encephalopathy in primary aldosteronism caused by adrenal adenoma

Two cases are reported as follows: 1) 1 female patient with accelerated-malignant hypertension secondary to an aldosterone-producing adrenal adenoma; and 2) 1 female patient with adrenal adenoma, severe hypertension, and hypertensive encephalopathy. This association is a rare clinical finding, and malignant hypertension may modify the hormonal characteristic of primary aldosteronism, making its diagnosis more difficult. The diagnosis of primary aldosteronism should be considered in patients with malignant hypertension or hypertensive encephalopathy if persistent hypokalemia occurs. Identification of primary aldosteronism is of paramount importance for the patients evolution, because the surgical treatment makes the prognosis more favorable.

Terapia hipolipemiante em situações especiais: hipotireoidismo e hepatopatias

Hypothyroidism is common in the elderly, especially among women. It should be suspected in the presence of classic signals and symptoms, and can be detected by an elevation of serum thyroid stimulating hormone (TSH). Lipid abnormalities in the presence of subclinical hypothyroidism are of minor importance. However, the importance of specific treatment (hormone replacement) increases with the magnitude of thyroid disturbance. Some hypolipidemic agents can aggravate prior liver disease, however, recent studies have shown that statins might be useful in the presence of steatohepatitis. Some associations of hypolipidemic drugs can increase liver enzymes, and careful monitoring is recommended.

Coronary Steal due to Collateral Circulation from Circumflex Coronary to Right Pulmonary Artery Leading to Unstable Angina in Takayasu's Arteritis

Mulher de 63 anos com arterite de Takayasu, envolvendo arco aortico, arterias subclavias e arteria pulmonar direita, com dor precordial progressiva. O eletrocardiograma de esforco revelou depressao do segmento ST. A cineangiocoronariografia nao mostrou lesoes estenoticas ostiais e nem epicardicas e, sim, comunicacao entre a arteria coronaria circunflexa e o ramo do lobo superior da arteria pulmonar direita. O fluxo sanguineo atraves da comunicacao arterial foi considerado de grau importante, provocando, provavelmente, sindrome do roubo de fluxo coronario e, consequentemente, o quadro de angina de peito com carater progressivo.A sixty three year old woman suffering fromTakayasu’s arteritis with involvement of the aortic arch,subclavia arteries and occlusion of the right pulmonaryartery, developed progressive precordial pain. Exerciseelectrocardiogram disclosed ST segment depression.Coronary arteriograms demonstrated no coronarystenosis, but collateral circulation arising from circumflexcoronary artery to right pulmonary artery. The collateralblood flow was considered to be of great importance, andcausing the coronary steal syndrome, leading to anginapectoris.Mulher de 63 anos com arterite de Takayasu, envol-vendo arco aortico, arterias subclavias e arteria pulmo-nar direita, com dor precordial progressiva. Oeletrocardiograma de esforco revelou depressao do seg-mento ST. A cineangiocoronariografia nao mostrou le-soes estenoticas ostiais e nem epicardicas e, sim, comuni-cacao entre a arteria coronaria circunflexa e o ramo dolobo superior da arteria pulmonar direita. O fluxosanguineo atraves da comunicacao arterial foi conside-rado de grau importante, provocando, provavelmente,sindrome do roubo de fluxo coronario e, consequentemen-te, o quadro de angina de peito com carater progressivo.A sixty three year old woman suffering from Takayasus arteritis with involvement of the aortic arch, subclavia arteries and occlusion of the right pulmonary artery, developed progressive precordial pain. Exercise electrocardiogram disclosed ST segment depression. Coronary arteriograms demonstrated no coronary stenosis, but collateral circulation arising from circumflex coronary artery to right pulmonary artery. The collateral blood flow was considered to be of great importance, and causing the coronary steal syndrome, leading to angina pectoris.

Statin Eligibility in Primary Prevention: From a Risk-Based Strategy to a Personalized Approach Based on the Predicted Benefit

Guidelines have recommended statin initiation based on the absolute cardiovascular risk. We tested the hypothesis that a strategy based on the predicted cardiovascular benefit, compared with the risk-based approach, modifies statin eligibility and the estimated benefit in a population in primary cardiovascular prevention. The study included 16,008 subjects (48 ± 6 years, 73% men) with low-density lipoprotein cholesterol levels of 70 to <190 mg/dl, not on lipid-lowering drugs, who underwent a routine health screening in a single center. For the risk-based strategy, criterion for statin eligibility was defined as a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of ≥7.5%. In the benefit-based strategy, subjects were considered for statin according to the predicted absolute cardiovascular risk reduction, so that the number of statin candidates would be the same as in the risk-based strategy. The benefit-based strategy would replace 11% of statin candidates allocated in the risk-based approach with younger, lower risk subjects with higher low-density lipoprotein cholesterol. Using the benefit-based strategy, 13% of subjects with 5.0% to < 7.5% ASCVD risk would shift from a statin-ineligible to a statin-eligible status, whereas 24% of those with 7.5% to <10.0% ASCVD risk would become statin ineligible. These effects would transfer the benefit from higher to lower risk subjects. In the entire population, no clinically meaningful change in the benefit would be expected. In conclusion, switching from a risk-based strategy to a benefit-based approach, while keeping the same rate of statin use in the population, is expected to promote substantial changes in statin eligibility in subjects at intermediate cardiovascular risk, modifying the subpopulation to be benefited by the treatment.

The Expected Cardiovascular Benefit of Plasma Cholesterol Lowering with or Without LDL-C Targets in Healthy Individuals at Higher Cardiovascular Risk

Background: There is controversy whether management of blood cholesterol should be based or not on LDL-cholesterol (LDL-c) target concentrations. Objectives: To compare the estimated impact of different lipid-lowering strategies, based or not on LDL-c targets, on the risk of major cardiovascular events in a population with higher cardiovascular risk. Methods: We included consecutive individuals undergoing a routine health screening in a single center who had a 10-year risk for atherosclerotic cardiovascular disease (ASCVD) ≥ 7.5% (pooled cohort equations, ACC/AHA, 2013). For each individual, we simulated two strategies based on LDL-c target (≤ 100 mg/dL [Starget-100] or ≤ 70 mg/dL [Starget-70]) and two strategies based on percent LDL-c reduction (30% [S30%] or 50% [S50%]). Results: In 1,897 subjects (57 ± 7 years, 96% men, 10-year ASCVD risk 13.7 ± 7.1%), LDL-c would be lowered from 141 ± 33 mg/dL to 99 ± 23 mg/dL in S30%, 71 ± 16 mg/dL in S50%, 98 ± 9 mg/dL in Starget-100, and 70 ± 2 mg/dL in Starget-70. Ten-year ASCVD risk would be reduced to 8.8 ± 4.8% in S50% and 8.9 ± 5.2 in Starget-70. The number of major cardiovascular events prevented in 10 years per 1,000 individuals would be 32 in S30%, 31 in Starget-100, 49 in S50%, and 48 in Starget-70. Compared with Starget-70, S50% would prevent more events in the lower LDL-c tertile and fewer events in the higher LDL-c tertile. Conclusions: The more aggressive lipid-lowering approaches simulated in this study, based on LDL-c target or percent reduction, may potentially prevent approximately 50% more hard cardiovascular events in the population compared with the less intensive treatments. Baseline LDL-c determines which strategy (based or not on LDL-c target) is more appropriate at the individual level.

Highlights from the I international symposium of thrombosis and anticoagulation in internal medicine, October 23-25, 2008, Sao Paulo, Brazil

The importance of thrombosis and anticoagulation in clinical practice is rooted firmly in several fundamental constructs that can be applied both broadly and globally. Awareness and the appropriate use of anticoagulant therapy remain the keys to prevention and treatment. However, to assure maximal efficacy and safety, the clinician must, according to the available evidence, choose the right drug, at the right dose, for the right patient, under the right indication, and for the right duration of time. The first International Symposium of Thrombosis and Anticoagulation in Internal Medicine was a scientific program developed by clinicians for clinicians. The primary objective of the meeting was to educate, motivate and inspire internists, cardiologists and hematologists by convening national and international visionaries, thought-leaders and dedicated clinician-scientists in Sao Paulo, Brazil. This article is a focused summary of the symposium proceedings.

Association between Thyroid-Stimulating Hormone Levels and Non-Alcoholic Fatty Liver Disease Is Not Independent from Metabolic Syndrome Criteria

Introduction: Thyroid hormones are involved in the regulation of body composition, lipid metabolism, and insulin resistance. Thus, it is possible that they might play a role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). However, the role of thyroid function on NAFLD is not well defined. In this study, we evaluated the relationship between thyroid-stimulating hormone (TSH) levels, within the reference range, and presence of NAFLD in asymptomatic individuals. Study Design: We included all individuals evaluated at a preventive clinic of the Hospital Israelita Albert Einstein, between 2014 and 2015. The prevalence of NAFLD (analyzed by abdominal ultrasound), according to TSH quartiles, within the reference range, was determined. The association between TSH quartiles and NAFLD was analyzed by logistic regression adjusted for possible confounders. Results: We evaluated 10,539 individuals (73% male, age 43.4 ± 9.4 years). The prevalence of NAFLD was 34, 38, 38, and 39% in the first to the fourth TSH quartiles (0.46–1.44, 1.45–1.97, 1.98–2.68, and 2.69–4.68 mUI/L, respectively, p for trend < 0.001). At univariate analysis, higher TSH levels were associated with the diagnosis of NAFLD. When data were adjusted for the metabolic syndrome characteristics (waist circumference, HDL-cholesterol and triglycerides levels, presence of diabetes, and systemic arterial hypertension), the association was no longer significant. Conclusions: Although the TSH variability within the reference range is associated with NAFLD in univariable models, once adjusted for metabolic syndrome factors no significant association is noted.

Low-density lipoprotein-cholesterol lowering in individuals at intermediate cardiovascular risk: Percent reduction or target level?

Recommendations for blood cholesterol management differ across different guidelines.

Impact of self-reported fasting duration on lipid profile variability, cardiovascular risk stratification and metabolic syndrome diagnosis

OBJECTIVE We sought to investigate the impact of self-reported fasting duration times on the lipid profile results and its impact on the cardiovascular risk stratification and metabolic syndrome diagnosis. SUBJECTS AND METHODS We analyzed data from all consecutive individuals evaluated in a comprehensive health examination at the Hospital Israelita Albert Einstein from January to December 2015. We divided these patients in three groups, according to the fasting duration recalled (< 8h, 8-12h and > 12h). We calculated the global cardiovascular risk and diagnosed metabolic syndrome according to the current criteria and estimated their change according to fasting duration. RESULTS A total of 12,196 (42.3 ± 9.2 years-old, 30.2% females) patients were evaluated. The distribution of cardiovascular risk was not different among groups defined by fasting duration in both men and women (p = 0.547 for women and p = 0.329 for men). Similarly, the prevalence of metabolic syndrome was not influenced by the fasting duration (p = 0.431 for women and p = 0.166 for men). CONCLUSION Self-reported fasting duration had no significant impact on the lipid profile results, including triglyceride levels. Consequently, no changes on the cardiovascular risk stratification using the Framingham risk score nor changes on the prevalence of metabolic syndrome were noted.