Francisco Helfenstein Fonseca

Increased arterial stiffness in resistant hypertension is associated with inflammatory biomarkers

Abstract Background. Increased levels of inflammatory biomarkers such as interleukin-6 (IL-6), 10 (IL-10), 1β (IL-1β), tumor necrosis factor-α (TNF-α) high-sensitivity C-reactive protein (hs-CRP) are associated with arterial stiffness in hypertension. Indeed, resistant hypertension (RHTN) leads to unfavorable prognosis attributed to poor blood pressure (BP) control and target organ damage. This study evaluated the potential impact of inflammatory biomarkers on arterial stiffness in RHTN. Methods. In this cross-sectional study, 32 RHTN, 20 mild hypertensive (HTN) and 20 normotensive (NT) patients were subjected to office BP and arterial stiffness measurements assessed by pulse wave velocity (PWV). Inflammatory biomarkers were measured in plasma samples. Results. PWV was increased in RHTN compared with HTN and NT (p < 0.05). TNF-α levels were significantly higher in RHTN and HTN than NT patients. No differences in IL-6 levels were observed. RHTN patients had a higher frequency of subjects with increased levels of IL-10 and IL-1β compared with HTN and NT patients. Finally, IL-1β was independently associated with PWV (p < 0.001; R2 = 0.5; β = 0.077). Conclusion. RHTN subjects have higher levels of inflammatory cytokines (TNF-α, IL-1β and IL-10) as well as increased arterial stiffness, and detectable IL-1β levels are associated arterial stiffness. These findings suggest that inflammation plays a possible role in the pathophysiology of RHTN.

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.

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).

I posicionamento brasileiro em hipertensão arterial e diabetes mellitus

The association between AH and DM was first described in the 70s, observed in both sexes and at any age range. The prevalence of hypertension is two to three-fold higher in diabetics than in the general population5, and about 70% of diabetics are hypertensive3,6. A meta-analysis of 102 prospective studies and 698,782 individuals showed that the presence of DM increases by two-fold the risk of coronary artery disease (CAD), cerebrovascular accident (CVA) and CV death. According to this meta-analysis, 10% of CV deaths in developed countries can be attributed to the presence of DM7.

Distrofia muscular de duchenne: análisis electrocardiográfica de 131 pacientes

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).

Rationale and design for a cluster randomized quality-improvement trial to increase the uptake of evidence-based therapies for patients at high cardiovascular risk: The BRIDGE-CARDIOVASCULAR PREVENTION trial

Background Translating evidence into clinical practice in the management of high cardiovascular risk patients is challenging. Few quality improvement interventions have rigorously evaluated their impact on both patient care and clinical outcomes. Objectives The main objectives are to evaluate the impact of a multifaceted educational intervention on adherence to local guidelines for the prescription of statins, antiplatelets and angiotensin converting enzyme inhibitors or angiotensin II receptor blockers for high cardiovascular risk patients, as well as on the incidence of major cardiovascular events. Design We designed a pragmatic two arm cluster randomized trial involving 40 clusters. Clusters are randomized to receive a multifaceted quality improvement intervention or to routine practice (control). The multifaceted intervention includes: reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint is the adherence to combined evidence‐based therapies (statins, antiplatelet therapy and angiotensin converting enzyme inhibitors or angiotensin receptor blockers) at 12 months after the intervention period in patients without contra‐indications for these medications. All analyses follow the intention‐to‐treat principle and take the cluster design into account using linear mixed logistic regression modeling. Summary If proven effective, this multifaceted intervention would have wide utility as a means of promoting optimal usage of evidence‐based interventions for the management of high cardiovascular risk patients.