Humberto Pierri

Efeitos Cardiovasculares da Testosterona

A testosterona e secretada durante tresepocas da vida: 1) no primeiro trimestre da vida intra-uterina,transitoriamente; 2) na vida neonatal e 3) continuamenteapos a puberdade. O nivel de testosterona produzido podeser calculado pela depuracao metabolica, pela media dosniveis de testosterona circulante, por diferenca arteriove-nosa testicular ou pela taxa de fluxo testicular.

Daytime systolic blood pressure load and previous stroke predict cardiovascular events in treated octogenarians with hypertension.

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Yu-Wei Chen and Chih-Jen Wu: concept and design. Han-Hsiang Chen: drafting the article. Ching-Wei Chang and Tsang-En Wang: providing intellectual content of critical importance to the work described. Chen-Wang Chang: analysis and interpretation of data. Sponsor’s Role: No sponsor participated in the design, methods, subject recruitment, data collection, analysis, or preparation of the letter.

Mycoplasma pneumoniae and Chlamydia pneumoniae in calcified nodules of aortic stenotic valves

Aortic Valve Stenosis (AVS) has been explained as an atherosclerotic process of the valve as they often exhibit inflammatory changes with infiltration of macrophages, T lymphocytes and lipid infiltration. The present study investigated whether the bacteria Chlamydia pneumoniae (CP) and Mycoplasma pneumoniae (MP), detected previously in atherosclerotic plaques, are also present in AVS. Ten valves surgically removed from patients with AVS were analyzed by immunohistochemistry, in situ hybridization, and electron microscopy. The mean and standard deviation of the percentage areas occupied by CP antigens and MP - DNA were respectively 6.21 +/- 5.41 and 2.27 +/- 2.06 in calcified foci; 2.8 +/- 3.33 and 1.78+/- 3.63 in surrounding fibrotic areas, and 0.21 +/- 0.17 and 0.12 +/- 0.13 in less injured parts of the valve. There was higher amount of CP and MP in the calcified foci and in the surrounded fibrosis than in more preserved valvular regions. In conclusion, the fact that there were greater amounts of CP and MP in calcification foci of AVS favors the hypothesis that AS is not an inevitable degenerative process due to aging, but rather that it may be a response to the presence of these bacteria, similarly to the morphology detected in atherosclerosis damage.

Clinical Predictors of Prognosis in Severe Aortic Stenosis in Unoperated Patients >75 Years of Age

In elderly patients with severe aortic stenosis, clinical evaluation can dictate decision making. Asymptomatic patients in normal sinus rhythm, without left atrial enlargement and without bundle branch block, can be safely followed clinically, regardless of echocardiographic findings.

Depression as a Clinical Determinant of Dependence and Low Quality of Life in Elderly Patients with Cardiovascular Disease

Background The aging process promotes a progressive increase in chronic-degenerative diseases. The effect of these diseases on the functional capacity has been well recognized. Another health parameter concerns “quality of life related to health”. Among the elderly population, cardiovascular diseases stand out due to the epidemiological and clinical impact. Usually, these diseases have been associated with others. This set of problems may compromise both independence and quality of life in elderly patients who seek cardiologic treatment. These health parameters have not been well contemplated by cardiologists. Objective Evaluating, among the elderly population with cardiovascular disease, which are the most relevant clinical determinants regarding dependence and quality of life. Methods This group was randomly and consecutively selected and four questionnaires were applied: HAQ, SF-36, PRIME-MD e Mini Mental State. Results The study included 1,020 elderly patients, 63.3% women. The group had been between 60 and 97 years-old (mean: 75.56 ± 6.62 years-old). 61.4% were independent or mild dependence. The quality of life total score was high (HAQ: 88.66 ± 2.68). 87.8% of patients had a SF-36 total score > 66. In the multivariate analysis, the association between diagnoses and high degrees of dependence was significant only for previous stroke (p = 0.014), obesity (p < 0.001), lack of physical activity (p = 0.016), osteoarthritis (p < 0.001), cognitive impairment (p < 0.001), and major depression (p < 0.001). Analyzing the quality of life, major depression and physical illness for depression was significantly associated with all domains of the SF-36. Conclusion Among an elderly outpatient cardiology population, dependence and quality of life clinical determinants are not cardiovascular comorbidities, especially the depression.

Chlamydia pneumoniae and Mycoplasma pneumoniae in Calcified Nodes of Stenosed Aortic Valves

OBJECTIVE We investigated whether Chlamydia pneumoniae (CP) and Mycoplasma pneumoniae (MP) are present in aortic valve stenosis (AS). METHODS Immunohistochemistry was utilized to identify CP antigens, in situ hybridization to identify MP DNA, and electron microscopy was used to evaluate the following three groups: Normal - 11 normal autopsy valves; Atherosclerosis - 10 autopsy valves from patients with systemic atherosclerosis and no AS; and AS - 14 surgical specimens of AS analyzed in 3 sub-regions: AS-Preserved - peripheral, preserved regions; AS-Fibrosis - peri-calcified fibrotic tissue; and AS-Calcification - calcified nodules. RESULTS The positive area fraction of CP antigen median values were 0.09, 0.30, 0.18, 1.33, and 3.3 in groups Normal, Atherosclerosis, AS-Preserved, AS-Fibrosis, and AS-Calcification, respectively. CP density was significantly greater in Atherosclerosis and AS-Calcification than in Normal (P<0.05). Within the AS group, the amount of CP was greater in the Calcification and Fibrosis regions (P<0.05). MP-DNA positive area fraction (median values) were 0.12, 0.44, 0.07, 0.36, and 1.52 in groups Normal, Atherosclerosis, AS-Preserved, AS-Fibrosis, and AS-Calcification, respectively. The amount of MP-DNA was greater in AS-Calcification than in Normal (P<0.05). Within the AS group, MP-DNA was in larger quantity in the Calcification and Fibrosis regions (P<0.05). CONCLUSION AS Calcified nodes present higher concentration of CP and MP suggesting that these bacteria may be associated with the development of calcification and inflammation. This adds novel similarities between AS and the atherosclerosis process, which may have infection mechanisms involved.

Associação entre evolução da função cognitiva e mortalidade após a alta hospitalar em pacientes idosos com insuficiência cardíaca avançada

OBJECTIVE: To assess the relation between the evolution of cognitive performance and the prognosis of elderly patients after compensation of advanced heart failure. METHODS: Thirty-one patients older than 64 (68 ± 7) years and admitted with New York Heart Association class IV heart failure and ejection fraction = 0.45 (0.38 ± 0.06) were consecutively selected. They underwent cognitive tests (digit span, digit symbol, letter cancellation, trail making A and B) and the 6-minute walking test 4 days before (T1) and 6 weeks after (T2) hospital discharge, and their performances were compared using the t test. The prognostic value of the scores of the cognitive tests was analyzed with logistic regression, and the value of greatest accuracy of the tests was associated with the prognosis determined by the ROC curve. RESULTS: After 24.7 months, 17 (55%) patients had died. The performances in the 6-minute walking test and most cognitive tests improved between T1 and T2. The digit span score of the survivors ranged from 3.9 to 5.2 (P=0.003) and remained unaltered among those who died (4.1 to 3.9; P=0.496). An improvement < 0.75 points in the score was associated with mortality (relative risk of 8.1; P=0.011). CONCLUSION: In the elderly, after compensation of advanced heart failure, the lack of evolutionary improvement in cognitive performance was associated with a worse prognosis.

Effects of chlorthalidone and diltiazem on myocardial ischemia in elderly patients with hypertension and coronary artery disease

OBJECTIVE Antihypertensive therapy with thiazides decreases coronary events in elderly patients. However, the influence of diuretics on myocardial ischemia has not been fully investigated. The aim of this study was to compare the effect of chlorthalidone and diltiazem on myocardial ischemia. METHODS Following a randomized, double-blind, crossover protocol, we studied 15 elderly hypertensive patients aged 73.6+/-4.6 years with myocardial ischemia. All patients had angiographically documented coronary artery disease. We measured patients using 48- hour ambulatory electrocardiogram monitoring and exercise testing. After a 2-week period using placebo, patients received chlorthalidone or diltiazem for 4 weeks. RESULTS Both treatments lowered systolic and diastolic blood pressures. The number of ischemic episodes on ambulatory electrocardiogram recordings was reduced with the use of chlorthalidone (2.5+/-3.8) and diltiazem (3.2+/-4.2) when compared with placebo (7.9+/-8.8; p<0.05). The total duration of ischemic episodes was reduced in both treatments when compared with placebo (chlorthalidone: 19.2+/-31.9min; diltiazem: 19.3+/-29.6min; placebo: 46.1+/-55.3min; p<0.05). CONCLUSION In elderly hypertensive patients with coronary artery disease, chlorthalidone reduced myocardial ischemia similarly to diltiazem. This result is consistent with epidemiological studies and suggests that reduction of arterial blood pressure with thiazide therapy plays an important role in decreasing myocardial ischemia.

Effects of aging on the effectiveness of smoking cessation medication

Background Considering the pharmacokinetic and pharmacodynamic aspects of different medications, it is plausible that the age of a smoker could affect the half-life of these drugs. The aim of this study was to compare the effectiveness of smoking cessation drugs (nicotine replacement therapy, bupropion, and varenicline) used either in isolation or in combination in adults under and over 60 years of age. Methods Data were collected from 940 Brazilian patients participating in a smoking cessation program. Participants were prescribed smoking cessation medication to be used for at least 12 weeks and were followed for 52 weeks. Results Cessation rates were significantly different among younger and older participants who were using nicotine replacement therapy (NRT) alone. Being over 60 years of age was significantly associated with increased cessation success among those who used NRT alone (OR 2.34, 95% CI: 1.36 to 4.04, p = 0.002). The effectiveness of varenicline and bupropion were not significantly different according to age groups. Conclusion Using age as a predictor for tailoring smoking cessation drugs might potentially lead to a more individualized prescription of smoking cessation therapy. These results should be tested in randomized controlled trials.

Amilóidose cardíaca. Uma doença de muitas faces e diferentes prognósticos

PURPOSE: To identify the principal forms of cardiac amiloydosis presentation in a terciary hospital. METHODS: Eight cases whith cardiac amyloidosis were identified. Five were woman, their ages ranged from 23 to 83 years (mean 62). After a medical history and clinical examination the patients, were submitted to complementary tests: electrocardiogram (EKG), echocardiogram (ECHO), scintigraphy with technecium pirophosfate and cardiac biopsy these results allowed the identification of their clinical situation. RESULTS: Seven patients refered dyspnea, 6 were in heart failure, 1 patient had syncope. The EKG identified complete atrioventricular (AV) block in 4 patients, and antero septal inactive area in the other 4. The ECHO showed normal cardiac diameter in all (mean left ventricular diastolic diameter of 46.8) and slight reduction of left ventricular ejection fraction; hypertrophy of the left ventricular septal and posterior walls in all cases, in 7 cases there was a hyper refractile granular sparkling ECHO. Two different groups were identified: one with complete AV block and the second with restrictive cardiomyopathy. The prognosis was different in these two groups. Those with complete AV block evolved better after pacemaker implantation and those with restrictive cardiomyopathy had refractary heart failure and 3 of them died. CONCLUSION: The increased free wall and septal thickness, the slight systolic dysfunction and the infiltration aspect at ECHO allow us to identify the great majority of the cases. Those patients with restrictive cardiomyopathy evolve with refractory heart failure and most of them die in a few months.