José C. Lima

Anti-inflammatory effect of atorvastatin (80 mg) in unstable angina pectoris and non–Q-wave acute myocardial infarction

In this randomized trial, C-reactive protein increased during the first 5 days of an acute coronary syndrome in patients treated with placebo, but this phenomenon was not observed in those randomized to atorvastatin 80 mg/day. This suggests that short-term statin therapy inhibits inflammation in patients with non-ST-elevation acute coronary syndromes.

National alert campaign about increased cholesterol: determination of cholesterol levels in 81,262 Brazilians

OBJECTIVE To determine the levels of total cholesterol in a significant sample of the Brazilian population. METHODS Blood cholesterol was determined in 81.262 individuals > 18 years old (51% male, 44.7 +/- 15.7 years), using Accutrend equipment, in the cities São Paulo, Campinas, Campos do Jordão, São José dos Campos, Santos, Santo André , Ribeirão Preto, Porto Alegre, Rio de Janeiro, Belo Horizonte, Curitiba, Brasília, Salvador and documented in the presence of other risk factors (RF) for coronary artery disease (CAD) (systemic hypertension, CAD in the family, smoking, and diabetes). Participants were classified according to sex, age, and the presence or absence of RF, respectively, as 0 RF, 1 RF and > 2 RF. The percentage of individuals with cholesterol > 200 mg/dL and > 240 mg/dL was evaluated. RESULTS The prevalence of individuals with 0, 1, and > 2 risk factors was 30% (n = 24,589), 36% (n =29,324), and 34% (n = 27,349) respectively, (P=0.657), and the mean total cholesterol of the population was 199.0 +/- 35.0 mg/dL. Cholesterol levels above 200 and 240 mg/dL were found, respectively, in 40% (n = 32,515) and 13% (10.942) of individuals. The greater the number of risk factors the higher the levels of cholesterol (P<0.0001) and the greater the proportion of individuals with cholesterol > 200 mg/dL (P=0.032). No difference existed in the proportion of individuals with cholesterol > 240 mg/dL (P=0.11). CONCLUSION A great percentage of individuals with cholesterol levels above those recommended to prevent coronary artery disease was found.

Avaliação da função e da lesão renal: um desafio laboratorial

Nowadays, renal disease is an important public health problem, affecting millions of people in Brazil and in the world. The study of renal function and renal pathologic processes has aroused the interest of researchers, mainly in the field of development of new assays that could aid physicians in establishing early diagnosis, better classifying the disease, obtaining better outcome and monitoring drug therapeutics. In this article, seven laboratory markers of renal function or damage are evaluated: urea, creatinine, cystatin C, proteinuria, dysmorphic erythrocytes, microalbuminuria and liver-type fatty acid binding protein (L-FABP). For each one of them, a short historical report of its clinical utility and physiopathology is presented. Then technical and methodological approaches are described as well as its utility in clinical management of kidney patients. Although improvements have been reached and incorporated in laboratorial practice, none of these markers is effective enough to define precisely kidney function and/or damage and an extensive understanding of all of these markers is crucial to correct evaluate renal function.

Relation of severe deficiency of vitamin D to cardiovascular mortality during acute coronary syndromes.

Vitamin D deficiency is associated with risk for a first cardiovascular event in the general population, possibly because of inflammation, insulin resistance, and neurohumoral activation. However, its relation with outcomes in acute coronary syndromes has not been reported. To test the hypothesis that severe deficiency of vitamin D is independently associated with cardiovascular mortality during ACS, 206 patients admitted for unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation acute myocardial infarction had 25-hydroxyvitamin D serum levels measured at admission. Severe vitamin D deficiency was defined a priori as a value ≤10 ng/ml. The average concentration of vitamin D was 20 ± 8.2 ng/ml, and 10% of patients were severely deficient (95% confidence interval 6.6% to 15%). Cardiovascular mortality during hospitalization took place in 14 patients, an incidence of 6.8%. Patients with severe vitamin D deficiency had in-hospital cardiovascular mortality of 24%, significantly higher than the 4.9% observed in the remaining patients (relative risk 4.3, 95% confidence interval 1.8 to 10, p = 0.001). After adjustment for Global Registry of Acute Coronary Events (GRACE) score, Gensini angiographic score, and potential confounding variables, severe deficiency of vitamin D remained an independent predictor of in-hospital cardiovascular mortality (odds ratio 14, 95% confidence interval 1.2 to 158, p = 0.03). In conclusion, severe vitamin D deficiency is independently associated with in-hospital cardiovascular mortality in patients with acute coronary syndromes.

Troponin in Chagas disease

Chagas disease is still a major tropical diseasein Latin America, affecting 16 to 18 million people.About 6 million people are infected with thecausative organism, Trypanosoma cruzi , in Brazil[1]. However, it often remains for decades in itsindeterminate form, symptomless, with tissue injuryin about 30% of the cases, which eventually willevolve to serious arrhythmia and sudden death [1].There is no effective clinical or laboratorytechnique to monitor chronic Chagas myocarditis.Several researchers have found that Troponin I andT are important biochemical markers of heartmuscle damage. Increased levels of myocardialtroponins have been found associated with acutemyocardial ischemia, infarction, myocarditis andheart failure [2-4].Recently, we tested sera from 60 Chagasdisease patients (24 with the indeterminate formand 36 with chronic chagasic cardiomyopathy. Serafrom 24 healthy volunteers (Control Group) weretested for Troponin I (Immulite 1000 Turbo DPC-Medlab). The Troponin I value was considerednormal when it was below 0.15ng/dl, and high whenit was above 0.30ng/dl. The upper limit was set tobe at least two standard deviations above thenormal value.The mean value for Troponin I was 0.46ng/dl inthe Chagas disease patients, and 0.027ng/dl in thecontrol group. The mean age was 44.1±9.9 yearsof the Chagas patients, and 34 were male. Whenwe tested We found 13 (54%) and 26 (74%)patients with high Troponin I, respectively, forchronic Chagas cardiomyopathy and theindeterminate form of Chagas disease. Twenty-onepatients from the Chagas disease group wereexcluded due to other cardiovascular diseases,myopathy or kidney disease.Troponin I levels were significantly higher amongthe Chagas disease patients with cardiomyopathywhen compared to the indeterminate form andcontrols, mean 0.60ng/dl vs 0.25ng/dl, respectively,and controls 0.027ng/dl (P < 0.001).All the patients with the indeterminate form ofChagas disease had normal EKGs, chest X-raysand echocardiograms. Possibly, the increased levelsof Troponin I, found in our sample, are related tochronic foci of myocardial inflammation, provokedby Chagas disease.Moreover, the utilization of a sensitive and easilymeasured biochemical marker should allow us toadopt different clinical cut-offs, facilitating theidentification of the different degrees of myocardialdamage, which now requires various diagnostic andtherapeutic approaches [5].The serum level of Troponin I is elevated indifferent clinical presentations of Chagas’ diseaseand may become an important element for earlydetection of myocardial inflammation, to preventfurther myocardial damage.References

Validação da medida de proteína C-reativa de alta sensibilidade (PCR-as) por quimioluminescência para estimativa de risco cardiovascular em indivíduos ambulatoriais: análise comparativa com nefelometria

BACKGROUND: High-sensitivity c-reactive protein (hs-CRP) is an established risk predictor in primary prevention. Among available laboratory methods, enzyme linked immunosorbent assay (ELISA) and nephelometry are the most validated for this clinical application. Immunoluminometry is another high-sensitivity method of hs-CRP, with definitive prognostic value in acute coronary syndromes. However, it lacks validation for cardiovascular risk prediction in the outpatient setting, whose hs-CRP values are in a lower range in relation to unstable patients. OBJECTIVE: In an outpatient setting, test the hypothesis that the immunoluminometric method has enough accuracy to measure hs-CRP and classify individuals according to cardiovascular risk. METHOD: C-reactive protein was measured by the methods of immunoluminometry and nephelometry in 152 serum samples obtained from different outpatient subjects. Taken nephelometry as a gold-standard, performance of the immunoluminometric method was evaluated. RESULTS: There was a strong linear association between the two methods, according to the correlation coefficient (r = 0.996; p 3mg/l) - kappa = 0.96; p < 0.001. CONCLUSION: The immunoluminometric method of hs-CRP represents an alternative to nephelometry for the assessment of cardiovascular risk in an outpatient population.

Valor prognóstico da troponina I de alta sensibilidade versus troponina T nas síndromes coronarianas agudas

BACKGROUND Despite superior diagnostic accuracy of high-sensitivity cardiac troponins, their prognostic value has not been validated against conventional cardiac troponins. OBJECTIVE To test the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI), compared with conventional cardiac troponin T (cTnT) in the setting of non-ST elevation acute coronary syndromes. METHODS At hospital admission, a plasma sample was collected from 103 consecutive patients with unstable angina or non-ST elevation acute myocardial infarction. In this sample, troponin was measured both by hs-cTnI and cTnT methods. Their prognostic value was compared as to the occurrence of major cardiovascular events, defined as a combination of death, nonfatal acute myocardial infarction or refractory unstable angina during hospitalization. RESULTS During median hospitalization of 8 days (interquartile range = 5 - 11), the incidence of cardiovascular events was 10% (5 deaths, 3 non-fatal myocardial infarctions and 2 non-fatal refractory anginas). High-sensitivity troponin I significantly predicted cardiovascular events, with a C-statistics of 0.73 (95% CI = 0.59 - 0.87), similarly to cTnT (0.70; 95% CI = 0.55 - 0.84) - P = 0.75. The definition of positive cardiac marker that provided the best prognostic accuracy was hs-cTnI > 0.055 µg/L and cTnT > 0.010 µg/L, with equal sensitivity of 90% and specificity of 52% for both assays. Positive hs-cTnI was associated with 17% incidence of events, compared with 2% in patients with negative hs-cTnI (P = 0.02). CONCLUSION High-sensitivity troponin I predicts cardiovascular events similarly to conventional troponin T in the setting of non-ST-elevation ACS.

Moderate renal dysfunction is not associated with elevated Troponin T in acute coronary syndromes

FUNDAMENTO: A interpretacao dos resultados de troponina em pacientes com sindromes coronarianas agudas (SCA) e doenca renal e dificultada pelo fato de que a disfuncao renal aumenta os niveis de troponina, independente da necrose miocardica. Embora tenha sido demonstrado que a doenca renal em estagio terminal esta associada com niveis elevados de troponina T cardiaca (TnT), ainda nao e conhecido se esse biomarcador e alterado por niveis menos graves de disfuncao renal. OBJETIVO: Avaliar se disfuncao renal moderada esta associada com elevacao dos niveis de TnT em pacientes com SCA. METODOS: Um total de 145 individuos com SCA e clearance de creatinina > 30 ml/min foram estudados. O clearance de creatinina foi estimado atraves da formula de Cockcroft-Gault e a TnT foi medida na admissao hospitalar. Disfuncao renal moderada foi definida como clearance de creatinina de 30-59 ml/min e TnT positiva como niveis > 0,01 ug/l. RESULTADOS: Nenhuma correlacao foi observada entre o clearance de creatinina e TnT (r = - 0,06, P=0,45). Os niveis de TnT foram similares entre individuos no primeiro (mediana=0,05 ug/l), segundo (mediana=0 ug/l), terceiro (mediana=0,07 ug/l) e quarto quartis (mediana=0 ug/l) de clearance de creatinina - P=0,63. De forma similar, nao houve diferenca nos valores de troponina entre individuos com disfuncao renal moderada (mediana=0,02 ug/l) e individuos com funcao renal normal/quase normal (mediana=0,03 ug/l) - P=0.63. A prevalencia de TnT positiva foi similar entre individuos com disfuncao renal moderada e funcao renal normal/quase normal (55% vs 52%, P=0,65). CONCLUSAO: Disfuncao renal moderada nao esta associada com elevacao dos niveis de TnT em pacientes com SCA. (Arq Bras Cardiol 2010; 95(5): 600-605)

Validação de um escore para predição de eventos hemorrágicos em síndromes coronarianas agudas

FUNDAMENTO: Sangrado es una complicacion grave en pacientes tratados por sindromes coronarios agudos (SCA) con antitromboticos y terapias invasivas. Consecuentemente, el beneficio de esas terapias debe ser analizado contra los potenciales riesgos de complicaciones hemorragicas. De esta forma, la determinacion de un escore para estimar el riesgo individual de sangrado puede representar una importante herramienta en la toma de decisiones clinicas. OBJETIVO: Crear y validar un escore de riesgo de sangrado para pacientes con SCA. METODOS: Fueron utilizados predictores independientes de sangrado relatados por el Registro GRACE. Variables con odds ratio (OR) > 2,5 en ese Registro sumaron 3 puntos (historico anterior de sangrado), OR=1,5-2,4 sumaron 2 puntos (clearance de creatinina 30, infra o supra-desnivel del segmento ST, enfermedad arterial periferica y tabaco). El escore fue validado en una cohorte de 383 individuos con SCA. Sangrado intrahospitalario fue definido como caida de hematocrito > 10%, transfusion de sangre > 2 unidades, sangrado intracerebral o sangrado fatal. RESULTADOS: La incidencia de eventos hemorragicos fue de 3,1% y la estadistica-C del escore fue 0,66 (IC95% = 0,52-0,80), indicando capacidad predictiva para esos eventos. Aquellos con escore > 7 presentaron 6% de incidencia de sangrado, comparados con 1,9% si el escore era 7 y un mayor riesgo impuesto por el tratamiento con Clopidogrel (P=0,02), bloqueadores IIb/IIIa (P=0,06) y revascularizacion quirurgica (P<0,001). CONCLUSION: El escore discrimina el riesgo de sangrado y es potencialmente util en la toma de decision clinica en SCA.BACKGROUND bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE this study aims to create and validate a bleeding risk score for patients with ACS. METHODS independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10%, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS the incidence of bleeding events was 3.1% and the scores C-statistics was 0.66 (95% CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6% incidence of bleeding, compared with 1.9% if the score was < 7 (RR = 3.2; 95%CI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION the score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.

Validation of a score for predicting bleeding events during acute coronary syndromes

FUNDAMENTO: Sangrado es una complicacion grave en pacientes tratados por sindromes coronarios agudos (SCA) con antitromboticos y terapias invasivas. Consecuentemente, el beneficio de esas terapias debe ser analizado contra los potenciales riesgos de complicaciones hemorragicas. De esta forma, la determinacion de un escore para estimar el riesgo individual de sangrado puede representar una importante herramienta en la toma de decisiones clinicas. OBJETIVO: Crear y validar un escore de riesgo de sangrado para pacientes con SCA. METODOS: Fueron utilizados predictores independientes de sangrado relatados por el Registro GRACE. Variables con odds ratio (OR) > 2,5 en ese Registro sumaron 3 puntos (historico anterior de sangrado), OR=1,5-2,4 sumaron 2 puntos (clearance de creatinina 30, infra o supra-desnivel del segmento ST, enfermedad arterial periferica y tabaco). El escore fue validado en una cohorte de 383 individuos con SCA. Sangrado intrahospitalario fue definido como caida de hematocrito > 10%, transfusion de sangre > 2 unidades, sangrado intracerebral o sangrado fatal. RESULTADOS: La incidencia de eventos hemorragicos fue de 3,1% y la estadistica-C del escore fue 0,66 (IC95% = 0,52-0,80), indicando capacidad predictiva para esos eventos. Aquellos con escore > 7 presentaron 6% de incidencia de sangrado, comparados con 1,9% si el escore era 7 y un mayor riesgo impuesto por el tratamiento con Clopidogrel (P=0,02), bloqueadores IIb/IIIa (P=0,06) y revascularizacion quirurgica (P<0,001). CONCLUSION: El escore discrimina el riesgo de sangrado y es potencialmente util en la toma de decision clinica en SCA.BACKGROUND bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE this study aims to create and validate a bleeding risk score for patients with ACS. METHODS independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10%, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS the incidence of bleeding events was 3.1% and the scores C-statistics was 0.66 (95% CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6% incidence of bleeding, compared with 1.9% if the score was < 7 (RR = 3.2; 95%CI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION the score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.