Joselina Luzia Menezes Oliveira

Suspicion of Obstructive Sleep Apnea by Berlin Questionnaire predicts events in patients with Acute Coronary Syndrome

FUNDAMENTO: De um ponto de vista mecanistico, a apneia obstrutiva do sono (SAOS) pode causar disturbios extras a homeostase cardiovascular na presenca de sindrome coronariana aguda (SCA). OBJETIVO: Investigar se um diagnostico clinico padronizado de SAOS, em pacientes com SCA, prediz o risco de eventos cardiovasculares durante hospitalizacao. METODOS: Em um estudo de coorte prospectivo, um grupo de 200 pacientes com diagnostico de SCA estabelecido entre Setembro de 2005 e Novembro de 2007, foram estratificados pelo Questionario de Berlim (QB) para o risco de SAOS (alto ou baixo risco). Foi testado se o subgrupo de alto risco para SAOS apresenta maior tendencia a eventos cardiovasculares. O endpoint primario avaliado foi um desfecho composto de morte cardiovascular, eventos cardiacos isquemicos recorrentes, edema pulmonar agudo e acidente vascular cerebral durante a hospitalizacao. RESULTADOS: Noventa e quatro (47%) dos pacientes identificados pelo QB apresentavam suspeita de SAOS. Alto risco para SAOS estava associado com uma mortalidade mais elevada, embora sem diferenca estatistica (4,25% vs 0,94%; p=0,189), mas com uma estatisticamente significante maior incidencia de desfecho composto de eventos cardiovasculares (18,08% vs 6,6%; p=0,016). No modelo de regressao logistica, os preditores multivariados de desfecho composto de eventos cardiovasculares foram idade (OR = 1,048; IC95%: 1,008 a 1,090; p=0,019), fracao de ejecao do VE (OR = 0,954; IC95%: 0,920 a 0,989; p=0,010), e risco mais elevado de SAOS (OR = 3,657; IC95%: 1,216 a 10,996; p=0,021). CONCLUSAO: O uso de um questionario simples e validado (QB) para identificar pacientes com risco mais elevado de SAOS pode ajudar a prever o desfecho cardiovascular durante a hospitalizacao. Alem disso, nossos dados sugerem que SAOS e muito comum em pacientes com SCA.BACKGROUND From a mechanistic standpoint, obstructive sleep apnea (OSA) may further disturb cardiovascular homeostasis in the setting of acute coronary syndrome (ACS). OBJECTIVE We sought to investigate if a standardized clinical diagnosis of OSA, in acute coronary syndrome patients, predicts the risk of cardiovascular events during hospitalization. METHODS In a prospective cohort study, a group of 200 patients diagnosed with ACS between September 2005 and November 2007 were stratified by the Berlin Questionnaire (BQ) regarding the risk for OSA (high or low risk). We tested if the subgroup of high risk for OSA was prone to a higher frequency of cardiovascular events. The primary endpoint evaluated was a composite outcome of cardiovascular death, recurrent cardiac ischemic events, acute pulmonary edema and stroke during hospitalization. RESULTS Ninety four (47%) patients assessed by the BQ were likely to have OSA. High risk for OSA was associated with a non-significant higher mortality (4.25% vs 0.94%; p=0.189), but a significant higher incidence of composite cardiovascular events (18.08% vs 6.6%; p=0.016). In the logistic regression model, multivariate predictors of composite cardiovascular events were age (OR= 1.048; 95% CI 1.008 to 1.090; p=0.019), left ventricular ejection fraction (OR= 0.954; 95% CI 0.920 to 0.989; p=0.010), and higher risk for OSA (OR= 3.657; 95% CI 1.216 to 10.996; p=0.021). CONCLUSION The use of a simple and validated questionnaire (BQ) to identify patients with higher risk for OSA may help in the prediction of cardiovascular outcome during hospitalization. Moreover, our data suggests that OSA is very common in patients with ACS.

Suspeita de Apneia Obstrutiva do Sono definida pelo Questionário de Berlim prediz eventos em pacientes com Síndrome Coronariana Aguda

FUNDAMENTO: De um ponto de vista mecanistico, a apneia obstrutiva do sono (SAOS) pode causar disturbios extras a homeostase cardiovascular na presenca de sindrome coronariana aguda (SCA). OBJETIVO: Investigar se um diagnostico clinico padronizado de SAOS, em pacientes com SCA, prediz o risco de eventos cardiovasculares durante hospitalizacao. METODOS: Em um estudo de coorte prospectivo, um grupo de 200 pacientes com diagnostico de SCA estabelecido entre Setembro de 2005 e Novembro de 2007, foram estratificados pelo Questionario de Berlim (QB) para o risco de SAOS (alto ou baixo risco). Foi testado se o subgrupo de alto risco para SAOS apresenta maior tendencia a eventos cardiovasculares. O endpoint primario avaliado foi um desfecho composto de morte cardiovascular, eventos cardiacos isquemicos recorrentes, edema pulmonar agudo e acidente vascular cerebral durante a hospitalizacao. RESULTADOS: Noventa e quatro (47%) dos pacientes identificados pelo QB apresentavam suspeita de SAOS. Alto risco para SAOS estava associado com uma mortalidade mais elevada, embora sem diferenca estatistica (4,25% vs 0,94%; p=0,189), mas com uma estatisticamente significante maior incidencia de desfecho composto de eventos cardiovasculares (18,08% vs 6,6%; p=0,016). No modelo de regressao logistica, os preditores multivariados de desfecho composto de eventos cardiovasculares foram idade (OR = 1,048; IC95%: 1,008 a 1,090; p=0,019), fracao de ejecao do VE (OR = 0,954; IC95%: 0,920 a 0,989; p=0,010), e risco mais elevado de SAOS (OR = 3,657; IC95%: 1,216 a 10,996; p=0,021). CONCLUSAO: O uso de um questionario simples e validado (QB) para identificar pacientes com risco mais elevado de SAOS pode ajudar a prever o desfecho cardiovascular durante a hospitalizacao. Alem disso, nossos dados sugerem que SAOS e muito comum em pacientes com SCA.BACKGROUND From a mechanistic standpoint, obstructive sleep apnea (OSA) may further disturb cardiovascular homeostasis in the setting of acute coronary syndrome (ACS). OBJECTIVE We sought to investigate if a standardized clinical diagnosis of OSA, in acute coronary syndrome patients, predicts the risk of cardiovascular events during hospitalization. METHODS In a prospective cohort study, a group of 200 patients diagnosed with ACS between September 2005 and November 2007 were stratified by the Berlin Questionnaire (BQ) regarding the risk for OSA (high or low risk). We tested if the subgroup of high risk for OSA was prone to a higher frequency of cardiovascular events. The primary endpoint evaluated was a composite outcome of cardiovascular death, recurrent cardiac ischemic events, acute pulmonary edema and stroke during hospitalization. RESULTS Ninety four (47%) patients assessed by the BQ were likely to have OSA. High risk for OSA was associated with a non-significant higher mortality (4.25% vs 0.94%; p=0.189), but a significant higher incidence of composite cardiovascular events (18.08% vs 6.6%; p=0.016). In the logistic regression model, multivariate predictors of composite cardiovascular events were age (OR= 1.048; 95% CI 1.008 to 1.090; p=0.019), left ventricular ejection fraction (OR= 0.954; 95% CI 0.920 to 0.989; p=0.010), and higher risk for OSA (OR= 3.657; 95% CI 1.216 to 10.996; p=0.021). CONCLUSION The use of a simple and validated questionnaire (BQ) to identify patients with higher risk for OSA may help in the prediction of cardiovascular outcome during hospitalization. Moreover, our data suggests that OSA is very common in patients with ACS.

Função diastólica do ventrículo esquerdo em obesos graves em pré-operatório para cirurgia bariátrica

BACKGROUND Obesity is a chronic and multifactorial disease, associated with increased cardiovascular risk, especially diastolic heart failure. OBJECTIVE To evaluate left ventricular diastolic function in morbidly obese patients in the pre-operative for bariatric surgery, correlating it with cardiovascular risk factors and heart structure. METHODS This is a cross-sectional study with 132 patients eligible for bariatric surgery submitted to transthoracic echocardiography assessment and of cardiovascular risk factors, as follows: 97 women (73.5%), mean age 38.5 ± 10.5 years and BMI of 43.7 ± 7.2 kg / m(2). Patients were divided into three groups: 61 with normal diastolic function, 24 with mild diastolic dysfunction and 47 with moderate/severe diastolic dysfunction, of which 41 with moderate diastolic dysfunction (pseudonormal pattern) and six with severe diastolic dysfunction (restrictive pattern). RESULTS Hypertension, age and gender were different in the groups with diastolic dysfunction. Groups with dysfunction had higher left atrial diameter, left ventricular diameter, left atrial volume in four and two chambers, left atrial volume index and left ventricular mass index corrected for body surface area and height. CONCLUSION The high frequency of left ventricular diastolic dysfunction in the preclinical phase in morbidly obese patients justifies the need for careful echocardiographic assessment, aiming at identifying individuals at higher risk, so that early intervention measures can be carried out.

GH response to hypoglycemia and clonidine in the GH-releasing hormone resistance syndrome

GH secretion by the pituitary is the result of the balance between the stimulatory effect of GHRH and the inhibitory effect of SS. Patients with mutations in GHRH receptor (GHRH-R) gene (GHRH-R) offer a unique model to study the mechanism of action of different GH secretion stimuli. In the past, we have demonstrated a small but significant GH response to a GH secretagogue (GHRP-2) in a homogenous cohort of patients with severe GH deficiency (GHD) due to a homozygous null mutation in GHRH-R (IVS1+1G→A). Now, we sought to determine if we could detect a GH response to hypoglycemia (ITT: insulin tolerance test) or clonidine (CL) in these patients. Nine young GHD subjects underwent both ITT and CL tests, and 2 additional subjects underwent only CL test. There was a small but significant GH increase during ITT, but not during CL test. These results indicate that a minimal albeit significant GH response to ITT can occur despite complete lack of GHRH-R function.

Exercise stress echocardiography in the identification of coronary artery disease in the elderly with chronotropic incompetence

BACKGROUND Chronotropic incompetence (CTI) is frequent in elderly patients and may limit the role of the exercise test in the identification of coronary artery disease (CAD) in this population. OBJECTIVE To assess the value of CTI in an elderly population in the diagnosis of CAD. METHODS A total of 3,308 patients were studied, 804 were elderly individuals (age > 65 years) who underwent exercise stress echocardiography (ESE). Based on the heart rate (HR) reached during the exercise test, were divided into two groups: G1 150 patients who did not reach 85% of the age-predicted HR, and G2 654 patients who did. The groups were compared to clinical characteristics, segmental left ventricular contractility rate (WMSI) and coronary angiography (CAG). RESULTS Clinical characteristics were similar between the groups. WMSI was higher in G1 than in G2, both at rest (1.09 +/- 0.21 versus 1.04 +/- 0.15) and after exercise (1.15 +/- 0.29 versus 1.08 +/- 0.2) (p < 0.001). Abnormalities in wall contractility were more frequent in G1 than in G2 (55% versus 37%; p < 0.05), thus suggesting that elderly with CTI have a higher frequency of CAD. CAG was performed in 69% ESE positive for myocardial ischemia. In the G1 group, 91% of the ESE were true positive versus 84.5% in G2, that is, presence of obstructive coronary artery disease (> 50%). CONCLUSION CTI is associated with a higher frequency of contractile alterations in the elderly population and adds a positive predictive value to ESE in the identification of patients with obstructive CAD.

Parâmetros clínicos e ecocardiográficos associados a baixo índice cronotrópico em pacientes não idosos

BACKGROUND Despite abundant evidence of increased morbidity and mortality, chronotropic incompetence (CI) is not a routine diagnosis well defined in protocols of cardiac evaluation and its clinical importance is still underestimated. OBJECTIVE To evaluate the clinical and echocardiographic parameters associated with HF in non-elderly patients submitted to stress echocardiography (SE). METHODS One thousand seven hundred ninety-eight patients with a mean age of 48.4 ± 7.5 years, who underwent SE between January/2000 and August/2009 were evaluated. Patients with chronotropic index smaller than 0.8 were considered chronotropic incompetent as compared to competent patients as to clinical and echocardiographic characteristics. RESULTS The duration of the exercise was 9.3 ± 2.4 minutes on average. Two hundred and seventy (15%) patients were chronotropic incompetent. The chronotropic index of this group was 0.7 ± 0.1 vs. 1.0 ± 0.1 for competent patients. Multivariate logistic regression analysis identified the following parameters as independently associated with HF: dyspnea on examination [odds ratio (OR) = 4.27, p <0.0001], previous chest pain on medical history (OR = 1.51; p = 0.0111), higher left ventricular mass rate in incompetent patients (LVMI) (OR = 1.16, p = 0.0001), metabolic equivalents (METs) (OR = 0.70, p = 0 , 0001), ST segment depression (OR = 0.58, p = 0.0003) and high systolic blood pressure (ΔSBP) (OR = 0.87, p = 0.0011). Myocardial ischemia was not associated with HF. CONCLUSION HF is associated with functional parameters, such as dyspnea on exertion, history of chest pain and lower METS. It is also associated with structural benchmark index of left ventricular mass. In addition, chronotropic incompetence does not appear to increase the chance of myocardial ischemia in non-elderly patients.

Effects of depot growth hormone replacement on thyroid function and volume in adults with congenital isolated growth hormone deficiency

Background: Conflicting data exist on the effects of GH replacement therapy (GHRT) on thyroid function and thyroid volume (TV) in GH-deficient (GHD) patients. Aim: The aim of this study was to assess the effects of GHRT on thyroid function and TV in adults with congenital lifetime isolated GHD (IGHD). Subjects and methods: We studied 20 GH-naïve adults with IGHD due to a homozygous mutation of the GHRH-receptor gene at baseline, after 6-month depot-GH replacement therapy (pGH), and 6-month washout (6mo). Total T3, free T4 (FT4), reverse T3 (rT3), TSH, IGF-I, SHBG, and TV were measured; body surface area-corrected TV (CTV) was calculated. Results: IGF-I and T3 increased pGH. T3 levels remained elevated at 6mo. GHRT did not significantly change FT4, rT3, TSH, and SHBG. TV and CTV increased pGH and remained elevated at 6mo. Conclusions: GHRT in IGHD adults caused an increase in serum T3 levels and TV, suggesting an important role of the GH-IGF-I axis in thyroid function.

Trombo biventricular e fibrose endomiocárdica na síndrome antifosfolípide

A SAF e uma doenca sistemica autoimune caracterizada pela deteccao plasmatica de anticorpos antifosfolipides, tais como o anticardiolipina e o anticoagulante lupico, que se manifesta clinicamente mediante: trombose arterial e/ou venosa recorrentes, trombocitopenia, abortamentos de repeticao e anemia hemolitica autoimune, alem de alteracoes cardiacas, neurologicas e cutâneas1. Constitui-se na principal causa adquirida de hipercoagulabilidade, ocorrendo em 2% da populacao geral e apresenta alta morbimortalidade2.

Dextrocardia with situs inversus associated with non-compaction cardiomyopathy

Dextrocardia is a rare condition usually diagnosed incidentally and associated with other congenital anomalies. It is characterized by the position of the heart in the right hemithorax, with its base-apex axis directed to the bottom right. Its incidence associated with situs inversus, in the general population, is 1:10.0001. Non-compaction cardiomyopathy (non-compaction CMP), in turn, has an incidence ranging from 0.014 to 1.3%2, may occur alone or associated with other congenital defects and results from failure in the process of compaction of myocardial fibers, resulting in the persistence of trabeculations and deep recesses that communicate with the ventricular cavity2. A rare association of these two diseases is described. Cases similar to the one reported have not been found3-5.

Prognostic value of chronotropic incompetence in elderly patients undergoing exercise echocardiography

BACKGROUND Chronotropic incompetence (CI), defined as failure to achieve less than 80% of age-expected heart rate, is a predictor of mortality and adverse cardiovascular events and may confer a worse prognosis in elderly diabetic individuals. OBJECTIVE To evaluate the prognostic value of chronotropic incompetence (CI) in elderly diabetic patients considering endpoints with acute myocardial infarction (AMI), cerebrovascular disease (CVD) and overall mortality and compare clinical and echocardiographic characteristics between patients with and without CI. METHOD A total of 298 elderly diabetic patients undergoing exercise echocardiography (EE) were studied from January 2001 to December 2010. Of these, 109 were chronotropic incompetent (group 1) and were compared with the chronotropic competent ones (group 2) regarding the occurrence of cardiovascular events, clinical and echocardiographic characteristics. RESULTS Chronotropic incompetents patients showed a higher frequency of cerebrovascular disease (9.2% vs. 3.2, p = 0.027) and higher mortality was observed in those who had cerebrovascular disease or acute myocardial infarction. The presence of typical angina and dyspnea prior to the performance of EE and male gender were more frequent in group 1. Rest and exercise left ventricular wall motion score index, rate of left ventricle mass and left atrium diameter were higher in chronotropic incompetent individuals. CONCLUSION Chronotropic incompetence was independently associated with the occurrence of cerebrovascular disease in elderly diabetic individuals.