Juliana Martins

Psychoneuroendocrine characteristics of common obesity clinical subtypes.

OBJECTIVE: To relate psychological profiles, cerebral asymmetry and the hypothalamus–pituitary–adrenal axis (HPA) reactivity to clinical characteristics of common obesity.METHODS: Sixty consecutive adult female overweight and obese patients attending the outpatient endocrine department were included in this study. Clinical evaluation specifically selected a priori the following indexes: obesity age of onset, parenthood obesity, carbohydrate craving, binge eating with purging, obesity degree (defined by the body mass index (BMI)—weight (kg)/height (m2)), body fat distribution (defined by the abdominal–thigh ratio (A/T)) and initial weight loss after medical treatment. Psychological evaluation was performed with the Minnesota Multiphasic Personality Inventory (MMPI). In the last 30 patients, the Edinburgh Inventory of Manual Preference (EIMP) and the corticotrophin-releasing hormone (CRH) test were also performed.RESULTS: Clinical characteristics defined a priori were independent variables as evaluated by contingency table analysis. Factorial analysis of variance (ANOVA) revealed a significantly different MMPI profile, according to parental obesity, with post-hoc significantly higher scores on the hypochondriasis (Hs), paranoia (Pa), psychasthenia (Pt) and schizophrenia (Sc) scales in patients with obese parents. Obese patients presented significantly higher dichotomized manual preference indexes in relation to overweight patients. Parental obesity, binge eating behaviour with purging, body fat distribution and the dichotomized manual preference index were independent significant factors for the ACTH response in the CRH test, together explaining 41% of the response variability. Age of onset of obesity and the dichotomized manual preference index were independent and significant factors for the cortisol response, together explaining 37% of its variability. A non-normal distribution was found for the ACTH response: high- and low-responders presented significantly different MMPI profiles, with high-responders presenting higher scores on all clinical scales except masculinity/femininity (Mf).CONCLUSION: Overweight/obese subjects with parental obesity present a distinctive personality profile and a higher ACTH response in the CRH test. Cerebral asymmetry may be a relevant factor for obesity development and is associated with the HPA reactivity. HPA reactivity is a sensitive index integrating clinical, psychological and neural asymmetric factors.

Dyslipidaemia in female overweight and obese patients. Relation to anthropometric and endocrine factors

OBJECTIVE: To characterize serum lipid abnormalities in overweight and obese female patients and to quantify the relative importance of associated factors.METHODS: Cross sectional study at the first visit to the out-patient department. 237 consecutive overweight and obese female patients (age 31±14 y, body mass index (BMI) 34.2±6.0 kg/m2) were studied. Evaluation included a questionnaire-based assessment of dietary and physical activity habits, determination of anthropometric indexes (BMI, abdominal/thigh ratio (A/T) and conicity index (CI)) and endocrine evaluation. Statistical analysis by factorial ANOVA and multiple regression.RESULTS: Dyslipidaemia was present in 46% of the patients, with hypercholesterolaemia (35%) being more frequent than hypertriglyceridaemia (10%). Age but not dietary habits or physical activity patterns was significantly related to serum lipid concentrations, independently accounting for 6–10% of their variability. Pharmacological drug use resulted in increased serum triglyceride concentrations, explaining less than 5% of their variability. Serum cholesterol concentrations were not significantly related either to anthropometric or to endocrine indexes. For serum triglyceride concentrations, anthropometric indexes accounted for 6% of their variability and endocrine indexes–postprandial insulin, serum cortisol, testosterone and androstenedione together accounted for 32%.CONCLUSION: In mild to moderate female obesity of the peripheral type, dyslipidaemia is common. However the most common abnormality, hypercholesterolaemia is not significantly related to anthropometric or endocrine indexes, while these together account for more than one third of variability in serum triglyceride concentrations.

New-onset atrial fibrillation during acute coronary syndromes: Predictors and prognosis

INTRODUCTION New-onset atrial fibrillation (AF) frequently complicates myocardial infarction, with an incidence of 6-21%. OBJECTIVE To assess the predictors and prognosis of new-onset AF during acute coronary syndromes (ACS). METHODS We performed a retrospective observational cohort study including 902 consecutive patients (mean age 64 years, 77.5% male) admitted to a single center over a two-year period, with a six-month follow-up. RESULTS AF rhythm was identified in 13.8% patients, of whom 73.3% presented new-onset AF and 26.8% pre-existing AF. New-onset AF was more frequent in older (p<0.001) and hypertensive patients (p=0.001) and in those with previous valvular heart disease (p<0.001) and coronary artery bypass grafting (p=0.049). During hospitalization, patients with new-onset AF more often had respiratory infection (p=0.002) and heart failure (p<0.001), and higher values of NT-proBNP (p=0.007) and peak creatinine (p=0.001). On echocardiography they had greater left atrial (LA) diameter (p<0.001) and more frequent significant mitral regurgitation (p<0.001) and left ventricular ejection fraction (LVEF) ≤40% (p<0.001) and were less likely to have significant coronary lesions (p=0.009) or to have undergone coronary revascularization (p<0.001). In multivariate analysis, age (OR 1.06, p=0.021), LVEF ≤40% (OR 4.91, p=0.002) and LA diameter (OR 1.14, p=0.008) remained independent predictors of new-onset AF. Together with age, diabetes and maximum Killip class, this arrhythmia was an independent predictor of overall mortality (OR 3.11, p=0.032). CONCLUSIONS Age, LVEF ≤40% and LA diameter are independent predictors of new-onset AF during ACS. This arrhythmia is associated with higher overall mortality (in-hospital and in follow-up).

An unusual trigger causing Takotsubo Syndrome

Article history: Received 18 July 2016 Accepted 7 August 2016 Available online 09 August 2016 subendocardial late gadolinium enhancement in the mid and distal inferolateral segments, as well as an area of low signal intensity suggestive of microvascular obstruction. Data compatible with acute phase of coronary syndrome in obtuse marginal territory and Takotsubo Syndrome (Fig. 1 panels E–I, Video 3). Therewere no in hospital complications. Shewas discharged asymp-

Impact of atrial fibrillation type during acute coronary syndromes: Clinical features and prognosis

INTRODUCTION Atrial fibrillation (AF) is widely recognized as an adverse prognostic factor during acute myocardial infarction, although the impact of AF type - new-onset (nAF) or pre-existing (pAF) - is still controversial. OBJECTIVES To identify the clinical differences and prognosis of nAF and pAF during acute coronary syndromes (ACS). METHODS We performed a retrospective observational cohort study including 1373 consecutive patients (mean age 64 years, 77.3% male) admitted to a single center over a three-year period, with a six-month follow-up. RESULTS AF rhythm was identified in 14.5% patients, of whom 71.4% presented nAF and 28.6% pAF. When AF types were compared, patients with nAF more frequently presented with ST-elevation ACS (p=0.003). Patients with pAF, in turn, were older (p=0.032), had greater left atrial diameter (p=0.001) and were less likely to have significant coronary lesions (p=0.034). Regarding therapeutic strategy, nAF patients were more often treated by rhythm control during hospital stay (p<0.001) and were less often anticoagulated at discharge (p=0.001). Compared with the population without AF, nAF was a predictor of death during hospital stay in univariate (p<0.001) and multivariate analysis (OR 2.67, p=0.047), but pAF was not. During follow-up, pAF was associated with higher mortality (p=0.014), while nAF patients presented only a trend towards worse prognosis. CONCLUSIONS AF during the acute phase of ACS appears to have a negative prognostic impact only in patients with nAF and not in those with pAF.

Revascularização multivaso versus revascularização da artéria culprit em pacientes com síndrome coronária aguda sem supradesnivelamento do segmento ST e doença coronária multivaso

INTRODUCTION There have been no prospective randomized trials that enable the best strategy and timing to be determined for revascularization in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (CAD). OBJECTIVES To compare short- and long-term adverse events following multivessel vs. culprit-only revascularization in patients with NSTE-ACS and multivessel CAD. METHODS This was a retrospective observational study that included all patients diagnosed with NSTE-ACS and multivessel CAD who underwent percutaneous coronary intervention (PCI) between January 2010 and June 2013 (n=232). After exclusion of patients with previous coronary artery bypass grafting (n=30), a multivessel revascularization strategy was adopted in 35.1% of patients (n=71); in the others (n=131, 64.9%), only the culprit artery was revascularized. After propensity score matching (PSM), two groups of 66 patients were obtained, matched according to revascularization strategy. RESULTS During follow-up (1543±545 days), after PSM, patients undergoing multivessel revascularization had lower rates of reinfarction (4.5% vs. 16.7%; log-rank p=0.018), unplanned revascularization (6.1% vs. 16.7%; log-rank p=0.048), unplanned PCI (3.0% vs. 13.6%; log-rank p=0.023) and the combined endpoint of death, reinfarction and unplanned revascularization (16.7 vs. 31.8%; log-rank p=0.046). CONCLUSIONS In real-world patients presenting with NSTE-ACS and multivessel CAD, a multivessel revascularization strategy was associated with lower rates of reinfarction, unplanned revascularization and unplanned PCI, as well as a reduction in the combined endpoint of death, reinfarction and unplanned revascularization.

Modified shock index: A bedside clinical index for risk assessment of ST-segment elevation myocardial infarction at presentation

INTRODUCTION Prompt identification of higher-risk patients presenting with ST-segment elevation myocardial infarction (STEMI) is crucial to pursue a more aggressive approach. OBJECTIVE We aimed to assess whether the modified shock index (MSI), the ratio of heart rate to mean arterial pressure, could predict six-month mortality among patients admitted with STEMI. METHODS A retrospective observational cohort study was performed in a single center including 1158 patients diagnosed with STEMI, without cardiogenic shock on admission, between July 2009 and December 2014. They were divided into two groups: group 1 - patients with MSI<0.93 (72%); group 2 - patients with MSI≥0.93 (28%). The primary endpoint was six-month all-cause mortality. RESULTS MSI≥0.93 identified patients who were more likely to have signs of heart failure (p=0.002), anemia (p<0.001), renal insufficiency (p=0.014) and left ventricular systolic dysfunction (p=0.045). They more often required inotropic support (p<0.001), intra-aortic balloon pump (p<0.001) and mechanical ventilation (p<0.001). Regarding in-hospital adverse events, they had a higher prevalence of malignant arrhythmias (p=0.01) and mechanical complications (p=0.027). MSI≥0.93 was an independent predictor of overall six-month mortality (adjusted HR 2.00, 95% CI 1.20-3.34, p=0.008). CONCLUSION MSI was shown to be a valuable bedside tool which can rapidly identify high-risk STEMI patients at presentation.

0298: Prosthetic valve endocarditis. A 15-years cohort study

Introduction Prosthetic valve endocarditis (PVE) is an uncommon complication after valve replacement surgery, but potentially fatal. The scarcity of clinical trials makes harder the diagnostic and therapeutic approach of this entity. Aim To define the clinical characteristics and in-hospital evolution of a population with PVE. Methods Retrospective study based on a sample of 173 patients (P) with the diagnosis of infective endocarditis (IE), according to the modified Duke criteria, admitted from 1998 to 2013. We analyzed demographic and clinical features, complications and in-hospital mortality of P with PVE. Results We found 34 P (20%) with PVE, mean age 60.2±17.6 years with a female predominance (53%). The most common form was the community-acquired IE, registering 11 P (32%) with health care-associated IE. There was a preferential engagement of the mitral valve (56%) and 26% had early PVE. The cardinal complaints at presentation were constitutional symptoms (97%) and fever (74%); 50% of P showed signs of acute heart failure (HF). The most common analytical abnormalities were elevated inflammatory biomarkers (CRP 94% and leukocytosis 41%), anemia (88%) and increased creatinine (60%). The microbial agent was isolated in 24 P (71%), being Staphylococcus spp (26%) and Streptococcus spp (21%) the most common. The prosthesis dehiscence (60%), severe regurgitation (29%) and perivalvular abscess (21%) were the most frequent complications seen at initial echo-cardiographic evaluation. The most common adverse events were acute kidney injury (74%), persistence of HF (56%), septic shock (15%) and stroke (12%). There was need for urgent referral to surgery in 38% of P. The in-hospital mortality was higher than other P with IE (21% vs 13%). Conclusion The PVE is associated with a poor prognosis at short term. Its adverse developments should lead to the early identification of riskier P and timely consideration of the possible benefit of surgery.

0299: De novo atrial fibrillation in the acute coronary syndrome

Introduction De novo atrial fibrillation (AF) is common in the acute coronary syndrome (ACS), but most patients (P) are discharged in sinus rhythm (SR). The recurrence of arrhythmia in follow-up (FU) remains unknown and its undervaluation may have prognostic impact. Aim To characterize a population with ACS and de novo AF and determine its prognostic impact. To evaluate the recurrence of AF and the incidence of ischemic stroke/systemic embolism in FU. Methods We analyzed 2383 P consecutivelly admitted with ACS and with a minimum of 180 days FU. De novo AF has been defined as AF first detected on admission or during hospitalization. Results It has been observed de novo AF in 199 P (8.4%), the majority being male (70.4%). These patients were significantly older (p The echocardiographic evaluation showed a higher prevalence of mitral insufficiency (p The in-hospital mortality (9.5% vs 3.3%, p 95 patients with de novo AF were followed for a median period of 690 days and it was observed the occurrence of ischemic stroke/systemic embolism in 9 P (9.5%), but only one was under oral anticoagulation. AF occurred in 37.5% of P that were in SR on discharge. Conclusion The presence of de novo AF was associated with increased risk of adverse events, although it may constitute only a marker of severity. We observed recurrence of AF in a considerable sample, which denotes the need for appropriate evaluation of thromboembolic risk of these P.

Elective percutaneous coronary intervention complicated by coronary rupture

Coronary artery rupture is a rare but potentially fatal complication of percutaneous coronary intervention (PCI) that can result in life-threatening cardiac tamponade. A 69-year-old man was referred for PCI of a 90% calcified lesion in the mid left anterior descending artery (LAD) involving the second diagonal branch (D2; Figure 1, arrow). After the left coronary ostium was cannulated and crossed with two BMW wires, one to the LAD and other to the D2, predilation with a 2.5 mm×15 mm Trek balloon was performed and an unsuccessful attempt was made to cross the stenosis with a 2.75 mm×22 mm Resolute Integrity drug-eluting stent. Predilation was repeated with a 2.75 mm×15 mm Trek non-compliant balloon at high pressure. Suddenly, balloon rupture was detected and the angiogram showed LAD rupture with extensive contrast extravasation into the pericardium (Figure 2, arrows; Video 1). Protamine sulfate was used to reverse the effect of heparin and the drug-eluting stent was deployed with balloon inflation for 10 minutes to seal the type III perforation but, as dye extravasation persisted, a 3.0 mm×19 mm GraftMaster covered stent was superimposed, followed by rapid cessation of contrast leakage (Video 2). The D2 branch was lost (Figure 3, arrows), and periprocedural myocardial infarction occurred. The final image showed pericardial effusion (Figure 4; Video