Maria da Consolação Vieira Moreira

Genetic Characterization of Trypanosoma cruzi Directly from Tissues of Patients with Chronic Chagas Disease : Differential Distribution of Genetic Types into Diverse Organs

We have previously shown that a low-stringency single-specific primer-polymerase chain reaction (LSSP- PCR) is a highly sensitive and reproducible technique for the genetic profiling of Trypanosoma cruzi parasites directly in tissues from infected animals and humans. By applying LSSP-PCR to the study of the variable region of kinetoplast minicircle from T. cruzi, the intraspecific polymorphism of the kinetoplast-deoxyribonucleic acid (kDNA) sequence can be translated into individual kDNA signatures. In the present article, we report on our success using the LSSP-PCR technique in profiling the T. cruzi parasites present in the hearts of 13 patients with chagasic cardiopathy and in the esophagi of four patients (three of them with chagasic megaesophagus). In two patients, one with the cardiodigestive clinical form of Chagas disease and the other with cardiopathy and an esophageal inflammatory process, we could study both heart and esophagus and we detected distinct kDNA signatures in the two organs. This provides evidence of a differential tissue distribution of genetically diverse T. cruzi populations in chronic Chagas disease, suggesting that the genetic variability of the parasite is one of the determining factors of the clinical form of the disease.

I Latin American Guidelines for the assessment and management of decompensated heart failure

Edimar Alcides Bocchi, Fabio Vilas-Boas, Sergio Perrone, Angel G Caamano, Nadine Clausell, Maria da Consolacao VMoreira, Jorge Thierer, Hugo Omar Grancelli, Carlos Vicente Serrano Junior, Denilson Albuquerque, Dirceu Almeida,Fernando Bacal, Luis Felipe Moreira, Adonay Mendonza, Antonio Magana, Arturo Tejeda, Daniel Chafes, Efraim Gomez,Erick Bogantes, Estela Azeka, Evandro Tinoco Mesquita, Francisco Jose Farias B Reis, Hector Mora, Humberto Vilacorta,Jesus Sanches, Joao David de Souza Neto, Jose Luis Vuksovic, Juan Paes Moreno, Julio Aspe y Rosas, Lidia ZytynskiMoura, Luis Antonio de Almeida Campos, Luis Eduardo Rohde, Marcos Parioma Javier, Martin Garrido Garduno, MucioTavares, Pablo Castro Galvez, Raul Spinoza, Reynaldo Castro de Miranda, Ricardo Mourilhe Rocha, Roberto Paganini,Rodolfo Castano Guerra, Salvador Rassi, Sofia Lagudis, Solange Bordignon, Solon Navarette, Waldo Fernandes, AntonioCarlos Pereira Barretto, Victor Issa, Jorge Ilha Guimaraes.

I Latin American Guidelines for the diagnosis and treatment of Chagas' heart disease: executive summary.

Jadelson Pinheiro de Andrade, Jose Antonio Marin Neto, Angelo Amato Vincenzo de Paola, Fábio Vilas-Boas, Glaucia Maria Moraes Oliveira, Fernando Bacal, Edimar Alcides Bocchi, Dirceu Rodrigues Almeida, Abilio Augusto Fragata Filho, Maria da Consolação Vieira Moreira, Sergio Salles Xavier, Wilson Alves de Oliveira Junior, João Carlos Pinto Dias et al Sociedade Brasileira de Cardiologia, Rio de Janeiro, RJ Brasil

Brain natriuretic peptide predicts survival in Chagas' disease more effectively than atrial natriuretic peptide

Chagas’ disease, caused by the protozoan Trypanosoma cruzi , remains a leading cause of heart disease in Latin America. It is believed that approximately 20 million people are infected with this parasite. An acute phase follows the parasite infection and is characterised by an active infection, inflammation, and myocardial damage.1 Symptoms of chronic cardiomyopathy develop in 20–30% of previously asymptomatic individuals decades after initial infection. Severe congestive heart failure (CHF) is a common finding, and necropsies show notable dilation of all four cardiac chambers. Areas of extensive myocardial fibrosis and left ventricular apical aneurysms are common findings.1 Although atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are predictive of left ventricular hypertrophy and dysfunction, they respond differently, for example, to cardiac volume load in fetal circulation or diabetic cardiomyopathy.2 BNP has recently gained increased importance in the clinical diagnosis of cardiovascular diseases, and BNP guided treatment of CHF was found to reduce cardiovascular morbidity.3 The major studies and clinical trials on CHF have excluded Chagas patients. Thus the aim of our study was: firstly, to describe plasma ANP and BNP concentrations in Chagas patients compared to controls as a screening test for ventricular dysfunction; secondly, to investigate a possible correlation with the functional New York Heart Association (NYHA) class and left ventricular ejection fraction (LVEF) and the prognostic potency in Chagas’ disease; and thirdly, to compare peptide concentrations with those in patients with other dilated cardiomyopathies (DCM) in order to investigate this tool as a diagnostic marker for discriminating between the two types of heart failure. An institutional review committee approved the study, and all patients gave written consent. The study population was examined between July 2001 and February 2003. Ninety consecutively recruited patients with at least two positive serologies for Chagas’ …

Prognostic Value of Natriuretic Peptides in Chagas’ Disease: A 3-Year Follow-Up Investigation

Background: Chagas’ disease (CD) affects around 18 million people in Latin America. To determine the diagnostic and prognostic value of natriuretic peptides in patients with CD, we measured atrial (ANP) and brain natriuretic peptide (BNP), and compared the findings with other dilated cardiomyopathies (DCM). Methods: Blood samples were obtained from 111 CD patients, 62 patients with DCM due to other causes, and 43 gender- and age-matched healthy subjects. The CD and DCM patients were subdivided according to their NYHA classification. Natriuretic peptide concentrations were determined by immunoradiometric assays. Results: ANP and more pronounced BNP levels were increased in CD and DCM patients in relation to the NYHA class. Circulating BNP concentrations were higher in CD patients in NYHA classes I–II than in the corresponding DCM patients (p = 0.020). Importantly, ANP and BNP were already significantly elevated in CD patients without systolic ventricular dysfunction (p ≤ 0.001). In CD patients, both peptides were highly correlated with echocardiographic parameters (p < 10–14). Both ANP and BNP had comparable ability to predict death or the necessity for heart transplant (p < 0.0001). Conclusion: Natriuretic peptide levels can be used as a marker of asymptomatic CD without ventricular dysfunction and thus could be an ideal tool to identify these patients for early therapy.

Levosimendana em pacientes com insuficiência cardíaca descompensada: eficácia em uma coorte brasileira. Resultados do estudo BELIEF

BACKGROUND Levosimendan is a new inodilatory agent that enhances cardiac contractility via Ca(2+) sensitization and induces vasodilation through the activation of KATP/BKCa. OBJECTIVE To study the efficacy and safety of levosimendan in a decompensated heart failure (DHF) Brazilian cohort, and in b-adrenergic agonist resistant patients. METHODS The Brazilian Evaluation of Levosimendan Infusion Efficacy (BELIEF) study was prospective, multicenter, observational and included 182 high-risk DHF patients, all of which received open-label levosimendan. Primary end point was hospital discharge without additional inotropic therapy (responder). Secondary end points were changes in hemodynamics, clinical parameters, and brain natriuretic peptide (BNP). RESULTS Mortality rate was 14.8%, and 139 of 182 patients were responders. In non responders it was 62.8%. Systolic blood pressure was a predictor of response. In b-adrenergic agonist resistant group, 55.8% were responders. Overall, 54 patients experienced at least one adverse event; most of them resolved either spontaneously or after levosimendan dose reduction. A significant improvement in quality of life was verified at 2-6 months of follow-up (p<0.0001). CONCLUSION Our results suggest levosimendan infusion as an alternative therapy in the short term management of DHF patients. HF severity can influence the response to levosimendan treatment. Prospective studies are warranted in a Brazilian cohort including Chagas heart disease.

Epilepsy or Syncope? An Analysis of 55 Consecutive Patients with Loss of Consciousness, Convulsions, Falls, and No EEG Abnormalities

Background:  Patients with loss of consciousness and convulsion often have the diagnosis of epilepsy despite normal electroencephalograms (EEGs).

Identifying Potential Predictors of High-Quality Oral Anticoagulation Assessed by Time in Therapeutic International Normalized Ratio Range: A Prospective, Long-Term, Single-Center, Observational Study

BACKGROUND The efficacy and risks of oral anticoagulation are largely associated with maintaining the quality of anticoagulation control. Nevertheless, few studies have addressed which factors, if any, are associated with this control. OBJECTIVE This study aimed to identify predictors of high-quality oral anticoagulation. METHODS A prospective observational study enrolled all adult patients on intended long-term oral anticoagulation attending a public anticoagulation clinic. Patients with high-quality anticoagulation, defined as percentage of time in therapeutic international normalized ratio (INR) range (TTR) ≥66%, were compared with those with poor anticoagulation control (TTR <66%). Measures included cognitive, psychological, and relevant behavioral factors, in addition to traditionally implicated ones, such as age, comorbidity, and concurrent medications. RESULTS Participation was requested from all 233 patients followed up at the anticoagulation clinic. Eighty-six did not meet the inclusion criteria (49 due to intended anticoagulation duration <90 days, 37 due to the need for a caregiver responsible for medications). A total of 147 patients were enrolled, of whom 13 (8.8%) were lost to follow-up. Therefore, data were analyzed from 134 patients (mean [SD] age, 55 [14.2] years [range, 19-87 years]), who were followed up for a mean (SD) duration of 272 (87) days. The total mean TTR was 64.7%, which is comparable to values achieved in clinical trials. The good-control group had 61 patients (45.5%) (mean TTR, 77.7% [8.5%]) and the poor-control group had 73 patients (54.5%) (mean TTR, 50.4 [11.7%]). On multivariate logistic regression analysis, high-quality anticoagulation was independently associated with regular vitamin K intake, expressed by its variability in daily dosage (odds ratio [OR] = 0.79; 95% CI, 0.64-0.98); male sex (OR = 2.41; 95% CI, 1.06-5.49); duration of anticoagulation treatment >2 months (OR = 3.23; 95% CI, 1.25-8.36); presence of family support (OR = 3.32; 95% CI, 1.16-9.48); functional and cognitive ability to take medications as prescribed, defined as good medication management capacity (MMC; as assed using the Drug Regimen Unassisted Grading Scale) (OR = 4.18; 95% CI, 1.63-10.68); and no regular use of alcohol (OR = 8.59; 95% CI, 1.45-51.09). CONCLUSIONS The data suggest that independent predictors of high-quality oral anticoagulation included regular vitamin K intake, male sex, duration of anticoagulation treatment >2 months, presence of family support, good MMC, and no regular alcohol use. These findings may help clinicians to decide whether to start anticoagulation in intermediate-risk patients, to identify patients who will require closer attention on their anticoagulation management, and to direct their efforts to improve the quality of oral anticoagulation.

Efeito na Ressuscitação Cardiopulmonar utilizando treinamento teórico versus treinamento teórico-prático

Correspondencia: Heberth Cesar Miotto • Rua Paracatu, 1555/1202 Santo Agostinho 30180-091 Belo Horizonte, MG Brasil E-mail: hcmiotto@cardiol.br, hcmiotto@terra.com.br Articulo recibido el 25/08/09; revisado recibido el 23/10/09; aceptado el 15/12/09. Resumen Fundamento: El conocimiento teorico y la habilidad de realizar resucitacion cardiopulmonar (RCP) de calidad son esenciales para la sobrevida del paciente victima de muerte subita.

Thermoregulation in hypertensive men exercising in the heat with water ingestion

Hydration is recommended in order to decrease the overload on the cardiovascular system when healthy individuals exercise, mainly in the heat. To date, no criteria have been established for hydration for hypertensive (HY) individuals during exercise in a hot environment. Eight male HY volunteers without another medical problem and 8 normal (NO) subjects (46 +/- 3 and 48 +/- 1 years; 78.8 +/- 2.5 and 79.5 +/- 2.8 kg; 171 +/- 2 and 167 +/- 1 cm; body mass index=26.8 +/- 0.7 and 28.5 +/- 0.6 kg/m2; resting systolic (SBP)=142.5 and 112.5 mmHg and diastolic blood pressure (DBP)=97.5 and 78.1 mmHg, respectively) exercised for 60 min on a cycle ergometer (40% of VO2peak) with (500 ml 2 h before and 115 ml every 15 min throughout exercise) or without water ingestion, in a hot humid environment (30 masculine C and 85% humidity). Rectal (Tre) and skin (Tsk) temperatures, heart rate (HR), SBP, DBP, double product (DP), urinary volume (Vu), urine specific gravity (Gu), plasma osmolality (Posm), sweat rate (S R), and hydration level were measured. Data were analyzed using ANOVA in a split plot design, followed by the Newman-Keuls test. There were no differences in Vu, Posm, Gu and S R responses between HY and NO during heat exercise with or without water ingestion but there was a gradual increase in HR (59 and 51%), SBP (18 and 28%), DP (80 and 95%), Tre (1.4 and 1.3%), and Tsk (6 and 3%) in HY and NO, respectively. HY had higher HR (10%), SBP (21%), DBP (20%), DP (34%), and Tsk (1%) than NO during both experimental situations. The exercise-related differences in SBP, DP and Tsk between HY and NO were increased by water ingestion (P<0.05). The results showed that cardiac work and Tsk during exercise were higher in HY than in NO and the difference between the two groups increased even further with water ingestion. It was concluded that hydration protocol recommended for NO during exercise could induce an abnormal cardiac and thermoregulatory responses for HY individuals without drug therapy.