Mario Luiz Ribeiro

Insuficiência cardíaca com fração de ejeção preservada e com disfunção sistólica na comunidade

BACKGROUND In developed countries, heart failure with preserved ejection fraction (HFpEF) is more prevalent than heart failure with reduced ejection fraction (HFrEF) in the community. However, it has not been completely established if this fact is also observed within our community. OBJECTIVE To determine the most prevalent form of heart failure (HFpEF or HFrEF) and whether the prevalence of HFpEF is higher in the community. METHODS This is a cross-sectional study conducted with patients clinically diagnosed with HF who were seen in community-based health care centers from January to December 2005. Echodopplercardiograms were performed for all patients. The form of HF was stratified according to the presence of abnormalities and the shortening fraction observed on the echodopplercardiogram. RESULTS The study evaluated 170 patients (61.0 +/- 13.3 years of age), most of them women and elderly. HFpEF was the more prevalent form of HF (64.2%, p<0.001), affecting mostly elderly women (62%, p = 0.07), whereas the opposite condition, HFrEF, was observed mostly in elderly men (63.6%, p = 0.07). Patients with no HF represented one-third of the cases (27.6%). HFrEF patients had more lower-limb edema, coronary disease, diabetes, chronic renal failure, higher Boston scores and hospital readmissions. Use of alcoholic beverages and smoking were also more common among HFrEF patients. CONCLUSION HFpEF is the most prevalent form of HF in the community especially among elderly women, whereas HFrEF affects mostly elderly men and is associated with greater clinical severity, main risk factors and no changes in lifestyle. Despite the signs and symptoms of HF, this condition was not confirmed for one-third of the cases.

Hypertension in Patients with Cancer

There is a known association between chemotherapy and radiotherapy for treatment of cancer patients and development or worsening of hypertension. The aim of this article is to review this association. A literature search was conducted for articles reporting this association on the databases PubMed, SciELO and LILACS between 1993 and 2013. There was a high coprevalence of hypertension and cancer, since both diseases share the same risk factors, such as sedentary lifestyle, obesity, smoking, unhealthy diet and alcohol abuse. The use of chemotherapy and adjuvant drugs effective in the treatment of cancer increased the survival rate of these patients and, consequently, increased the incidence of hypertension. We described the association between the use of angiogenesis inhibitors (bevacizumab, sorafenib and sunitinib), corticosteroids, erythropoietin and non-steroidal anti-inflammatory drugs with the development of hypertension. We also described the relationship between hypertension and carotid baroreceptor injury secondary to cervical radiotherapy. Morbidity and mortality increased in patients with cancer and hypertension without proper antihypertensive treatment. We concluded that there is need for early diagnosis, effective monitoring and treatment strategies for hypertension in cancer patients in order to reduce cardiovascular morbidity and mortality.

Doppler echocardiographic evaluation of HIV-positive patients in different stages of the disease

OBJECTIVE To evaluate by Doppler echocardiography (DE) early abnormalities of ventricular function in HIV-positive patients, as well as other cardiac abnormalities that can be detected by this method, with special emphasis on mitral valve flow. METHODS 84 HIV-positive patients, 59 with CD4 cell count > 500/mm3 (Group A) and 25 with CD4 cell count < 500/mm3 (Group B), were analyzed. CD4 cells were counted and matched with structural data and systolic and diastolic function of the left ventricle (LV), as analyzed by DE. The results were compared with those obtained in 47 healthy individuals (Group C). RESULTS 8% of patients in Group B had mild pericardial effusion; 31.5% showed decreased systolic function of the LV, and 12% had moderate mitral regurgitation. A wave velocity from the mitral inflow was different among the 3 groups, being higher in Group B, where the deceleration time of the E wave of the mitral inflow and the E/A ratio were significantly lower with a normal value of the isovolumic relaxation time (IVRT). CONCLUSION HIV-positive patients with a CD4 cell count > 500/mm3 had no abnormalities by DE. Patients with a more advanced infection (those with a CD4 cell count < 500/mm3), had a significantly abnormal LV systolic function and a higher incidence of pericardial effusion and mitral regurgitation. Mitral valve inflow by Doppler did not indicate diastolic dysfunction.

Estudo da reatividade vascular em portadores de HIV com e sem uso de inibidor de protease

BACKGROUND A great number of HIV-infected patients using antiretroviral drugs develop endothelial dysfunction and atherothrombosis, which lead to a high medical and social burden. Thus, it is important to identify pathophysiological mechanisms involved with the endothelial function in these patients, so that early intervention can be made to avoid disease progression. OBJECTIVE To evaluate endothelial function using endothelium-dependent and independent vasodilation in HIV-positive patients and in a control group. METHODS A total of 27 HIV-positive patients and 16 controls were evaluated. Endothelium-dependent (reactive hyperemia) and independent (SL nitroglycerine) vasodilation of the brachial artery was used to evaluate the endothelial function. RESULTS HIV-positive patients receiving protease inhibitors (PI) showed significantly lower endothelium-independent vasodilation than the HIV-negative (p=0.020) and HIV-positive without PI (p=0.034) subgroups. The change in brachial artery diameter during active hyperemia was not statistically significant in any subgroup. Multiple linear regression analysis showed that only PI was associated with the relative delta of brachial reactivity to vasodilator in HIV-positive patients at 60s and 90s. CONCLUSION HIV-positive patients receiving PI presented endothelium-independent dysfunction when compared to HIV-positive patients not receiving PI and to the control group.FUNDAMENTO: Considerando o alto numero de pacientes infectados por HIV em uso de antirretrovirais, evoluindo com alteracao da funcao endotelial e aterotrombose, levando ao alto custo medico social, e importante identificar mecanismos fisiopatologicos envolvidos com a funcao endotelial em portadores de HIV, para que, precocemente, possamos intervir e evitar a progressao da doenca. OBJETIVO: Avaliar a funcao endotelial pela vasodilatacao endotelio dependente e independente em pacientes HIV positivo e em grupo controle. METODOS: O estudo avaliou 27 pacientes HIV positivo e 16 do grupo controle. A avaliacao da funcao endotelial foi realizada por meio da vasodilatacao da arteria braquial endotelio dependente (hiperemia reativa) e independente (nitroglicerina SL). RESULTADOS: Pacientes HIV positivo em uso de inibidor de protease (IP) apresentaram vasodilatacao endotelio independente significativamente menor que os subgrupos HIV negativo (p = 0,020) e HIV positivo sem uso de IP (p = 0,034). A variacao do diâmetro da arteria braquial durante hiperemia reativa nao apresentou significância estatistica em qualquer subgrupo. A analise de regressao linear multipla mostrou que apenas o IP estava associado ao delta relativo da reatividade braquial pelo vasodilatador, nos pacientes HIV positivo, aos 60 e 90 segundos. CONCLUSAO: Os pacientes HIV positivo em uso de IP apresentam disfuncao endotelio independente quando comparados a pacientes HIV positivo que nao fazem uso de IP e a um grupo controle.

Study of vascular reactivity in HIV patients whether or not receiving protease inhibitor

BACKGROUND A great number of HIV-infected patients using antiretroviral drugs develop endothelial dysfunction and atherothrombosis, which lead to a high medical and social burden. Thus, it is important to identify pathophysiological mechanisms involved with the endothelial function in these patients, so that early intervention can be made to avoid disease progression. OBJECTIVE To evaluate endothelial function using endothelium-dependent and independent vasodilation in HIV-positive patients and in a control group. METHODS A total of 27 HIV-positive patients and 16 controls were evaluated. Endothelium-dependent (reactive hyperemia) and independent (SL nitroglycerine) vasodilation of the brachial artery was used to evaluate the endothelial function. RESULTS HIV-positive patients receiving protease inhibitors (PI) showed significantly lower endothelium-independent vasodilation than the HIV-negative (p=0.020) and HIV-positive without PI (p=0.034) subgroups. The change in brachial artery diameter during active hyperemia was not statistically significant in any subgroup. Multiple linear regression analysis showed that only PI was associated with the relative delta of brachial reactivity to vasodilator in HIV-positive patients at 60s and 90s. CONCLUSION HIV-positive patients receiving PI presented endothelium-independent dysfunction when compared to HIV-positive patients not receiving PI and to the control group.FUNDAMENTO: Considerando o alto numero de pacientes infectados por HIV em uso de antirretrovirais, evoluindo com alteracao da funcao endotelial e aterotrombose, levando ao alto custo medico social, e importante identificar mecanismos fisiopatologicos envolvidos com a funcao endotelial em portadores de HIV, para que, precocemente, possamos intervir e evitar a progressao da doenca. OBJETIVO: Avaliar a funcao endotelial pela vasodilatacao endotelio dependente e independente em pacientes HIV positivo e em grupo controle. METODOS: O estudo avaliou 27 pacientes HIV positivo e 16 do grupo controle. A avaliacao da funcao endotelial foi realizada por meio da vasodilatacao da arteria braquial endotelio dependente (hiperemia reativa) e independente (nitroglicerina SL). RESULTADOS: Pacientes HIV positivo em uso de inibidor de protease (IP) apresentaram vasodilatacao endotelio independente significativamente menor que os subgrupos HIV negativo (p = 0,020) e HIV positivo sem uso de IP (p = 0,034). A variacao do diâmetro da arteria braquial durante hiperemia reativa nao apresentou significância estatistica em qualquer subgrupo. A analise de regressao linear multipla mostrou que apenas o IP estava associado ao delta relativo da reatividade braquial pelo vasodilatador, nos pacientes HIV positivo, aos 60 e 90 segundos. CONCLUSAO: Os pacientes HIV positivo em uso de IP apresentam disfuncao endotelio independente quando comparados a pacientes HIV positivo que nao fazem uso de IP e a um grupo controle.

Cirrhotic Cardiomyopathy: Another Case of a Successful Approach to Treatment of Hepatorenal Syndrome

Hepatorenal syndrome (HRS) is defined as a failure of renal function, potentially reversible, in patients with liver cirrhosis and ascites. Recently, a component of cardiomyopathy associated with HRS was described, but the use of positive inotropic medicine as part of the treatment of the acute phase has not been extensively evaluated. We report a second case in our hospital of a patient with HRS type I without previous heart disease, with secondary hemodynamic decompensation due to liver disease, in which the abnormalities in systolic function by speckle-tracking echocardiography were observed and could be reversed by the use of inotropes. After partial response to current therapies, the patient presented a clinical and laboratorial response with improvement of renal function after infusion of dobutamine. Clinical studies are needed for the therapy approach to HRS taking into account myocardial dysfunction as a major contributing factor for renal dysfunction.

Cardiovascular effects of radiotherapy on the patient with cancer

The incidence of cancer (CA) has increased globally and radiotherapy (RT) is a vital component in its treatment. Cardiovascular injuries induced by RT in the treatment of thoracic and cervical CA have been causing problems in clinical practice for decades, and are among the most serious adverse effects of radiation experienced by the growing number of cancer survivors. This article presentes a review on the Lilacs, Scielo and Pubmed databases of the main cardiovascular injuries, their mechanisms, clinical presentations, treatments and prevention proposals. Injuries caused by RT include diseases of the pericardium, coronary artery disease, valvular disease, myocardial disease with systolic and diastolic dysfunction, conduction disorders, and carotid artery and great vessels disease. Thoracic and cervical irradiation increases cardiovascular morbidity and mortality. Despite the great progress in the improvement of RT techniques, totally excluding prime areas of the cardiovascular system from the irradiation field is not yet possible. Guidelines must be created for monitoring, diagnosis and treatment of patients with CA treated with RT.

Speckle Tracking and Transthyretin Amyloid Cardiomyopathy

Background Amyloidosis is a disease caused by deposits of insoluble fibrils in extracellular spaces. The most common type of familial amyloidosis is mediated by mutation of transthyretin, especially Val30Met. Symptoms and ejection fraction decrease may occur in cardiac amyloidosis only in case of poor prognosis. Myocardial strain detected by two-dimensional speckle tracking echocardiography can indicate changes in myocardial function at early stages of the disease. Objective To determine the accuracy of left ventricular longitudinal strain by two-dimensional speckle tracking echocardiography in patients with familial amyloidosis caused by Val30Met transthyretin mutation. Methods Eighteen consecutive patients, carriers of transthyretin mutation, were evaluated by two-dimensional speckle tracking echocardiography, by which myocardial strain curves were obtained, following the American Society of Echocardiography recommendations. Results Patients were divided into three groups: 1- Val30Met with cardiac amyloidosis; 2-Val30Met with extracardiac amyloidosis; 3 - Val30Met without evidence of disease. As the three groups were compared by the Mann-Whitney test, we found a statistically significant difference between groups 1 and 2 in the mean longitudinal tension (p=0.01), mean basal longitudinal strain (p=0.014); in mean longitudinal tension and mean longitudinal strain between groups 1 and 3 (p=0.005); and in the ratio of longitudinal strain of apical septum segment to longitudinal strain of basal septum (p=0.041) between groups 2 and 3. Conclusion Left ventricular longitudinal strain detected by two-dimensional speckle tracking echocardiography is able to diagnose left ventricular dysfunction in early stages of familial amyloidosis caused by transthyretin Val30Met mutation.

A Rare Case of Ascites due to Peritoneal Amyloidosis

Patient: Male, 65 Final Diagnosis: Peritoneal amyloidosis Symptoms: Anasarca • Dyspnea • Orthopnea Medication: — Clinical Procedure: Paracentesis and peritoneal biopsy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: The clinical manifestations of amyloidosis depend on the type of insoluble protein as well as the location of amyloid deposits in tissues or organs. In the gastrointestinal tract, the small intestine is the most common site of amyloid deposits, whereas peritoneal involvement and ascites are rare. Case Report: We report on a case of ascites due to peritoneal amyloidosis. A 65-year-old patient was admitted to our institution due to anasarca and pulmonary congestion, mimicking heart failure. We started the patient on diuretics and vasodilators. Despite improvement in pulmonary congestion and peripheral edema, his ascites was not reduced. Echocardiogram revealed restrictive cardiomyopathy and a speckle-tracking pattern suggestive of cardiac amyloidosis. Subcutaneous and peritoneal biopsies revealed amyloidosis. Conclusions: Amyloidosis is rare in the peritoneum and is usually asymptomatic. Ascites occurs in only 20% of patients with peritoneal amyloidosis. We searched PubMed using “ascites” and “amyloidosis” and identified only eight case reports of amyloidosis with ascites. Physicians should be particularly careful in heart failure and anasarca cases when ascites is disproportional or not responsive to diuretic treatment. To date, there is no specific treatment for peritoneal amyloidosis.

Estudio estructural y funcional carotídeo en familiares de pacientes con diabetes mellitus tipo 2

FUNDAMENTO: O diabete melito tipo 2 (DM2) e a principal causa de morbidade e mortalidade nos paises ocidentais, principalmente de origem cardiovascular. Com base na historia familiar de diabete, mesmo em individuos nao-diabeticos, como aumento de risco de doenca cardiaca coronariana, faz-se necessaria a utilizacao de reconhecidos marcadores substitutos de aterosclerose precoce, como as medidas ecograficas carotideas. OBJETIVO:Comparar tanto caracteristicas estruturais (espessura medio-intimal - EMI) quanto funcionais (medidas de distensibilidade) de arterias carotideas dos individuos com historia familiar (HF+) e dos nao-parentes de portadores de DM2 (HF-), todos sem fatores de risco cardiovasculares reconhecidos. METODOS:Trinta e dois individuos (19 HF+ e 13 HF-), com idade entre 21 e 47 anos, de ambos os sexos, foram submetidos a estudo ultra-sonografico de alta resolucao das carotidas (comuns e internas) bilateralmente. Os grupos apresentavam comparacao (p > 0,05) no que tangia a idade, indice de massa corporal (IMC), pressao arterial, glicose e insulina de jejum, leptina e proteina C reativa (PCR). RESULTADOS:A espessura medio-intimal das arterias carotidas comuns esquerdas (ACCE) foi estatisticamente mais elevada (p = 0,029) nos HF+ (0,568 ± 0,107 mm) que nos HF- (0,477± 0,116 mm). A analise de regressao multipla identificou como prognosticadores independentes da EMI de ACCE a idade, o IMC acima da normalidade, a PCR e o LDL-colesterol. CONCLUSAO:Individuos com historia familiar de DM2, mesmo sem desordens metabolicas laboratoriais detectadas, apresentaram maior espessamento medio-intimal em territorio carotideo comum esquerdo que aqueles sem tal parentesco, no entanto nao houve alteracao funcional do vaso.BACKGROUND In Western countries type 2 diabetes mellitus (DM2) is the leading cause of morbidity and mortality, particularly from cardiovascular causes. Since a family history of diabetes, even in non-diabetic subjects, is regarded as an increased risk of coronary heart disease, the use of approved surrogate markers of early atherosclerosis, specially of ultrasonic measurements of the carotid arteries, is of vital importance. OBJECTIVE To analyze the structural properties (intima-media thickness) and functional properties (distensibility measurement) of the carotid arteries in subjects with (FH+) a family history of type 2 diabetes, in comparison to subjects without (FH-) a family history of type 2 diabetes, both groups with no known cardiovascular risk factors. METHODS 32 individuals (male and female, age range, 21-47 years; 19 FH+, 13 FH-) had their right and left common and internal carotid arteries measured, using high-resolution B-mode ultrasonography. Both groups had similar (p>0.05) age, BMI, blood pressure, and fasting blood glucose and insulin, leptin, and C-reactive protein (CRP) levels. RESULTS The intima-media thickness (IMT) of the left common carotid artery (LCCA) in the FH+ group (0.568+/-0.107mm) was statistically greater (p=0.029) than in the FH- group (0.477+/-0.116mm). Multiple regression analysis identified age, overweight and obesity (determined by BMI), CRP, and LDL-cholesterol levels as independent predictors of the IMT in the LCCA. CONCLUSION FH+ individuals with no metabolic disorders presented greater IMT of the left common carotid artery (structural alteration) than FH- individuals, but normal vessel function.