Miguel Mota Carmo

Effects of CPAP on nitrate and norepinephrine levels in severe and mild-moderate sleep apnea

BackgroundReduced plasma nitrate (NOx) levels and increased urinary norepinephrine (U-NE) levels have been described in severe obstructive sleep apnea (OSA), and are reverted by continuous positive airway pressure (CPAP). The effect of CPAP on these biomarkers in mild-moderate OSA is not well understood.The aim of this study was to compare NOx and U-NE levels and blood pressure (BP) between male patients with mild-moderate and severe OSA and determine the impact of 1 month of CPAP therapy on these parameters.MethodsWe undertook a prospective study of 67 consecutive OSA patients (36 mild-moderate, 31 severe). Measurements of plasma NOx at 11 pm, 4 am and 7 am, 24-h U-NE and ambulatory BP were obtained at baseline and after 1 month of CPAP.ResultsAt baseline, NOx levels showed a significant decrease during the night in both groups (p < 0.001). U-NE level and BP were significantly higher in the severe OSA group. After 1 month of CPAP, there was a significant increase in NOx levels and a reduction in U-NE level and BP only in patients with severe OSA.ConclusionsOne month of CPAP results in significant improvements in NOx levels, 24-h U-NE level and BP in patients with severe OSA, but not in patients with mild-moderate OSA.Trial registrationClinicalTrials.gov: http://NCT01769807

Nonobstructive coronary disease leading to Stemi: assessment of residual stenosis after thrombus aspiration

AimsNonobstructive coronary atherosclerotic lesions can lead to ST-elevation myocardial infarction (STEMI). Thrombus aspiration during a primary percutaneous coronary intervention provides a setting to evaluate the degree of stenosis of culprit lesions leading to STEMI. The aim of this study was to assess the degree of culprit lesion residual stenosis after thrombus aspiration and to compare the demographic, clinical, and angiographic characteristics between patients with obstructive versus nonobstructive residual stenosis. Methods and resultsFrom a single-center registry of 483 consecutive patients with STEMI undergoing a primary percutaneous coronary intervention, 172 patients underwent thrombus aspiration and were eligible for our study. We defined two groups according to the residual stenosis after thrombus aspiration: group A (n=119, 69%) with residual stenosis greater than or equal to 50%, and group B (n=53, 31%) with residual stenosis less than 50%.In terms of the baseline angiographic characteristics, patients with residual stenosis less than 50% had significantly lower prevalence of multivessel disease (15.1 vs. 46.2%, P<0.001). On multivariable analysis of the preprocedural variables, absence of vascular disease (odds ratio 4.99, 95% confidence interval 1.08–23.12, P=0.040) and age less than 59 years (odds ratio 2.67, 95% confidence interval 1.25–5.73, P=0.011) were independent predictors of culprit residual stenosis less than 50%. ConclusionIn this population, a significant proportion of patients with STEMI had nonobstructive residual stenosis after thrombus aspiration. These patients were younger, had a lower prevalence of vascular disease in other vascular territories, and less multivessel disease, suggesting an earlier stage of atherosclerosis.

Carotid Intima-Media Thickness and Carotid Plaques Improves Prediction of Obstructive Angiographic Coronary Artery Disease in Women

Does carotid intima–media thickness (cIMT), a surrogate marker of cardiovascular events, have predictive incremental value over established risk factors for stable coronary artery disease (CAD)? Prospective study of 300 patients, with suspected stable CAD, admitted for an elective coronary angiography and carotid ultrasound. The CAD patients had a higher cIMT, which showed a modest predictive accuracy for CAD (area under the receiver–operating characteristic curve 0.638, 95% confidence interval 0.576-0.701, P < .001). The cIMT was an independent predictor of CAD, together with age, gender, and diabetes. C-statistic for CAD prediction by traditional risk factors was not significantly different from a model that included cIMT, carotid plaque presence, or both. However, in women, it was significantly increased by the addition of cIMT or carotid plaque presence. Although cIMT cannot be used as a sole indicator of CAD, it should be considered in the panel of investigations that is requested, particularly in women who are candidates for coronary angiography.

Body mass index as a predictor of the presence but not the severity of coronary artery disease evaluated by cardiac computed tomography

Background The relation between body mass index (BMI) and coronary artery disease (CAD) extension remains controversial. The aim of this study was to evaluate the correlation between BMI and CAD extension documented by coronary computed tomography angiography (CCTA). Methods and results Prospective registry including 1706 consecutive stable patients that performed CCTA (dual source scanner) for the evaluation of CAD. The population was stratified by BMI: normal 530 (31.1%), overweight 802 (47.0%) and obesity 374 (21.9%). BMI was significantly higher in patients with CAD (27.7 ± 4.3 vs 26.8 ± 4.3 kg/m2, p < 0.001); these patients were also older, more often male and had higher prevalence of diabetes, hypertension and dyslipidemia. By multivariate analysis (logistic regression) BMI remains an independent predictor of CAD (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01–1.06; p = 0.012). Regarding the severity of CAD, BMI was not significantly different among patients with and without obstructive CAD (27.7 ± 4.3 vs 27.2 ± 4.3 kg/m2, p = 0.120). In 319 patients (4516 segments; 4077 evaluable), a detailed atherosclerotic burden was evaluated and compared among BMI classes, defined according to the presence of plaque and the degree of stenosis. Obstructive CAD was identified in 16.9% of the patients and 45.1% had non-obstructive CAD. The discriminative threshold for high burden, established by the segment involvement score (SIS), was >5 segments with plaque (15.4% patients). The prevalence of SIS >5 among the BMI classes was: 18.7%, 13.7% and 13.6% for normal, overweight and obesity respectively (p values for the specific classes versus all other patients: 0.241, 0.450 and 0.663). Conclusions In this population of stable patients undergoing CCTA for suspected CAD, BMI was an independent predictor of its presence, but was not correlated with the coronary disease severity.

Changes of soluble CD40 ligand in the progression of acute myocardial infarction associate to endothelial nitric oxide synthase polymorphisms and vascular endothelial growth factor but not to platelet CD62P expression

Reported in vitro data implicated soluble CD40 ligand (sCD40L) in endothelial dysfunction and angiogenesis. However, whether sCD40L could exert that influence in endothelial dysfunction and angiogenesis after injury in acute myocardial infarction (AMI) patients remains unclear. In the present study, we evaluated the association of sCD40L with markers of platelet activation, endothelial, and vascular function during a recovery period early after AMI. To achieve this goal, the time changes of soluble, platelet-bound, and microparticle-bound CD40L levels over 1 month were assessed in AMI patients and correlated with endothelial nitric oxide synthase (eNOS) polymorphisms, vascular endothelial growth factor (VEGF) concentrations, and platelet expression of P-selectin (CD62P). The association of soluble form, platelet-bound, and microparticle-bound CD40L with CD62P expression on platelets, a marker of platelet activation, was also assessed to evaluate the role of CD40L in the thrombosis, whereas the association with eNOS and VEGF was to evaluate the role of CD40L in vascular dysfunction. This work shows for the first time that time changes of sCD40L over 1 month after myocardial infarct onset were associated with G894T eNOS polymorphism and with the VEGF concentrations, but not to the platelet CD62P expression. These results indicate that, in terms of AMI pathophysiology, the sCD40L cannot be consider just as being involved in thrombosis and inflammation but also as having a relevant role in vascular and endothelial dysfunction.

Can Metabolic Syndrome Presence Predict Carotid Intima-Media Thickness?

The aim of this investigation was to analyze metabolic syndrome (MS) impact on carotid intima‐media thickness (cIMT). Prospective study of 300 patients with suspected coronary artery disease admitted for an elective coronary angiography were evaluated. Patients with previously known cardiac disease were excluded. In the population, 23.0% were diabetics and 40.5% had MS (but no diabetes). cIMT was not significantly different in patients with MS, but was significantly higher in diabetic patients compared with MS and control patients. Independent predictors of cIMT were age, male gender, insulin, and high‐density lipoprotein (HDL) cholesterol (the last one with an inverse association). In patients without MS, only age and HDL cholesterol were associated. In patients with MS, independent predictors were age, male gender, and glucose, and abdominal obesity showed an inverse relationship. In patients with stable angina, MS is not an independent predictor of cIMT. Nonmodifiable variables (age and gender) are the most important determinants of cIMT, as well as blood glucose, in MS patients. Abdominal obesity was protective. J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.

The Role of Inflammatory Biomarkers in the Assessment of Coronary Artery Disease

Coronary artery disease (CAD) is the world’s leading cause of illness and death. In 2005, approximately 7.6 million deaths were attributed to coronary artery disease, accounting for almost 13% of the total deaths (WHO, 2011). From a pathophysiological point of view the disease could be considered as a severe clinical manifestation of atherosclerosis (Mallat & Tedgui, 2001). The disruption of an atherosclerotic plaque with superimposed thrombosis had been identified as the main cause of acute coronary syndromes, including acute myocardial infarction (AMI), and sudden death (Gensini & Dilaghi, 2002; Shah, 2003). The initially silent progression of arterial plaque, prompted by classic risk factors (including hypertension, diabetes mellitus, dyslipidaemia, age, stress, physical inactivity, dietary habits and cigarette smoking), is followed by a phase of acute or chronic progression toward an increasing degree of stenosis that eventually causes thrombosis (Gensini & Dilaghi, 2002; Fuster et al., 2005). Plaque disruption and/or endothelial activation represent the main trigger event for AMI, through exposure of plaque thrombogenic components to platelets and to clotting components of flowing blood. In this phase, haemostasis related risk factors and platelet status play a crucial role. However, current research supports the view of atherosclerosis as an inflammatory process that initiates and promotes lesion development to the point of acute thrombotic complications and clinical events. Thus, the time has come to embrace inflammation as a common pathway for atherogenic risk factors and for providing new opportunities for therapeutic intervention (Libby, 2003). Acute myocardial infarction is a critical clinical presentation of coronary artery disease in many asymptomatic patients and often the event is fatal. Establishing the presence of coronary lesions either in asymptomatic patients or in symptomatic patients with acute or chronic chest pain can be a challenging task. Consequently, major clinical research efforts

Avaliação da função dos músculos respiratórios em doentes com falência ventricular esquerda

The decrease in strength of respiratory muscles, determined by measuring the maximal respiratory pressures in the mouth, has been evoked as a mechanism of dyspnoea in patients with left ventricular failure (LVF). Knowing the limitations of this technique in the evaluation of the “real” strength, we propose to apply in this group of patients the different techniques available to study the maximal respiratory pressures. We studied 20 male patients, with LVF (GI), classes II and III of New York Heart Association (NYHA), and we compared them with 19 male aged-matched controls without cardiopulmonary disease (GII). We assessed the maximal respiratory pressures at the mouth level, expiratory (PME) and inspiratory (PMI), the nasal Sniff (SNIF-N) and the esophageal Sniff (SNIF-E). We have obtained the following results: PME: GI – 138.7 ± 42.1 cmH2O; GII – 152.5 ± 40.8.8 cmH2O; p:NS; PMI: GI – 74.1 ± 22.2 cmH2O; GII – 85.8 ± 16.6 cmH2O; p < 0.03; SNIF-N: GI – 95.6 ± 22.2 cmH2O; GII – 96.6 ± 16.6 cmH2O; p:NS; SNIF-E: GI – 96.2 ± 20.6 cmH2O; GII – 97.5 ± 18.5 cmH2O; p:NS. When comparing PMI with SNIF-N we found a statistical significant difference between the groups: GI – p < 0.0002 e GII – p < 0.009. There was no statistical difference between SNIF-N and SNIF-E. In conclusion, PMI underestimates the strength of inspiratory muscles. LVF patients in NYHA classes II and III did not present a decrease in the global strength of respiratory muscles, once there were no significant differences in PME and SNIF values, between patients and control group. Finally we did not detect differences between SNIFF-N and SNIFF-E pressures so we think that the assessment of SNIFF-N pressure can be used as a non-invasive method to evaluate the strength of inspiratory muscles. REV PORT PNEUMOL 2001; VII (6):

Importância da deformação longitudinal na deteção da cardiotoxicidade induzida por quimioterapia e na identificação de padrões específicos de afetação segmentar

INTRODUCTION Serial echocardiographic assessment of left ventricular ejection fraction (LVEF) is the gold standard in screening for chemotherapy-induced cardiotoxicity (CIC). Measurement of myocardial deformation using speckle tracking enables more detailed assessment of myocardial contractility. The aim of this study was to determine the relationship between global and regional longitudinal strain and CIC. METHODS This was a prospective study of 158 breast cancer patients undergoing chemotherapy with anthracyclines with or without adjuvant trastuzumab who underwent serial monitoring by transthoracic echocardiography with assessment of myocardial deformation. CIC was defined as a decrease in LVEF to <53%. Global longitudinal strain (GLS) was estimated using EchoPAC BT12 software on a GE Vivid E9 cardiac ultrasound system. Patients were classified according to the 2015 ASE/EACVI criteria as having impaired myocardial deformation when GLS was reduced (less negative), with a cutoff of -18%. RESULTS During a mean follow-up of 5.4 months (1-48 months), the incidence of CIC was 18.9%. A decrease in GLS was observed during follow-up for the entire cohort (baseline GLS -20.1±3.5% vs. -18.7±3.4% at last follow-up assessment, p=0.001). A total of 97 patients (61.4%) were observed to have impaired myocardial deformation (GLS ≥18%) at some point during follow-up. This decrease was more significant in patients who eventually developed CIC (GLS -17.2±2.5%, p=0.02). On analysis of regional strain, impaired contractility was observed in the septal (6 out of 6) and anterior (2 out of 3) segments. Multivariate logistic regression showed that patients who developed impaired longitudinal strain had a 4.9-fold increased risk of developing CIC (odds ratio 4.88, confidence interval 1.32-18.0, p=0.017). CONCLUSIONS Worsening of myocardial deformation as assessed by speckle tracking is common in breast cancer patients undergoing chemotherapy, with predominantly septal and anterior wall involvement. Impaired myocardial deformation was independently associated with increased incidence of CIC.

Predictors of response to cardiac resynchronization therapy: A prospective cohort study

INTRODUCTION Cardiac resynchronization therapy (CRT) has modified the prognosis of chronic heart failure (HF) with left ventricular systolic dysfunction. However, 30% of patients do not have a favorable response. The big question is how to determine predictors of response. AIMS To identify baseline characteristics that might influence echocardiographic response to CRT. METHODS AND RESULTS We performed a prospective single-center hospital-based cohort study of consecutive HF patients selected to CRT (NYHA class II-IV, left ventricular ejection fraction (LVEF) <35% and QRS complex ≥120 ms). Responders were defined as those with a ≥5% absolute increase in LVEF at six months. Clinical, electrocardiographic, laboratory, echocardiographic, autonomic, endothelial and cardiopulmonary function parameters were assessed before CRT device implantation. Logistic regression models were used. Seventy-nine patients were included, 54 male (68.4%), age 68.1 years (standard deviation 10.2), 19 with ischemic etiology (24%). At six months, 51 patients (64.6%) were considered responders. Although by univariate analysis baseline tricuspid annular plane systolic excursion (TAPSE) and serum creatinine were significantly different in responders, on multivariate analysis only TAPSE was independently associated with response, with higher values predicting a positive response to CRT (OR=1.13; 95% CI: 1.02-1.26; p=0.020). TAPSE ≥15 mm was strongly associated with response, and TAPSE <15 mm with non-response (p=0.005). Responders had no TAPSE values below 10 mm. CONCLUSION From a range of clinical and technical baseline characteristics, multivariate analysis only identified TAPSE as an independent predictor of CRT response, with TAPSE <15 mm associated with non-response. This study highlights the importance of right ventricular dysfunction in CRT response. ClinicalTrials.gov identifier: NCT02413151.Introduction Cardiac resynchronization therapy (CRT) has modified the prognosis of chronic heart failure (HF) with left ventricular systolic dysfunction. However, 30% of patients do not have a favorable response. The big question is how to determine predictors of response.