Telmo Pereira

Arterial stiffness predicts cardiovascular outcome in a low-to-moderate cardiovascular risk population: the EDIVA (Estudo de DIstensibilidade VAscular) project.

Background Pulse wave velocity (PWV) is a recognized marker of arterial stiffness, although little knowledge exists of their relationship to long-term cardiovascular risk in general populations. Methods and results A prospective, multicenter, observational study included 2200 Portuguese nationals (1290 men), aged between 18 and 91 years (mean 46.33 ± 13.76 years). They underwent clinical assessment and annual PWV measurement using a Complior device, and major adverse cardiovascular events (MACEs) – death, stroke, myocardial infarction, unstable angina, peripheral arterial disease, revascularization, or renal failure – were recorded. During a mean follow-up of 21.42 ± 10.76 months, there were 47 nonfatal MACEs (2.1% of the sample). PWV was significantly higher in individuals with events than in those without events (11.76 ± 2.13 vs. 10.01 ± 2.01 m/s, respectively, P < 0.001). The study population was divided into two groups by PWV, classified as normal (PWV < 95th percentile) or high (PWV >95th percentile), according to predefined criteria for normality. Cumulative event-free survival at 2 years was 99.3% in the normal PWV group and 95% in the high PWV group. The hazard ratio for MACE in the high PWV group was 9.901 [95% confidence interval (CI) 5.00–19.59, P < 0.001], and 4.832 (95% CI 2.35–9.94, P < 0.001) when adjusted for other risk factors. For absolute PWV, the adjusted hazard ratio (per 1 m/s change) was 1.316 (95% CI 1.13–1.53, P < 0.001). Conclusion The results of the initial analysis of this study highlight the clinical relevance of PWV as a cardiovascular risk marker and demonstrate that PWV measurement can make an important contribution to assessment of cardiovascular prognosis.

An approach of hypertension prevalence in a sample of 5381 Portuguese children and adolescents. The AVELEIRA registry. “Hypertension in Children”

Abstract Introduction. The distribution of blood pressure (BP) in children and adolescents remains relatively unknown. Thus, it is imperative to ascertain BP distribution at a young age, which constitutes the main objective of this registry. Methods. Cross-sectional assessment of BP in 5381 Portuguese children and adolescents, mean age 12.50±3.23 years (4–18 years), body mass index (BMI) 19.65±4.00 kg/m2 (9.37–60.30 kg/m2), mostly male (4519), mean age 12.70±3.16 years, and with 862 females, mean age 11.44±3.34 years. BP and heart rate were measured three times after a 10-min resting period, with a validated automatic blood pressure monitor (OMRON 705IT) and an appropriately sized cuff over the brachial artery. About 30% of the youngsters were amateur registered athletes and 70% were beginning their sportive activity at the time of evaluation. Results. BP distribution was 12.8% stage 1 hypertension, 21.6% high-normal, and 65.6% normal (similar between genders). Registered athletes and subjects beginning their sports activity revealed different hypertension prevalence (9.8% vs 14.3%, respectively; p < 0.0001). Overweight was found in 7.8%. Hypertension and high-normal BP increased with increasing BMI. Body weight classification was independently associated with hypertension and high-normal BP. Registered sportive practice was independently associated with a reduction in hypertension prevalence. Conclusions. The proportion of children with BP above the 90th percentile was high, with an overall prevalence of hypertension of 12.8%, independent of gender and related to overweight. The implications of these observations are even more important when we consider the epidemiology of hypertension in Portugal and its link with stroke as the leading cause of death and disability.

Comparative study of two generations of the Complior device for aortic pulse wave velocity measurements.

IntroductionThe purpose of this study was to evaluate intraobserver and interobserver reproducibility of carotid–femoral pulse wave velocity (PWV) with the Complior method, by comparing two generations of the device and the manual method. MethodsWe studied 31 participants (9 women) with a mean age of 47.67±12.55 years, who were submitted to sequential measures of carotid–femoral PWV by two experienced operators. The evaluations were made by randomly switching between the manual method, the Complior first generation, and the Complior SP (third generation). ResultsThe analysis of concordance of measurements of PWV showed strong intraobserver and interobserver correlations. The intraobserver correlation coefficients were 0.984, 0.977, and 0.966, respectively, for manual evaluation, the Complior first generation, and the Complior SP (P<0.0001). In the case of interobserver reproducibility, we found correlations of 0.940, 0.979, and 0.974, respectively, for manual evaluation, the Complior first generation, and Complior SP (P<0.0001). Good indicators of reproducibility were also a withdrawal of the Bland–Altman analysis, with most values within 2 standard deviations. The mean difference±SD for intraobserver and interobserver agreement was −0.006±0.05 and −0.06±0.09 for manual determination; −0.02±0.06 and −0.04±0.06 for Complior first generation; and 0.16±0.09 and 0.15±0.07 for the Complior SP. ConclusionThe data showed a high reproducibility of the Complior method, documented by excellent correlations and low mean differences in measurements within and between observers. These data showed unequivocally that this method met the quality requirements for its inclusion in integrated clinical follow-up programs.

Central arterial hemodynamic effects of dark chocolate ingestion in young healthy people: a randomized and controlled trial.

Introduction. The aim of this study was to assess the vascular benefits of dark chocolate in healthy and young individuals. Methods. A randomized and controlled trial was carried out involving 60 healthy volunteers, randomized into two groups: control group (CG; n = 30) and intervention group (IG; n = 30). The IG ingested a daily dosage of 10 g of dark chocolate (>75% cocoa) for a month. Blood pressure (BP), flow-mediated dilation (FMD), arterial stiffness index (ASI), aortic pulse wave velocity (PWV), and pulse wave analysis (PWA) were assessed at baseline and one week after the one-month intervention period. Results. Arterial function improved after intervention in the IG, with PWV decreasing from 6.13 ± 0.41 m/s to 5.83 ± 0.53 m/s (P = 0.02), with no significant differences observed in the CG. A significant decrease in ASI (0.16 ± 0.01 to 0.13 ± 0.01; P < 0.001) and AiX (−15.88 ± 10.75 to −22.57 ± 11.16; P = 0.07) was also depicted for the IG. Endothelial function improved in the IG, with the FMD increasing 9.31% after the 1-month intervention (P < 0.001), with no significant variation in the CG. Conclusion. The daily ingestion of 10 g dark chocolate (>75% cocoa) during a month significantly improves vascular function in young and healthy individuals.

Death and Disability in Patients with Sleep Apnea - A Meta-analysis

Background Several studies have been attempting to ascertain the risks of Sleep Apnea Syndrome (SAS) and its morbidity and mortality. Objective The main objective was to verify whether SAS increases the risk of death; the secondary objective was to evaluate its morbidity in relation to cardiovascular disease and the number of days hospitalized. Methods A systematic review and a meta-analysis were performed of the published literature. The research focused on studies comparing the number of deaths in patients with untreated SAS and in patients with non-SAS. Results The meta-analysis was based on 13 articles, corresponding to a total of 13394 participants divided into two groups (non-SAS = 6631; SAS = 6763). The meta-analysis revealed a clear association of SAS with the occurrence of fatal events, where the presence of SAS corresponded to a 61% higher risk of total mortality (OR=1.61; CI: 1.43 - 1.81; p < 0.00001), while the risk of death from cardiac causes was 2.52 times higher in these patients (OR = 2.52; IC: 1.80 - 3.52; p < 0.00001). Similar results were obtained for mortality from other causes (OR = 1.68; CI: 1.08 - 2.61; p = 0.02). Resembling results were obtained in the remaining outcomes: non-fatal cardiovascular events were higher in the SAS group (OR = 2.46; IC: 1.80 - 3.36; p < 0.00001), the average number of days hospitalized was also higher in the SAS group (IV = 18.09; IC: 13.34 - 22.84; p < 0.00001). Conclusion The results show that untreated SAS significantly increases the risk of death, cardiovascular events and the average number of days hospitalized.

Ventricular repolarization in diabetic patients: characterization and clinical implications

BACKGROUND Diabetes mellitus is a chronic and very common condition, and there has been lately a considerable increase in its prevalence and incidence. Diabetic patients have increased cardiovascular mortality, in which malignant ventricular arrhythmias seem to be implicated. OBJECTIVE To study the effects of diabetes on ventricular repolarization parameters responsible for an increased susceptibility to malignant ventricular arrhythmias and/or sudden death. METHODS We selected a group of 110 diabetic patients and a group of 110 controls with the same distribution of age, gender and race. We evaluated the following parameters of ventricular repolarization: QT(max), QT(mean), QT(min), QTc(max), QTc(mean), QTc(min), QT and QTc dispersions, T(peak)-T(end) and jT(peak)-jT(end) intervals (D(II), V(2) and V(5)), T(peak)-T(end) and jT(peak)-jT(end) dispersions. The electrocardiograms (ECG) were performed by the same operator and reviewed by the same observers. QT intervals were corrected according to Bazzets formula. RESULTS We found significantly higher values of QTc(max) (p < 0.001), QTc(mean) (p < 0.001), QT dispersion (p < 0.001), QTc dispersion (p < 0.001), T(peak)-T(end) dispersion ( p < 0.001), and jT(peak)-jT(end) dispersion (p < 0.001) in diabetic patients than in controls. In diabetic patients, we observed prolonged values of QTc interval (5.5%), QT dispersion (0.9%), QTc dispersion (0%), T(peak)-T(end) interval (7.3%), jT(peak)-jT(end) interval (6.4%), T(peak)-T(end) dispersion (16.4%), and jT(peak)-jT(end) dispersion (12.7%). In the controls there were no prolonged values of any of the parameters. CONCLUSION We concluded that diabetes causes prolongation and spatial dispersion of repolarization, and it may contribute to a greater ventricular electrical instability, whose expected clinical expression may be malignant ventricular arrhythmias.

Cirurgia de revascularização miocárdica com circulação extracorpórea versus sem circulação extracorpórea: uma metanálise

Ha controversias quanto aos eventuais beneficios da cirurgia de revascularizacao miocardica sem a tecnica de circulacao extracorporea (SCEC) comparativamente a revascularizacao miocardica com circulacao extracorporea (CEC). Para obter uma perspectiva melhor sobre essa importante questao, foi realizada uma metanalise de ensaios clinicos randomizados, cotejando as duas tecnicas. O objectivo do presente trabalho foi verificar qual a tecnica aplicada na Cirurgia de Revascularizacao Miocardica, CEC ou SCEC, que oferece melhores resultados, por metanalise de estudos randomizados publicados comparando CEC com SCEC. Realizou-se uma pesquisa bibliografica informatizada nos motores de busca PubMed, Embase, B-on e Science Direct, durante o periodo de marco de 2009 a janeiro de 2010. Os estudos abrangidos foram recuperados de acordo com criterios predeterminados. A revisao sistematizada de estudos clinicos randomizados foi executada, de forma a avaliar as diferencas entre ambas as tecnicas de revascularizacao (SCEC versus CEC) na mortalidade e na morbidade. Os artigos selecionados nao incluem pacientes de alto risco e avaliacao longitudinal a longo prazo. A metanalise incidiu em nove ensaios clinicos randomizados, correspondendo a um total de 75.086 pacientes, e comparou a CEC a SCEC. No que diz respeito a mortalidade, observou-se reducao de 18% no risco de mortalidade cardiovascular (OR - 0,82; IC95 - 0,70 - 0,98; p = 0,03) e de 27% no risco de ocorrencia de AVC no pos-operatorio (OR - 0,73; IC95 - 0,63 - 0,85; p = 0,0001), ambos a favor da tecnica cirurgica SCEC. Em relacao a ocorrencia de complicacoes associadas ao procedimento, nao foram encontradas diferencas significativas entre ambas as tecnicas cirurgicas, particularmente no que se refere a ocorrencia de complicacoes renais (OR - 0,97; IC95 - 0,84 - 1,14; p = 0,74) e de septicemia (OR - 0,98; IC95 - 0.64 - 1.51, p = 0,93, respectivamente). A revascularizacao miocardica SCEC reduz significativamente a ocorrencia de eventos cardiovasculares maiores (mortalidade e AVC), comparativamente a revascularizacao com CEC.There are controversies about the possible benefits of off pump coronary artery bypass grafting (OPCABG) compared to on-pump coronary artery bypass grafting (ONCABG). For a better perspective on this important issue, we performed a meta-analysis of randomized controlled trials, comparing the two techniques. The objective of this study was to verify which technique applied in Coronary Artery Bypass Surgery, OPCABG or ONCABG, provides better results through a meta-analysis of published randomized trials comparing the two techniques. We carried out a computer-based literature search in PubMed, Embase, B-on and Science Direct from March 2009 to January 2010. The studies covered were recovered according to predetermined criteria. A systematic review of randomized clinical trials was performed in order to evaluate the differences between the two revascularization techniques (OPCABG versus ONCABG) regarding mortality and morbidity. Selected studies did not include patients at high risk and long-term longitudinal evaluations. The meta-analysis focused on nine randomized clinical trials, corresponding to a total of 75,086 patients, and compared OPCABG to ONCABG. Regarding mortality, a reduction of 18% in the risk of cardiovascular mortality (OR: 0.82, 95%CI: 0.70 to 0.98, p = 0.03) and 27% in the risk of stroke postoperatively (OR: 0.73, 95%CI: 0.63 to 0.85, p = 0.0001) were observed, both in favor of OPCABG. Concerning the occurrence of complications associated with the procedure, no significant differences were found between the two surgical techniques, particularly with regard to the occurrence of kidney complications (OR: 0.97, 95%CI: 0.84-1.14, p = 0, 74) and sepsis (OR 0.98, 95%CI: 0.64-1.51, p = 0.93, respectively). Off-pump CABG significantly reduces the occurrence of major cardiovascular events (mortality and CVA) compared to on-pump CABG surgery.

A distensibilidade da aorta prediz o acidente vascular cerebral em pacientes hipertensos

BACKGROUND Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrells C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

On-pump versus off-pump coronary-artery bypass surgery: a meta-analysis

Ha controversias quanto aos eventuais beneficios da cirurgia de revascularizacao miocardica sem a tecnica de circulacao extracorporea (SCEC) comparativamente a revascularizacao miocardica com circulacao extracorporea (CEC). Para obter uma perspectiva melhor sobre essa importante questao, foi realizada uma metanalise de ensaios clinicos randomizados, cotejando as duas tecnicas. O objectivo do presente trabalho foi verificar qual a tecnica aplicada na Cirurgia de Revascularizacao Miocardica, CEC ou SCEC, que oferece melhores resultados, por metanalise de estudos randomizados publicados comparando CEC com SCEC. Realizou-se uma pesquisa bibliografica informatizada nos motores de busca PubMed, Embase, B-on e Science Direct, durante o periodo de marco de 2009 a janeiro de 2010. Os estudos abrangidos foram recuperados de acordo com criterios predeterminados. A revisao sistematizada de estudos clinicos randomizados foi executada, de forma a avaliar as diferencas entre ambas as tecnicas de revascularizacao (SCEC versus CEC) na mortalidade e na morbidade. Os artigos selecionados nao incluem pacientes de alto risco e avaliacao longitudinal a longo prazo. A metanalise incidiu em nove ensaios clinicos randomizados, correspondendo a um total de 75.086 pacientes, e comparou a CEC a SCEC. No que diz respeito a mortalidade, observou-se reducao de 18% no risco de mortalidade cardiovascular (OR - 0,82; IC95 - 0,70 - 0,98; p = 0,03) e de 27% no risco de ocorrencia de AVC no pos-operatorio (OR - 0,73; IC95 - 0,63 - 0,85; p = 0,0001), ambos a favor da tecnica cirurgica SCEC. Em relacao a ocorrencia de complicacoes associadas ao procedimento, nao foram encontradas diferencas significativas entre ambas as tecnicas cirurgicas, particularmente no que se refere a ocorrencia de complicacoes renais (OR - 0,97; IC95 - 0,84 - 1,14; p = 0,74) e de septicemia (OR - 0,98; IC95 - 0.64 - 1.51, p = 0,93, respectivamente). A revascularizacao miocardica SCEC reduz significativamente a ocorrencia de eventos cardiovasculares maiores (mortalidade e AVC), comparativamente a revascularizacao com CEC.There are controversies about the possible benefits of off pump coronary artery bypass grafting (OPCABG) compared to on-pump coronary artery bypass grafting (ONCABG). For a better perspective on this important issue, we performed a meta-analysis of randomized controlled trials, comparing the two techniques. The objective of this study was to verify which technique applied in Coronary Artery Bypass Surgery, OPCABG or ONCABG, provides better results through a meta-analysis of published randomized trials comparing the two techniques. We carried out a computer-based literature search in PubMed, Embase, B-on and Science Direct from March 2009 to January 2010. The studies covered were recovered according to predetermined criteria. A systematic review of randomized clinical trials was performed in order to evaluate the differences between the two revascularization techniques (OPCABG versus ONCABG) regarding mortality and morbidity. Selected studies did not include patients at high risk and long-term longitudinal evaluations. The meta-analysis focused on nine randomized clinical trials, corresponding to a total of 75,086 patients, and compared OPCABG to ONCABG. Regarding mortality, a reduction of 18% in the risk of cardiovascular mortality (OR: 0.82, 95%CI: 0.70 to 0.98, p = 0.03) and 27% in the risk of stroke postoperatively (OR: 0.73, 95%CI: 0.63 to 0.85, p = 0.0001) were observed, both in favor of OPCABG. Concerning the occurrence of complications associated with the procedure, no significant differences were found between the two surgical techniques, particularly with regard to the occurrence of kidney complications (OR: 0.97, 95%CI: 0.84-1.14, p = 0, 74) and sepsis (OR 0.98, 95%CI: 0.64-1.51, p = 0.93, respectively). Off-pump CABG significantly reduces the occurrence of major cardiovascular events (mortality and CVA) compared to on-pump CABG surgery.

Criteria to predict carriers of a novel SCN5A mutation in a large Portuguese family affected by the Brugada syndrome

AIMS Brugada syndrome (BrS) is a life-threatening arrhythmia disorder associated with autosomal-dominant mutations in the SCN5A gene. We aimed to characterize the diagnostic challenges and clinical manifestations of a novel SCN5A mutation associated with BrS. METHODS AND RESULTS From a novel SCN5A mutation (c.664C>T; p.Arg222X) identified in a proband with the characteristic electrocardiographic pattern and the history of sudden collapse, 122 family members were studied including 40 carriers of the mutation. The electrocardiographic diagnosis of BrS requires type 1 Brugada electrocardiogram (ECG) pattern in >1 right precordial lead (V1-V3), but recently an isolated lead with coved-type ECG was proposed to be enough for the diagnosis. In this family, these proposed criteria (PC) were more sensitive in detecting mutation carriers than the conventional criteria without repercussion on the specificity. Carriers had, on average, longer P-wave duration, PR, and QRS intervals and higher transmural dispersion of repolarization. The prevalence of late potentials was higher in carriers, and individual signal average ECG (SAECG) parameters (QRSf, LAS, and RMS40) also were related to SCN5A gene mutation. Three non-carriers were found to be affected by BrS, two with a spontaneous type 1 ECG with alternative placement of the precordial electrodes, and one only after the pharmacological provocative test, suggesting that other genes may play a role in the pathophysiology of this disease. CONCLUSION The PC for BrS diagnosis should be implemented. Some parameters from the spontaneous ECG and the SAECG are more effective tools than the characteristic repolarization pattern to discriminate between carriers of SCN5A mutations.