Waldomiro Carlos Manfroi

Metabolic abnormalities, antiretroviral therapy and cardiovascular disease in elderly patients with HIV

One of the most recent phenomena related to the acquired immunodeficiency syndrome (AIDS) is the emergence of a new vulnerable population: the elderly. One of the factors that account for this increase is the development of combination antiretroviral therapy (ART), which has provided better quality of life and life expectancy for HIV-positive patients. However, ART is associated with adverse effects such as dyslipidemia, diabetes mellitus and insulin resistance, which are risk factors for cardiovascular disease. Due to the impact of ART on lipid and glucose metabolism, many studies were published involving HIV infection and cardiovascular disease, as well as their risk factors and the use of ART, but few of them reported on the cardiotoxicity of this therapy in the elderly. The objective of this study is to review the main metabolic changes caused by the use of antiretroviral therapy and its impact on an increased risk of cardiovascular disease in elderly people with HIV.One of the most recent phenomena related to the acquired immunodeficiency syndrome (AIDS) is the emergence of a new vulnerable population: the elderly. One of the factors that account for this increase is the development of combination antiretroviral therapy (ART), which has provided better quality of life and life expectancy for HIV-positive patients. However, ART is associated with adverse effects such as dyslipidemia, diabetes mellitus and insulin resistance, which are risk factors for cardiovascular disease. Due to the impact of ART on lipid and glucose metabolism, many studies were published involving HIV infection and cardiovascular disease, as well as their risk factors and the use of ART, but few of them reported on the cardiotoxicity of this therapy in the elderly. The objective of this study is to review the main metabolic changes caused by the use of antiretroviral therapy and its impact on an increased risk of cardiovascular disease in elderly people with HIV.

Alterações metabólicas, terapia antirretroviral e doença cardiovascular em idosos portadores de HIV

One of the most recent phenomena related to the acquired immunodeficiency syndrome (AIDS) is the emergence of a new vulnerable population: the elderly. One of the factors that account for this increase is the development of combination antiretroviral therapy (ART), which has provided better quality of life and life expectancy for HIV-positive patients. However, ART is associated with adverse effects such as dyslipidemia, diabetes mellitus and insulin resistance, which are risk factors for cardiovascular disease. Due to the impact of ART on lipid and glucose metabolism, many studies were published involving HIV infection and cardiovascular disease, as well as their risk factors and the use of ART, but few of them reported on the cardiotoxicity of this therapy in the elderly. The objective of this study is to review the main metabolic changes caused by the use of antiretroviral therapy and its impact on an increased risk of cardiovascular disease in elderly people with HIV.One of the most recent phenomena related to the acquired immunodeficiency syndrome (AIDS) is the emergence of a new vulnerable population: the elderly. One of the factors that account for this increase is the development of combination antiretroviral therapy (ART), which has provided better quality of life and life expectancy for HIV-positive patients. However, ART is associated with adverse effects such as dyslipidemia, diabetes mellitus and insulin resistance, which are risk factors for cardiovascular disease. Due to the impact of ART on lipid and glucose metabolism, many studies were published involving HIV infection and cardiovascular disease, as well as their risk factors and the use of ART, but few of them reported on the cardiotoxicity of this therapy in the elderly. The objective of this study is to review the main metabolic changes caused by the use of antiretroviral therapy and its impact on an increased risk of cardiovascular disease in elderly people with HIV.

O estresse oxidativo e o exercício físico em indivíduos HIV positivo

Human immunodeficiency virus (HIV) infection is characterized by functional and structural changes related to the immunological system. Moreover, increase in oxidative stress (OS) in HIV patients, characterized by a reduction in the glutathione (GSH) levels, increases in glutathione disulfide (GSSG), in the ratio GSSG/GSH and in lipid peroxidation, as well as a reduction in antioxidant enzymes - catalase, superoxid dismutase (SOD) and gluthatione peroxidase (GPx) - is a consequence of the evolution in HIV-infected patients. Higher levels of antioxidant activity are necessary to maintain the immunological system cells redox balance and preserve their function. In an antioxidant depleted state, there is a reduction in the immunological response and an increase in HIV replication. The use of highly active antiretroviral therapy (HAART) has improved the clinical evolution of these patients. However, some patients remain showing higher OS and other effects of HAART, such as changes in lipidic and muscle metabolism. Exercise training has been used as a non pharmacological treatment in HIV-infected patients to promote improvements in anthropometrics, aerobic, muscle and psychological outcomes; however, there are insufficient data about the effects of exercise training in OS. This review analyzes the topics related to the oxidative stress in HIV-infected patients and the possible benefits of the physical exercise in the antioxidant capacity. Physical training is a complementary procedure for the patients, with or without use of the HAART, since it improves the cardiorespiratory, muscle, anthropometrics and psychological performance without inducing immunodepression. In relation to oxidative stress, it is inferred, from the data obtained in non-HIV individuals, that the physical training could promote adaptations that minimize the deleterious effect induced by OS through improvements in the activity of the enzymatic and non-enzymatic antioxidant defenses.

Management of mild aortic stenosis in patients undergoing coronary bypass surgery

, maximum transvalvar gra-dient less than 30mmHg, and maximum flow velocity lowerthan 3m/s. Even though the management of patients withobstructive aortic valvular disease has already been defi-ned for most situations, and basically depends on symp-toms, the approach with these patients remains controver-sial as noted in the literature. Aortic valvular replacementoccurring simultaneously with myocardial revasculariza-tion surgery is considered a class IIb indication accordingto the guidelines elaborated by the committee on manage-ment of patients with valvular disease of the American Col-lege of Cardiology/American Heart Association

Hemodynamic effects of sildenafil in patients with stable ischemic heart disease

BACKGROUND Recently the new specific phosphodiesterase-5 inhibitor sildenafil was introduced into therapy for erectile dysfunction. The hemodynamic effects of sildenafil may be potentially hazardous for patients with cardiac disease. Sildenafil has been reported to augment the hypotensive effects of nitrates. There is sparse information regarding the systemic and pulmonary hemodynamic effects of a single oral dose of sildenafil in patients with stable angina. METHODS Male patients referred for coronary angiography with diagnosis of chronic stable angina were enrolled in this study to assess the acute hemodynamic effects of sildenafil. Patients receiving long-acting or sublingual nitrates for the last 6 h before the study were excluded. Hemodynamic measurement were taken during right and left heart catheterization in the basal state and 60 min after 50 mg of oral sildenafil. RESULTS Twelve patients (age 53+/-7 years) were studied. All had stable angina CCS class II or III. Four had previous myocardial infarction. By coronary angiography, seven patients had at least one coronary artery with >70% stenosis, four had at least one with 50-70% stenosis, and one had only intimal irregularities. There were no significant effects of sildenafil on systemic or pulmonary arterial pressure, left ventricle end diastolic pressure, cardiac output, and systemic or pulmonary vascular resistance (P>0.05 for all). No adverse events were observed. CONCLUSION A single oral dose of sildenafil had no significant hemodynamic effect in supine patients with stable angina. Isolated administration of sildenafil does not appear to be associated to adverse cardiovascular effects.

Does serum ferritin correlate with coronary angiography findings

BACKGROUND A number of epidemiological studies have described a positive relationship between serum ferritin levels and coronary heart disease. In this prospective study, we evaluated the association between serum ferritin levels and the angiographic extent of coronary atherosclerosis. METHOD We studied 307 consecutive patients (60.9% male, age 60.1+/-11.0 years) referred for diagnostic coronary angiography. Risk factors for coronary artery disease, lipids and ferritin levels, as well clinical characteristics were recorded from all patients. Two experienced cardiologists blinded for clinical and laboratory data reviewed the cinefilms. Angiographic significant coronary artery disease (CAD) was defined as any more than a 50% diameter stenosis. RESULTS From the 307 patients, 196 (63.8%) were found to have angiographic significant CAD. The presence of significant CAD was associated with ferritin levels (P=0.015) as well as patient age (P<0.001), male sex (P<0.001), smoking (P<0.002), and cholesterol levels (P=0.028). By multivariate analysis, however, ferritin level was not an independent risk factor for CAD (P=0.27), while the association with all the other factors remained significant. CONCLUSION In patients referred for coronary angiography no independent relationship was found between angiographic significant coronary artery disease and serum ferritin levels.

Peculiaridades no tratamento da cardiopatia isquêmica no idoso

Considering that the worlds population average age is increasing and the proportions of those over the age of 80, the fastest growing population worldwide, new approaches to health care and treatment will be necessary. Due to the development of new drugs and by means of transluminal coronary angioplasty or coronary artery bypass graft, many elderly patients had their lives prolonged and their quality of life improved. We carried out a bibliography review to search for evidence to support the best treatment choice according to the clinical manifestation of the patient.

Multiple recurrences of cardiac myxomas with acute tumoral pulmonary embolism

We report the case of a 42-year-old female with a second recurrence of cardiac myxoma. Her first diagnosis was at the age of 24 years, when cardiac tumors were withdrawn from her right ventricle and left atrium. Her first recurrence was at the age of 36 years, when tumors were removed from the left and right atria, and the right ventricle. Six years later, the patient was admitted to the Hospital das Clínicas de Porto Alegre complaining of sudden dyspnea, dry cough, and pain in the right hypochondrium, which bore no relation to breathing. The transesophageal echocardiography showed a small tumor in the interatrial septum, close to the superior vena cava, and 2 larger tumors in the right ventricle, 1 close to the outflow tract and the other almost completely obstructing the right branch of the pulmonary artery. The patient was referred to surgery, in which myxomas were removed from the right atrium and ventricle with extension to the right pulmonary artery. The postoperative period was uneventful.

Volume plaquetário médio e doença cardiovascular

Platelets play an important role in intravascular thrombus development, a major cause of acute coronary syndrome (ACS). After erosion or rupture of atherosclerotic plaque, platelets activation plays a crucial role in prothrombotic events leading to myocardial infarction. Increased platelets reactivity is associated with increased platelet volume. Large platelets are enzymatically and metabolically more active and have high thrombotic potential. Mean platelet volume (MPV) is a marker of platelet function. Elevated levels of MPV have been identified as an independent risk factor for myocardial infarction in patients with coronary cardiac disease. However, the biological and prognostic value of increased levels of MPV is still controversial. The new hematological analyzers provide the platelet index as part of the hemogram, without additional costs to the laboratory, and it may be used as an early risk marker of cardiovascular events in association with traditional markers. In this study we describe the clinical value of MPV in coronary atherosclerosis and its role as a risk factor for ACS.

Acute Myocardial Infarction: The First Manifestation of Ischemic Heart Disease and Relation to Risk Factors

OBJECTIVE To assess the association between cardiovascular risk factors and acute myocardial infarction as the first manifestation of ischemic heart disease, correlating them with coronary angiographic findings. METHODS We carried out a cross-sectional study of 104 patients with previous acute myocardial infarction, who were divided into 2 groups according to the presence or absence of angina prior to acute myocardial infarction. We assessed the presence of angina preceding acute myocardial infarction and risk factors, such as age >55 years, male sex, smoking, systemic arterial hypertension, lipid profile, diabetes mellitus, obesity, sedentary lifestyle, and familial history of ischemic heart disease. On coronary angiography, the severity of coronary heart disease and presence of left ventricular hypertrophy were assessed. RESULTS Of the 104 patients studied, 72.1% were males, 90.4% were white, 73.1% were older than 55 years, and 53.8% were hypertensive. Acute myocardial infarction was the first manifestation of ischemic heart disease in 49% of the patients. The associated risk factors were systemic arterial hypertension (RR=0.19; 95% CI=0.06-0.59; P=0.04) and left ventricular hypertrophy (RR=0.27; 95% CI=0,.8-0.88; P=0.03). The remaining risk factors were not statistically significant. CONCLUSION Prevalence of acute myocardial infarction as the first manifestation of ischemic heart disease is high, approximately 50%. Hypertensive individuals more frequently have symptoms preceding acute myocardial infarction, probably due to ventricular hypertrophy associated with high blood pressure levels.