Wolney de Andrade Martins

Prevalence of Metabolic Syndrome in Elderly and Agreement among Four Diagnostic Criteria

Background Metabolic syndrome (MS) is an aggregation of risk factors that increase the incidence of cardiovascular events and diabetes mellitus (DM). Population aging is accompanied by higher prevalence of MS, which varies depending on the population studied and the diagnostic criteria used. Objective To determine prevalence of MS in the elderly using four diagnostic criteria and agreement between them. Methods Cross-sectional study on 243 patients older than 60 years (180 women) in Niterói, RJ. They were evaluated by clinical examination, fasting glucose, fasting insulin, lipid profile and anthropometric measurements - weight, height, waist circumference and waist/hip ratio. Prevalence of MS was estimated by World Health Organization (WHO) modified, National Cholesterol Education Program - Adult Treatment Panel III (NCEP-ATP III), International Diabetes Federation (IDF) and Joint Interim Statement (JIS) criteria. Results Prevalence was high with the four criteria WHO (51.9%), NCEP-ATPIII (45.2%), IDF (64.1%) and JIS (69.1%), and agreement between criteria by kappa was moderate in almost all comparisons WHO vs. IDF (k = 0.47;95% confidence interval (CI), 0.35 to 0.58); WHO vs. NCEP-ATPIII (k = 0.51; 95% CI, 0.40 to 0.61); WHO vs. JIS (k = 0.45; 95% CI, 0.33 to 0.56); IDF vs. NCEP-ATPIII (k = 0.55; 95% CI, 0.45 to 0.65) and NCEP-ATPIII vs. JIS (k = 0.53; 95% CI, 0.43-0.64), except between IDF vs. JIS (K = 0.89;95% CI, 0.83 to 0.95), which was considered good. Conclusion Prevalence of MS was high with the four diagnostic criteria, mainly by JIS. There was good agreement between JIS and IDF criteria and moderate among the others.

Doppler echocardiographic study in adolescents and young adults with sickle cell anemia

OBJECTIVE Anatomical and functional assessment of the heart through Doppler and echocardiography in patients with cell anemia (SCA). METHODS Twenty-five patients with SCA and ages ranging from 14 to 45 years were prospectively studied in a comparison with 25 healthy volunteers. All of them underwent clinical and laboratory evaluation and Doppler echocardiography as well. The measurements were converted into body surface indices. RESULTS There were increases in all chamber diameters and left ventricle (LV) mass of the SCA patients. It was characterised an eccentric hypertrophy of the left ventricle. The preload was increased (left ventricle end-diastolic volume) and the afterload was decreased (diastolic blood pressure, peripheral vascular resistance and end-systolic parietal stress ESPS). The cardiac index was increased due to the stroke volume. The ejection fraction and the percentage of the systolic shortening, as well as the systolic time intervals of the LV were equivalent. The isovolumetric contraction period of the LV was increased. The mitral E-septum distance and the end-systolic volume index (ESVi) were increased. The ESPS/ESVi ratio,a loading independent parameter, was decreased in SCA, suggesting systolic dysfunction. No significant differences in the diastolic function or in the pulmonary pressure occurred. CONCLUSION Chamber dilations, eccentric hypertrophy and systolic dysfunction confirm the evidence of the literature in characterizing a sickle cell anemia cardiomyopathy.

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.

The Prevalence of Stages of Heart Failure in Primary Care: A Population-Based Study

BACKGROUND Planning strategies to prevent heart failure (HF) in developing countries require epidemiologic data in primary care. The purpose of this study was to estimate the prevalence of HF stages and their phenotypes, HF with preserved ejection fraction (HFPEF), and HF with reduced EF (HFREF) and to determine B-type natriuretic peptide (BNP) levels to identify HF in the adult population. METHODS AND RESULTS This is a cross-sectional study including 633 individuals, aged ≥45 years, who were randomly selected and registered in a primary care program of a medium-sized city in Brazil. All participants were underwent clinical evaluations, BNP measurements, electrocardiograms, and tissue Doppler echocardiography in a single day. The participants were classified as stage 0 (healthy, 11.7%), stage A (risk factors, 36.6%), stage B (structural abnormalities, 42.7%), or stage C (symptomatic HF, 9.3%). Among patients with HF, 59% presented with HFPEF and 41% presented with HFREF. The mean BNP levels were 20 pg/mL(-1) in stage 0, 20 pg/mL(-1) in stage A, 24 pg/mL(-1) in stage B, 93 pg/mL(-1) in HFPEF, and 266 pg/mL(-1) in HFREF. The cutoff BNP level with optimal sensitivity (92%) and specificity (91%) to identify HF was 42 pg/mL(-1). CONCLUSION The present study demonstrated a high prevalence of individuals at risk for HF and the predominance of HFPEF in a primary care setting. The clinical examination, along with BNP and tissue Doppler echocardiography, may facilitate early detection of stages A and B HF and allow implementation of interventions aimed at preventing progression to symptomatic HF.

Vacinação contra influenza e pneumococo na insuficiência cardíaca: uma recomendação pouco aplicada

BACKGROUND Heart failure (HF) is associated with frequent decompensation and admissions to the emergency service. Influenza (INF) and Pneumococcal (pneumonia) vaccinations are recommended in the guidelines, however, respiratory infections are the third leading cause of hospitalization in heart failure. OBJECTIVE To assess the frequency of vaccination against INF and PNM in patients with HF in government healthcare units. METHODS An observational study carried out in Teresópolis, a mountain region in Rio de Janeiro, employed three strategies: (I) study of requests for vaccine against INF and/or PNM in the Health Department of Teresópolis between 2004 and 2006; (II) direct inquiry to 61 patients with heart failure treated in primary care about their vaccination status against INF and PNM; (III) direct inquiry about their vaccination status against INF and PNM to 81 patients with decompensated chronic heart failure treated in the only emergency service open to the public. RESULTS In strategy I, INF and/or PNM vaccination was 15.3% of those with indications for cardiovascular and respiratory diseases. The median time between indication and vaccination was 32 days. In strategy II, the percentage of patients vaccinated against INF, aged > 60, was 23.1% and 24.6% against PMN at all ages. In strategy III, the percentage of patients vaccinated against INF was 35.8% and against PNM was 2.5%. CONCLUSION The rate of vaccination against INF and PNM in patients with HF is very low and even lower in those with decompensated HF treated in emergency services.FUNDAMENTO: La insuficiencia cardiaca (IC) cursa con frecuentes descompensaciones y admisiones al servicio de emergencia. Vacunacion contra Influenza (INF) y Neumococo (PNM) son recomendadas en las directrices, entre tanto, las infecciones respiratorias son la tercera causa de hospitalizacion en la IC. OBJETIVO: Evaluar la frecuencia de la vacunacion contra INF y PNM en pacientes con IC en la red publica. METODOS: En estudio observacional realizado en Teresopolis, region serrana fluminense, fueron utilizadas tres estrategias: (I) estudio de las requisiciones para vacuna contra INF y/o PNM en la Secretaria Municipal de Salud, entre 2004 y 2006; (II) averiguacion directa a 61 pacientes con IC atendidos en la atencion basica sobre su situacion de vacuna contra INF y PNM; (III) averiguacion directa sobre situacion de vacuna contra INF y PNM a 81 pacientes con IC cronica descompensada atendidos en la unica emergencia abierta a la red publica. RESULTADOS: En la estrategia I, la vacunacion contra INF y/o PNM fue de 15,3% de aquellos con indicaciones por enfermedades cardiovasculares y respiratorias. La mediana del tiempo entre la indicacion y la vacunacion fue de 32 dias. En la estrategia II, el porcentual de vacunados contra INF, con edad > 60 anos, fue de 23,1%, y de 24,6% contra PMN en todas las edades. En la estrategia III, el porcentual de pacientes vacunados contra INF fue de 35,8% y contra PNM fue de 2,5%. CONCLUSION: La tasa de vacunacion contra INF y PNM en pacientes con IC es muy baja y aun menor en aquellos descompensados atendidos en servicio de emergencia.

Cardiovascular autonomic dysfunction in sickle cell anemia.

Sickle cell anemia (SCA) is associated to increased cardiac output, normal heart rate (HR), abnormal QT dispersion and lower diastolic blood pressure (DBP). The mechanisms are still unknown. The objective of this study was to test the hypothesis that there is cardiovascular autonomic dysfunction (CAD) in SCA. The secondary objectives were to distinguish the roles of chronic anemia and hemoglobinopathy and to evaluate the predominance of the sympathetic or parasympathetic systems in the pathogenesis of CAD. Sixteen subjects with SCA, 13 with sickle cell trait (SCT), 13 with iron deficiency anemia (IDA), and 13 healthy volunteers (HV) were evaluated. All subjects were submitted to 24h-electrocardiogram (24h-ECG), plasma norepinephrine (NE) measurement before and after isometric exercise (IE), and also Valsalva maneuver (VM), diving maneuver (DV), and tilt test (TT). Baroreflex sensitivity (BRS) was also evaluated. The minimum, average and maximum HR as well as the percentage of bradycardia and tachycardia at 24-h ECG were similar in all groups. NE at baseline and after IE did not differ between groups. The SCA group showed less bradycardia at phase IV of VM, less bradycardia during DV, and also less tachycardia and lower DBP during TT. BRS for bradycardia and tachycardia reflex was decreased in the SCA and SCT groups. In conclusion, 1) there is CAD in SCA, and it is characterized by the reduction of BRS and the limitation of HR modulation mediated by the parasympathetic system; 2) cardiovascular sympathetic activity is preserved in SCA; and 3) hemoglobinopathy is the preponderant ethiopathogenic factor.

Monitorização ambulatorial da pressão arterial e pressão casual em hiper-reatores ao esforço

BACKGROUND Developing hypertension is likely to be at least two times greater in individual with exaggerated blood pressure response on exercise testing (ET). Few reports have evaluated the parameters of 24-hour Ambulatory Blood Pressure Monitoring (ABPM) in normotensive individuals with exaggerated blood pressure response to exercise. OBJECTIVE To evaluate the relationship among the casual blood pressure with hyper-reactive response on ET and to compare Ambulatory Blood Pressure Monitoring (ABPM) data of hyper-reactive individuals with a control group in order to detect early disorders, that allows a preventive action with prognostic implication. METHODS Casual BP measurement and parameters of ABPM of 26 adult individuals, with mean age of 41.50+/-11.78 years, normotensive at rest and hyper-reactive on ET was compared to those of 16 adult individuals, with mean age of 41.38+/-11.55 years, normotensive at rest with normal BP response on exercise. The values <140 x 90 mmHg were considered normal for casual BP. The values <220 mmHg for systolic BP and/or an increase > or = 5 mmHg diastolic BP on ET for hyper-reactive response diagnosis. RESULTS Hyper-reactive individuals presented the systolic (p=0.03) and diastolic (p=0.002) casual BP and mean systolic BP (p=0.050), systolic pressure load during the day (p=0.011), and systolic (p=0.017) pressure load higher when compared to the control group. CONCLUSION Casual high normal BP had a positive correlation with exaggerated BP response. The hyper-reactive individuals showed particular characteristics in casual BP as well as in ABPM parameters, which, although within the range of reference values, differed from those of individuals with normal response to exercise.

Echocardiographic assessment of the different left ventricular geometric patterns in hypertensive patients

OBJECTIVE To identify left ventricular geometric patterns in hypertensive patients on echocardiography, and to correlate those patterns with casual blood pressure measurements and with the parameters obtained on a 24-hour ambulatory blood pressure monitoring. METHODS We studied sixty hypertensive patients, grouped according to the Joint National Committee stages of hypertension. Using the single- and two-dimensional Doppler Echocardiography, we analyzed the left ventricular mass and the geometric patterns through the correlation of left ventricular mass index and relative wall thickness. On ambulatory blood pressure monitoring we assessed the means and pressure loads in the different geometric patterns detected on echocardiography RESULTS We identified three left ventricular geometric patterns: 1) concentric hypertrophy, in 25% of the patients; 2) concentric remodeling, in 25%; and 3) normal geometry, in 50%. Casual systolic blood pressure was higher in the group with concentric hypertrophy than in the other groups (p=0.001). Mean systolic pressure in the 24h, daytime and nighttime periods was also higher in patients with concentric hypertrophy, as compared to the other groups (p=0.003, p=0.004 and p=0.007). Daytime systolic load and nighttime diastolic load were higher in patients with concentric hypertrophy ( p=0.004 and p=0.01, respectively). CONCLUSIONS Left ventricular geometric patterns show significant correlation with casual systolic blood pressure, and with means and pressure loads on ambulatory blood pressure monitoring.

Influenza and pneumococcal vaccination in heart failure: a little applied recommendation.

BACKGROUND Heart failure (HF) is associated with frequent decompensation and admissions to the emergency service. Influenza (INF) and Pneumococcal (pneumonia) vaccinations are recommended in the guidelines, however, respiratory infections are the third leading cause of hospitalization in heart failure. OBJECTIVE To assess the frequency of vaccination against INF and PNM in patients with HF in government healthcare units. METHODS An observational study carried out in Teresópolis, a mountain region in Rio de Janeiro, employed three strategies: (I) study of requests for vaccine against INF and/or PNM in the Health Department of Teresópolis between 2004 and 2006; (II) direct inquiry to 61 patients with heart failure treated in primary care about their vaccination status against INF and PNM; (III) direct inquiry about their vaccination status against INF and PNM to 81 patients with decompensated chronic heart failure treated in the only emergency service open to the public. RESULTS In strategy I, INF and/or PNM vaccination was 15.3% of those with indications for cardiovascular and respiratory diseases. The median time between indication and vaccination was 32 days. In strategy II, the percentage of patients vaccinated against INF, aged > 60, was 23.1% and 24.6% against PMN at all ages. In strategy III, the percentage of patients vaccinated against INF was 35.8% and against PNM was 2.5%. CONCLUSION The rate of vaccination against INF and PNM in patients with HF is very low and even lower in those with decompensated HF treated in emergency services.FUNDAMENTO: La insuficiencia cardiaca (IC) cursa con frecuentes descompensaciones y admisiones al servicio de emergencia. Vacunacion contra Influenza (INF) y Neumococo (PNM) son recomendadas en las directrices, entre tanto, las infecciones respiratorias son la tercera causa de hospitalizacion en la IC. OBJETIVO: Evaluar la frecuencia de la vacunacion contra INF y PNM en pacientes con IC en la red publica. METODOS: En estudio observacional realizado en Teresopolis, region serrana fluminense, fueron utilizadas tres estrategias: (I) estudio de las requisiciones para vacuna contra INF y/o PNM en la Secretaria Municipal de Salud, entre 2004 y 2006; (II) averiguacion directa a 61 pacientes con IC atendidos en la atencion basica sobre su situacion de vacuna contra INF y PNM; (III) averiguacion directa sobre situacion de vacuna contra INF y PNM a 81 pacientes con IC cronica descompensada atendidos en la unica emergencia abierta a la red publica. RESULTADOS: En la estrategia I, la vacunacion contra INF y/o PNM fue de 15,3% de aquellos con indicaciones por enfermedades cardiovasculares y respiratorias. La mediana del tiempo entre la indicacion y la vacunacion fue de 32 dias. En la estrategia II, el porcentual de vacunados contra INF, con edad > 60 anos, fue de 23,1%, y de 24,6% contra PMN en todas las edades. En la estrategia III, el porcentual de pacientes vacunados contra INF fue de 35,8% y contra PNM fue de 2,5%. CONCLUSION: La tasa de vacunacion contra INF y PNM en pacientes con IC es muy baja y aun menor en aquellos descompensados atendidos en servicio de emergencia.

Experiência de prova prática na seleção para a residência médica: exeqüibilidade, segurança e importância deste processo de avaliação

This paper relates the experience of a hands-on test model for the selection of medical residents in Serra dos Orgaos Universitary Center, Teresopolis, RJ. There was a first phase with a multiple-choice theoretical test (TT) and a second one with hands-on evaluation performed at the bedside (HO), both with eliminatory and classificatory effect. The five basic areas of medical teaching were evaluated through clinical examination of two patients: one from the clinical or surgical units and another from the maternal-child unit, selected at random. The HO test aimed to evaluate attitudes, skills and knowledge. There were two types of examination boards: the first was composed by teachers from the clinical and surgical areas, the so called clinical-surgical (CS) area and the second by teachers from the pediatric, obstetric and public health areas, called maternal-child and preventive (MCP) area. There was no correlation between TT an HO. The HO was responsible for final classification in five of the six residency programs offered. There was a correlation between CS and MCP scores (r = 0.483, p < 0.001) and uniformity in the evaluation in each board as well as between the different boards. The HO evaluation model showed to be feasible and secure and is an important instrument for adapting medical teaching to the Brazilian curricular guidelines.