Long-Term Impact of Left Bundle Branch Block on Cardiopulmonary Exercise Test Variables and Left Ventricular Systolic Function: A Two-Stage Observational Study.

INTRODUCTION: Left bundle branch block (LBBB) disrupts the electrical activation of the left ventricle (LV), potentially impairing its systolic function, leading to LBBB-induced cardiomyopathy. This study examined cardiopulmonary exercise test (CPET) variables in patients with and without LBBB and assessed the longitudinal development of left ventricular ejection fraction (LVEF). METHOD: An observational, comparative clinical study was executed in two stages at a private hospital in Brazil. The sample consisted of 27 individuals: 11 with LBBB and 16 without LBBB, all with preserved LVEF (>50%) and without confirmed ischemia. CPET variables were assessed, and after four years, participants had a transthoracic echocardiogram (TTE) for LVEF re-evaluation. Groups were compared using the t-test or the Chi-square (X²) test. Multivariate analysis of covariance (MANCOVA) determined effect magnitude. RESULTS: Patients with LBBB demonstrated significant differences in CPET variables, particularly in predicted peak V̇O2, predicted peak PO2, V̇E/V̇CO2 slope, and T½V̇O2. They also exhibited a more significant decline in LVEF over a four-year span compared to the patients without LBBB. Although initial preservation of LVEF, changes in contractile patterns due to LBBB interfered with its systolic function, suggesting early ventricular dysfunction indicated by a reduction in LVEF and an increase in the V̇E/V̇CO2 slope. Despite differences in cardiopulmonary function and changes in LVEF over time between patients with and without LBBB, the effect size was considered mild to moderate. CONCLUSIONS: LBBB patients with initially preserved LVEF displayed reduced exercise tolerance and a decrease in LVEF over time, emphasizing the need for vigilant monitoring and early intervention in these patients.

Bariatric Surgery: Late Outcomes in Patients Who Reduced Comorbidities at Early Follow-Up.

Backgroundand Objectives: In severe obesity, a relevant weight loss can promote the reduction of comorbidities, such as systemic arterial hypertension (SAH), dyslipidemia, and diabetes mellitus (DM2). Bariatric surgery (BS) has been an essential resource in the therapy of this disease with a short-term reduction of cardiometabolic risk (CR). This study aimed to evaluate the reduction of factors associated with the CR in patients undergoing BS at a 5-year follow-up. Materials and Methods: This is a longitudinal, retrospective study carried out with patients undergoing BS by the Brazilian Public Healthcare System (PHS). Anthropometric and clinical parameters related to the CR (DM2, dyslipidemia, and SAH), quantified by the Assessment of Obesity-Related Comorbidities (AORC) score, were evaluated at the following moments: admission and preoperative and postoperative returns (3 months, 6 months, 1 to 5 years). Results: The sample had a mean age of 44.69 ± 9.49 years and were predominantly in the age group 20-29 years (34.80%) and women (72.46%). At admission to the service, 42.3% had DM2, 50.7% dyslipidemia, and 78.9% SAH. Regarding BS, the gastric bypass technique was used in 92.86% of the sample, and the waiting time for the procedure was 28.3 ± 24.4 months. In the pre- and postoperative period of 3 months, there was a significant reduction in the frequency of DM2 (p < 0.003), dyslipidemia (p < 0.000), and SAH (p < 0.000). However, at postoperative follow-up from 6 months to 5 years, there was no significant reduction in the comorbidities studied. After five years, 35.7% had total remission of DM2 and 2.9% partial remission of DM2, 44.2% had control and remission of dyslipidemia, and 19.6% of SAH (AORC score ≤ 2 for the comorbidities). Conclusion: BS promoted a reduction of the CR in the first three months after BS in severely obese PHS users.

Cardiovascular Prognosis of Subclinical Chronic Obstructive Pulmonary Disease in Patients with Suspected or Confirmed Coronary Artery Disease.

Background: Chronic obstructive pulmonary disease (COPD) worsens prognosis in patients with coronary artery disease (CAD). However, the cardiovascular prognosis in patients with stable or mildly symptomatic COPD remains unclear. Here, we sought to determine the long-term cardiovascular events in patients with subclinical or early-stage COPD with concomitant CAD. Methods: This was a longitudinal analytical study involving 117 patients with suspected or established CAD who underwent assessment of pulmonary function by spirometry and who were followed up for six years (March 2015-January 2021). The patients were divided into two groups, one comprising COPD (n=44) and the other non-COPD (n=73) patients. Cox regression was used to evaluate the association between COPD and cardiovascular events, with adjustment for the established CAD risk factors, and the effect size was measured by the Cohen test. Results: COPD patients were older (p=0.028), had a greater frequency of diabetes (p=0.026), were more likely to be smokers (p<0.001), and had higher modified Medical Research Council scores (p<0.001). There was no difference between the groups regarding gender, body mass index, hypertension, dyslipidemia, family history of CAD, and type of angina. CAD frequency and the proportion of patients with severe and multivessel CAD were significantly higher among COPD than among non-COPD patients (all p<0.001). At six-year follow-up, patients with COPD were more likely to have experienced adverse cardiovascular events than those without COPD (p<0.001; effect size, 0.720). After adjusting for established CAD risk factors, COPD occurrence remained an independent predictor for long-term adverse cardiovascular events (OR: 5.13; 95% CI: 2.29-11.50; p<0.0001). Conclusion: COPD was associated with increased severity of coronary lesions and a greater number of adverse cardiovascular events in patients with suspected or confirmed CAD. COPD remained a predictor of long-term cardiovascular events in stable patients with subclinical or early-stage of COPD, independently of the established CAD risk factors.

Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography. / Resposta Exagerada da Pressão Arterial Sistólica ao Exercício e Isquemia Miocárdica à Ecocardiografia sob Estresse Físico.

BACKGROUND: Central Illustration : Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography ESBPRE: exaggerated systolic blood pressure response to exercise; HR: heart rate; SBP: systolic blood pressure. BACKGROUND: The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. OBJECTIVE: To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). METHODS: This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. RESULTS: Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). CONCLUSION: Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

BALANCE Dietary Index in Patients with Heart Failure, and Its Adherence in Sergipe, Brazil.

BACKGROUND: "The effective treatment of Heart Failure (HF) involves care with food intake. Recently, the Ministry of Health created the Brazilian Cardioprotective Diet and its dietary index, BALANCE, which assesses adherence to the standard's recommendations". METHODS: This observational prospective study is part of the Congestive Heart Failure Registry (VICTIM-CHF) of Aracaju/SE. Observations and data collection took place from April 2018 to February 2021. Sociodemographic and clinical aspects and food consumption were evaluated. Food intake was determined using the food frequency questionnaire. Foods were categorized using the BALANCE dietary index into green, yellow, blue and red food groups. The BALANCE dietary index was obtained using median and interquartile ranges, scores of the Mann-Whitney U test, and associations between clinical variables and the index, through linear regression. RESULTS: Participants included 240 patients with HF (61.12 ± 1.06 years), who were assisted by the Unified Health System (67.5%). Individuals with a partner showed greater adherence to the green food group recommendations (0.09; 0.00-0.17). The lowest adherence to recommendations regarding the blue food group was observed in individuals with excess weight, who had a higher consumption of foods rich in animal protein (0.54; 0.38-0.78). As for the red food group (ultra-processed foods) the highest adherence was observed by patients with diabetes mellitus (0.41; 0.05-0.77). The greatest adherence to the yellow food group, and a higher score, was observed in patients with the smallest left ventricular systolic diameter (LVSD). CONCLUSIONS: Being married was directly associated with the consumption of foods in the green group, while being overweight and having diabetes were inversely associated with adherence to the blue and red food groups, respectively. Greater adherence to the yellow food group recommendations was inversely associated with less change in the DSFVE.

Food Patterns of Hospitalized Patients with Heart Failure and Their Relationship with Demographic, Economic and Clinical Factors in Sergipe, Brazil.

Background: The high rates of hospitalization and mortality caused by Heart Failure (HF) have attracted the attention of health sectors around the world. Dietary patterns that involve food combinations and preparations with synergistic or antagonistic effects of different dietary components can influence the worsening and negative outcomes of this disease. Objectives: To describe the dietary patterns of patients hospitalized for HF decompensation and associate them with demographic, economic, and clinical factors, and the type of care provided in Sergipe. Materials and Methods: Cross-sectional study that is part of the Congestive Heart Failure Registry (VICTIM-CHF)" of Aracaju/SE. Prospective data collection took place with all patients hospitalized between April 2018 and February 2021 in cardiology referral hospitals, 2 public and 1 private. The data collected were sociodemographic, clinical, lifestyle, anthropometric and food consumption variables. Daily dietary intake was estimated by applying a semiquantitative food frequency questionnaire. The extraction of dietary patterns, by exploratory factor analysis, was performed after grouping the foods according to the nutritional value and form of preparation into 34 groups. To assess the association between the factorial scores for adherence to the standards and the variables studied, the Mann-Whitney U test was applied. Linear regressions were also performed, considering the dietary pattern (one for each pattern) as a dependent variable. Results: The study included 240 patients hospitalized for HF decompensation, most of them elderly (mean age 61.12 ± 1.06 years), male (52.08%) and attended by the Unified Health System­SUS (67.5%). Three dietary patterns were identified, labeled "traditional" (typical foods of the Brazilian northeastern population added to ultra-processed foods), "Mediterranean" (foods recommended by the Mediterranean diet) and "dual" (healthy foods combined with fast and easy-to-prepare foods like snacks, bread, sweets and desserts). Adherence to the "traditional" pattern was greater among men (p < 0.031) and non-diabetics (p < 0.003). The "Mediterranean" was more consumed by the elderly (p < 0.001), with partners (p = 0.001) and a lower income (p < 0.001), assisted by the SUS (p < 0.001) and without hypertension (p = 0,04). The "dual" diet pattern had greater adherence by the elderly (p < 0.001), self-declared non-black (p = 0.012), with higher income (p < 0.001), assisted in the private sector (p < 0.001) and with less impaired functional capacity (p = 0.037). It was also observed that being female (p = 0.031) and being older reduced the average scores of performing the "traditional" pattern (p = 0.002). Regarding the type of service, being from the public service reduced the average scores for adhering to the "dual" pattern (p = 0.008). Conclusions: Three dietary patterns representative of the population were found, called traditional, Mediterranean and dual, which were associated with demographic, economic and clinical factors. Thus, these standards must be considered in the development of nutritional strategies and recommendations in order to increase adherence to diets that are more protective against cardiovascular diseases.

Assessment of Malnutrition in Heart Failure and Its Relationship with Clinical Problems in Brazilian Health Services.

Malnutrition in heart failure (HF) is frequent and associated with a worse prognosis. Due to differences in investment and the profile of those assisted, the objective of this study was to evaluate the frequency of malnutrition in hospitalized patients with HF and its association with clinical outcomes in the public and private health systems. Methodology: A cross-sectional study, with 247 volunteers hospitalized with HF in three public hospitals and one private hospital in Aracaju, SE, Brazil. A subjective global nutritional assessment (SGA) and mini nutritional assessment (MNA) were performed. Results: Sample with 72.5% users of the public health system and 75.3% with malnutrition (public = 74.9%; private = 76.5%; p = 0.793). Regardless of the healthcare system, hospital stay (>14 days) was longer (p = 0.020) among those with malnutrition (48.4%) than well-nourished patients (29.5%). Malnutrition in the public system had higher mortality (7.5%; 5.8%; p < 0.001) and hospital transfer rate (21.1%; 0.0%; p < 0.001) than those in the private system. Death after discharge was observed only in the public system (p = 0.039). Conclusion: Malnutrition was frequent in both systems and was associated with longer hospital stays and, in the public hospital, in-hospital death and transfers.

Minimally invasive supratentorial neurosurgical approaches guided by Smartphone app and compass.

The precise location in the scalp of specifically planned points can help to achieve less invasive approaches. This study aims to develop a smartphone app, evaluate the precision and accuracy of the developed tool, and describe a series of cases using the referred technique. The application was developed with the React Native framework for Android and iOS. A phantom was printed based on the patient's CT scan, which was used for the calculation of accuracy and precision of the method. The points of interest were marked with an "x" on the patient's head, with the aid of the app and a compass attached to a skin marker pen. Then, two experienced neurosurgeons checked the plausibility of the demarcations based on the anatomical references. Both evaluators marked the frontal, temporal and parietal targets with a difference of less than 5 mm from the corresponding intended point, in all cases. The overall average accuracy observed was 1.6 ± 1.0 mm. The app was used in the surgical planning of trepanations for ventriculoperitoneal (VP) shunts and for drainage of abscesses, and in the definition of craniotomies for meningiomas, gliomas, brain metastases, intracranial hematomas, cavernomas, and arteriovenous malformation. The sample consisted of 88 volunteers who exhibited the following pathologies: 41 (46.6%) had brain tumors, 17 (19.3%) had traumatic brain injuries, 16 (18.2%) had spontaneous intracerebral hemorrhages, 2 (2.3%) had cavernomas, 1 (1.1%) had arteriovenous malformation (AVM), 4 (4.5%) had brain abscesses, and 7 (7.9%) had a VP shunt placement. In cases approached by craniotomy, with the exception of AVM, straight incisions and minicraniotomy were performed. Surgical planning with the aid of the NeuroKeypoint app is feasible and reliable. It has enabled neurological surgeries by craniotomy and trepanation in an accurate, precise, and less invasive manner.

Chronotropic incompetence and coronary artery disease.

OBJECTIVE: Although chronotropic incompetence (CI) represents an independent predictor of mortality and incidence of coronary artery disease, its pathophysiological mechanisms remain unknown. The purpose of this investigation was to evaluate wall motion abnormalities of the left ventricle and location of coronary arterial lesions in patients with and without CI. METHODS: After exclusion of confounding factors, 610 patients (mean age of 58.4 +/- 11 years; 275 men) with ischaemia who underwent exercise echocardiography were studied. Based on heart rate (HR) reached in treadmill testing, patients were divided into two groups: Chl (97 patients who did not reach 85% of maximum HR recommended for age) and ChC (513 patients who achieved 85% of the maximum age-predicted HR). RESULTS: There was a higher frequency of dyspnoea (5.2% vs. 0.6%, P = 0.003), systemic hypertension (69.1% vs. 57.3%, P = 0.031) and obesity (38.1% vs. 22.6%, P = 0.001), and a lower tolerance to effort (dyspnoea as limitation of physical effort: 36.1% vs. 8.0%, P < 0.0001; duration of treadmill test: 4.4 +/- 2.2 vs. 7.2 +/- 2.8, P < 0.0001; METs: 6.0 +/- 2.6 vs. 8.4 +/- 2.9, P = 0.002) in Chl compared to ChC. The wall motion score index (WMSI) was higher in Chl than in ChC, both at rest (1.15 +/- 0.29 vs. 1.07 +/- 0.19, P = 0.011) and after exercise (1.24 +/- 0.29 vs. 1.15 +/- 0.19, P = 0.002). Systolic function, which was evaluated in peak exercise through WMSI, was significantly more altered in the Chl group. The presence of severe injuries in right coronary was independently associated with CI (adjusted OR = 3.57, CI 95%: 1.86-6.87). CONCLUSION: Chronotropic incompetence is associated with ventricular dysfunction in peak exercise and critical right coronary artery lesions.

Coronary lesions in patients with COPD (Global Initiative for Obstructive Lung Disease stages I-III) and suspected or confirmed coronary arterial disease.

Background: Systemic inflammation is the pathophysiological link between coronary artery disease (CAD) and COPD. However, the influence of subclinical COPD on patients with suspected or diagnosed CAD is largely unknown. Thus, this study was designed to evaluate the degree of coronary involvement in patients with COPD and suspected or confirmed CAD. Methods: In this cross-sectional study, carried out between March 2015 and June 2017, 210 outpatients with suspected or confirmed CAD were examined by both spirometry and coronary angiography or multidetector computed tomography. These patients were divided into two groups: with and without COPD. Size, site, extent, and calcification of the coronary lesions, and the severity of COPD were analyzed. Results: COPD patients (n = 101) presented with a higher frequency of obstructive coronary lesions ≥50% (n = 72, 71.3%), multivessels (n = 29, 28.7%), more lesions of the left coronary trunk (n = 18, 17.8%), and more calcified atherosclerotic plaques and higher Agatston coronary calcium score than the patients without COPD (P < 0.0001). The more severe the COPD in the Global Initiative for Obstructive Lung Disease stages, the more severe the CAD and the more calcified coronary plaques (P < 0.0001). However, there was no difference between the two groups with respect to the main risk factors for CAD. In the univariate analysis, COPD was an independent predictor of obstructive CAD (odds ratio [OR] 4.78; 95% confidence interval: 2.21-10.34; P < 0.001). Conclusion: In patients with suspected CAD, comorbid COPD was associated with increased severity and extent of coronary lesions, calcific plaques, and elevated calcium score independent of the established risk factors for CAD. In addition, the more severe the COPD, the greater the severity of coronary lesions and calcification present.

Non-Targeted Self-Measured Blood Pressure and Hypertension Control in Public and Private Health Systems in Brazil

Abstract Background: It is estimated that more than 30% of the Brazilian population has systemic arterial hypertension (SAH), and mostly as an uncontrolled disease. The most recent Brazilian Guideline of Hypertension recommends the practice of self-measurement of blood pressure (BP) as one of the strategies for a better control of SAH, but there is no consensus about the efficiency of this tool. Objective: To assess the control of SAH and the practice of non-targeted self-measured BP (SMBP) among hypertensive users of the Unified Health System (SUS) and the Supplementary Network (SN). Methods: This is a cross-sectional, observational, analytical study, with a stratified probability sample. One thousand volunteers were investigated, being 500 from SUS and 500 from the SN. Uni and multivariate analyses were performed considering a 5% significance level. Results: Patients from SUS presented inferior sociodemographic data (schooling, social status) in relation to those of the SN (p < 0.001), and showed lower control of SAH (p = 0.014), as well as more visits to the emergency room in the past year due to hypertension (p = 0.002), and fewer regular appointments with the cardiologist (p = 0.004). SMBP was equally present in both assessed groups (p = 0.567), even though users of the SN have been more advised to not conduct such a practice (p = 0.002). SMBP (p < 0.001) was an independent factor for uncontrolled SAH both in SUS (OR = 3.424) and in the SN (OR = 3.474). Conclusion: Patients in SUS presented lower SAH control. The practice of SMBP, mostly practiced with an uncalibrated digital device, was equally present in both groups and became an independent factor of uncontrolled SAH.

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography.

BACKGROUND: In view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. OBJECTIVE: To evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA). METHODS: This is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted. RESULTS: The frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable. CONCLUSIONS: The frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Religiosity and Spirituality: The Relationship Between Psychosocial Factors and Cardiovascular Health

Abstract Background: Religiosity and Spirituality (R/S), despite being different entities, are multidimensional constructs, whose influence on cardiovascular health has been increasingly studied in recent decades. Objectives: To discriminate patients into subgroups according to R/S levels, in order to compare them regarding the distribution of cardiovascular comorbidities and clinical events. Methods: This is an observational, cross-sectional, analytical study. Two R/S scales were applied to a sample of patients seen at cardiology outpatient clinics. A cluster analysis was used to discriminate individuals into subgroups regarding R/S levels, which were subsequently compared regarding the frequencies of clinical variables related to cardiovascular health. A significance level of 5% was set for the statistical tests. Results: The sample included 237 patients with a mean age of 60.8 years (±10.7), of which 132 were female (55.7%). Cluster analysis (C) distinguished two groups: C1, with lower levels of R/S, and C2, with higher levels of R/S (p<0.001). C2 had a lower frequency of alcohol consumption (29.5% vs. 76.0%; p<0.001), smoking (12.9% vs. 51.0%; p<0.001), systemic arterial hypertension (SAH — 65.5% vs. 82.3%; p=0.005), dyslipidemia (58.3% vs. 77.1%; p=0.003), chronic coronary syndrome (36.7% vs. 58.3%; p=0.001), and prior cardiovascular events (15.8% vs. 36.5%; p<0.001) when compared to C1. There was also a higher frequency of females in C2 (82.0% vs. 17.7%; p<0.001). Conclusions: A better cardiovascular morbidity profile was observed in the group of patients with higher R/S levels, suggesting a probable positive relationship between R/S and cardiovascular health.

Resposta Exagerada da Pressão Arterial Sistólica ao Exercício e Isquemia Miocárdica à Ecocardiografia sob Estresse Físico / Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Resumo Fundamento A associação entre resposta exagerada da pressão arterial sistólica ao exercício (REPASE) e isquemia miocárdica é controversa e pouco estudada em indivíduos com síndrome coronariana crônica estabelecida ou suspeita. Objetivo Verificar a relação entre isquemia miocárdica e REPASE em indivíduos submetidos à ecocardiografia sob estresse físico (EEF). Métodos Trata-se de estudo transversal com 14.367 indivíduos submetidos à EEF, de janeiro de 2000 a janeiro de 2022, divididos em dois grupos: G1 - composto por pacientes cuja pressão sistólica de pico apresentou incremento ≥ 90 mmHg (valor correspondente ao percentil 95 da população estudada) -, e G2 - formado por indivíduos que não apresentaram resposta hipertensiva exagerada. Os grupos foram comparados mediante os testes t de Student e qui-quadrado. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica, REPASE, queixa de precordialgia típica prévia ao exame e angina durante o teste. Resultados Dos 14.367 pacientes, 1.500 (10,4%) desenvolveram REPASE e 7.471 (52,0%) eram do sexo feminino. Os percentuais de queixa prévia de precordialgia típica, angina durante o teste e isquemia miocárdica dos pacientes com REPASE foram de 5,8%, 2,4% e 18,1% contra 7,4%, 3,9% e 24,2%, em indivíduos sem REPASE, respectivamente (p = 0,021, p = 0,004, p < 0,001). Na análise multivariada, a REPASE foi associada, independentemente, a uma menor probabilidade de isquemia miocárdica (odds ratio: 0,73; intervalo de confiança de 95%: 0,58 a 0,93; p = 0,009). Conclusão O incremento exagerado da pressão arterial sistólica durante a EEF pode ser um marcador de exclusão de isquemia miocárdica.

Abstract Background The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. Objective To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). Methods This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. Results Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). Conclusion Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Subclinical Systolic Dysfunction during Chemotherapy for Breast Cancer

Abstract Background Cardiotoxicity is the main complication related to cancer therapy. Studies indicate that global longitudinal strain is an early detector of subclinical dysfunction of the left ventricle, preceding the decline in ejection fraction (EF). However, the reproducibility of such methodology has not been tested outside specialized centers. Objectives To assess the frequency of subclinical cardiotoxicity and to compare global longitudinal strain and EF measurements during the clinical course of patients undergoing chemotherapy for breast cancer. Methods This was an observational prospective study of 78 adult women who underwent serial echocardiograms (baseline and 1, 3, and 6 months after the beginning of chemotherapy), to evaluate biplane and 3D EF and global longitudinal strain. Cardiotoxicity and subclinical dysfunction were defined according to American Society of Echocardiography/European Association of Cardiovascular Imaging criteria. Statistical significance was set at p < 0.05. Results The mean age of the patients was 50.1 ± 11.48 years. The frequency of subclinical cardiotoxicity (defined by global longitudinal strain) was 14.9% after 30 days of chemotherapy, 16.7% after 3 months, and 19.7% after 6 months, compared to 4.5%, 3%, and 6.6%, respectively, when clinical cardiotoxicity was determined according to EF. The group that developed subclinical cardiotoxicity by 30 days (group A) had a higher frequency of clinical cardiotoxicity at 3 months (p=0.028) and a lower mean biplane EF after 30 days (p= 0.036) than the group that showed no evidence of subclinical cardiotoxicity (group B). Conclusion Subclinical cardiotoxicity was frequent and began early, being associated with a drop in EF during the clinical course.

Aging, heart rate variability and patterns of autonomic regulation of the heart.

OBJECTIVES: To evaluate the effects of aging, gender and body mass index on the heart rate variability (HRV), and to compare the patterns of global autonomic regulation (GAR) and parasympathetic outflow (PO) throughout the aging process. DESIGN, SETTING AND PARTICIPANTS: CROSS-SECTIONAL: Large sample of community-based adults and elderly people. Individuals aged from 40 to 100 years, functionally independent and with satisfactory cognitive function defined as the self-capacity to interact with an interviewer (N= 1743). MATERIAL AND METHODS: The study enrolled individuals of both genders, stratified into five age-groups. We did adjustments for hypertension, dyslipidemia and non-insulin-dependent diabetes, as well as the body mass index (BMI). All groups undertook long-term electrocardiograms and five time-domain HRV parameters were measured, three (SDNN, SDANN, SDNN-index) reflecting the GAR and two (rMSSD and pNN50) the PO. RESULTS: SDNN, SDANN and SDNN-index decreased linearly with age and BMI, and women had lower values than men (p<0.001). There was a U-shaped pattern of rMSSD and pNN50, with the nadir between 60 and 69 years for both genders, and women had higher values than men (p<0.001). The lowest levels of all HRV variables were found in diabetics (p<0.001). There was no influence of hypertension or dyslipidemia. CONCLUSIONS: The GAR decreased linearly with the age in both genders. It is comparatively lower in women, diabetics and overweight individuals. The PO presented the U-shape in both genders with the nadir at the 7th decade. It was also comparatively lower in men and diabetics. Hypertension and dyslipidemia imparted no significant influence.

Level of Physical Activity and In-Hospital Course of Patients with Acute Coronary Syndrome.

BACKGROUND: Acute coronary syndrome (ACS) is one of the main causes of morbidity and mortality in the modern world. A sedentary lifestyle, present in 85% of the Brazilian population, is considered a risk factor for the development of coronary artery disease. However, the correlation of a sedentary lifestyle with cardiovascular events (CVE) during hospitalization for ACS is not well established. OBJECTIVE: To evaluate the association between physical activity level, assessed with the International Physical Activity Questionnaire (IPAQ), with in-hospital prognosis in patients with ACS. METHODS: Observational, cross-sectional, and analytical study with 215 subjects with a diagnosis of ACS consecutively admitted to a referral hospital for cardiac patients between July 2009 and February 2011. All volunteers answered the short version of the IPAQ and were observed for the occurrence of CVE during hospitalization with a standardized assessment conducted by the researcher and corroborated by data from medical records. RESULTS: The patients were admitted with diagnoses of unstable angina (34.4%), acute myocardial infarction (AMI) without ST elevation (41.4%), and AMI with ST elevation (24.2%). According to the level of physical activity, the patients were classified as non-active (56.3%) and active (43.7%). A CVE occurred in 35.3% of the cohort. The occurrence of in-hospital complications was associated with the length of hospital stay (odds ratio [OR] = 1.15) and physical inactivity (OR = 2.54), and was independent of age, systolic blood pressure, and prior congestive heart failure. CONCLUSION: A physically active lifestyle reduces the risk of CVE during hospitalization in patients with ACS.

Low Prevalance of Major Events Adverse to Exercise Stress Echocardiography.

BACKGROUND: Stress echocardiography is well validated for diagnosis and risk stratification of coronary artery disease. Exercise stress echocardiography (ESE) has been shown to be the most physiological among the modalities of stress, but its safety is not well established. OBJECTIVE: To study the complications related to ESE and clinical and echocardiographic variables most commonly associated with their occurrence. METHODS: Cross-sectional study consisting of 10250 patients submitted to ESE for convenience, from January 2000 to June 2014. Cardiac Arrhythmias (CA) were the most frequent complications observed during the examination. The volunteers were divided into two groups according to the occurrence of CA during ESE: G1 group, composed of patients who have CA, and G2 formed by individuals who did not show such complication. RESULTS: Group G1, consisting of 2843 patients (27.7%), and Group G2 consisting of 7407 patients (72.3%). There was no death, acute myocardial infarction, ventricular fibrillation or asystole. Predominant CAs were: supraventricular extrasystoles (13.7%), and ventricular extrasystoles (11.5%). G1 group had a higher mean age, higher frequency of hypertension and smoking, larger aortic roots and left atrium (LA) and lower ejection fraction than G2. G1 group also had more ischemic changes (p < 0.001). The predictor variables were age (RR 1.04; [CI] 95% from 1.038 to 1.049) and LA (RR 1.64; [CI] 95% from 1.448 to 1.872). CONCLUSION: ESE proved to be a safe modality of stress, with non-fatal complications only. Advanced age and enlargement of the left atrium are predictive of cardiac arrhythmias.

Ecoestresse físico na cardiomiopatia hipertrófica: como, quando e por quê? / Exercise stress echocardiography in hypertrophic cardiomyopathy: how, when and why?

Resumo Historicamente, o papel do ecocardiograma de estresse físico no manejo da cardiomiopatia hipertrófica tem sido negligenciado na prática clínica, de acordo com a análise das diretrizes do American College of Cardiology/ American Heart Association de 2002, que recomendavam cautela no uso dessa metodologia, em portadores de cardiomiopatia hipertrófica, devido ao risco de possível ocorrência tanto de arritmia cardíaca, como de colapso hemodinâmico no esforço. Atualmente, o estresse físico na cardiomiopatia hipertrófica integra a avaliação rotineira de pacientes sintomáticos com ou sem gradiente da via de saída do ventrículo esquerdo < 50 mmHg, em repouso. Para este grupo, é um método seguro e confiável para medir o gradiente da via de saída do ventrículo esquerdo durante o esforço e sólido diferenciador de pacientes com cardiomiopatia hipertrófica não obstrutivos (gradiente ausente, tanto em repouso quanto no esforço) daqueles com gradientes lábeis (gradiente ausente no repouso e presente no esforço). Portanto, na avaliação da cardiomiopatia hipertrófica, o estresse físico é igualmente útil na quantificação do grau de regurgitação mitral, nas alterações da contratilidade segmentar do ventrículo esquerdo e na avaliação da função diastólica do ventrículo esquerdo, diante do esforço, sendo capaz de predizer o futuro desenvolvimento de sintomas de insuficiência cardíaca. O método é também importante na determinação das diferentes estratégias de tratamento para cada paciente, desde a miomectomia cirúrgica ou a ablação septal alcoólica, para aqueles com gradiente lábil, com sintomas limitantes e refratários ao tratamento medicamentoso versus transplante cardíaco para aqueles sem gradiente.(AU)

Disfunção diastólica precoce em pacientes com câncer de mama submetidas à quimioterapia / Early diastolic dysfunction in breast cancer patients undergoing chemotherapy

Fundamento: A quimioterapia para o câncer de mama está associada a complicações cardiovasculares graves, como a insuficiência cardíaca. A fração de ejeção do ventrículo esquerdo é o principal parâmetro para avaliar a função sistólica nessas pacientes. Todavia, a ocorrência de disfunção diastólica pode preceder à disfunção sistólica. Objetivos: Avaliar as funções diastólica e sistólica do ventrículo esquerdo de portadoras de câncer de mama em tratamento quimioterápico com antraciclinas. Métodos: Trata-se de estudo observacional, longitudinal, analítico e prospectivo. Estudaram-se 62 mulheres com câncer de mama, com idades de 21 a 75 anos, que realizaram ecocardiogramas basais e após 3 meses de tratamento. Avaliaram-se parâmetros de função diastólica, e as pacientes foram classificadas em disfunção diastólica tipos:1, 2 ou 3. Definiu-se a disfunção sistólica como fração de ejeção do ventrículo esquerdo ≤ 53%. Resultados: Decorridos 3 meses de tratamento, 35 pacientes (56,4%) apresentavam disfunção diastólica tipo 1, e apenas uma (1,6%) do tipo 2. A disfunção diastólica ocorreu em 26 pacientes já na etapa basal e surgiu em dez indivíduos no decurso do tratamento. Os parâmetros de função diastólica velocidade de onda E e relação E/A diminuíram significativamente (p < 0,05) com a quimioterapia, todavia, os demais não tiveram variação significativa. Apenas três pacientes apresentaram disfunção sistólica, porém verificou-se maior redução da fração de ejeção do ventrículo esquerdo no grupo que desenvolveu disfunção diastólica durante o tratamento comparativamente ao grupo que apresentava já disfunção diastólica no período basal (p = 0,04). Conclusão: A disfunção diastólica ocorre precocemente em portadoras de câncer de mama submetidas à quimioterapia. O surgimento de disfunção diastólica no decurso do tratamento se associa à redução significativa da fração de ejeção do ventrículo esquerdo. (AU)

Background: Chemotherapy for breast cancer is associated with serious cardiovascular complications such as heart failure. The left ventricular ejection fraction is the main parameter used to assess systolic function in these patients. However, the occurrence of diastolic dysfunction may precede that of systolic dysfunction. Objectives: To evaluate left ventricle diastolic and systolic functions in women with breast cancer undergoing chemotherapy using anthracyclines. Methods: This observational, longitudinal, analytical, and prospective study included 62 women with breast cancer aged 21­75 years old who underwent echocardiography at baseline and after three months of treatment. Diastolic function parameters were evaluated, and the patients were classified as diastolic dysfunction type 1, 2, or 3. Systolic dysfunction was defined as a left ventricular ejection fraction ≤ 53%. Results: After three months of treatment, 35 patients (56.4%) had type 1 diastolic dysfunction, while one (1.6%) had type 2. Diastolic dysfunction was identified in 26 patients at baseline and developed in 10 patients during treatment. Diastolic function parameters, E wave velocity, and E/A ratio decreased significantly (p < 0.05) with chemotherapy; however, the others showed no significant variations. Only three patients had systolic dysfunction, but there was a greater reduction in left ventricular ejection fraction in the group that developed diastolic dysfunction during treatment versus the group with diastolic dysfunction at baseline (p = 0.04). Conclusion: Diastolic dysfunction occurs early in women with breast cancer undergoing chemotherapy. Its onset during the course of treatment is associated with a significantly reduced left ventricular ejection fraction. (AU)