Left ventricular structural and functional changes evaluated by echocardiography and two-dimensional strain in patients with sickle cell disease.

INTRODUCTION: Patients with sickle cell disease have increased left ventricular size, which is not usually accompanied by changes in systolic function indexes. We assessed echocardiographic abnormalities present in patients with sickle cell anemia (SCA) and compared echocardiographic parameters to other sickle cell diseases (OSCD). MATERIAL AND METHODS: A blind cross-sectional study with 60 patients with SCA and 16 patients with OSCD who underwent transthoracic echocardiography was performed. RESULTS: Echocardiographic findings were: left atrial volume index 47.7 ±11.5 ml/m² in SCA group and 31.7 ±8.42 ml/m² in OSCD group (p < 0.001); left ventricular diastolic diameter index 3.47 ±0.37 cm/m² in SCA group and 2.97 ±0.41 cm/m² in OSCD group (p < 0.001); left ventricular systolic diameter index 2.12 ±0.31 cm/m² in SCA group and 1.86 ±0.28 cm/m² in OSCD group (p < 0.001). There were no differences in the left ventricular ejection fraction: 68.2 ±6.69% in SCA group and 67.1 ±6.21% in OSCD group (p = 0.527). The ratio between mitral E wave and mean mitral annulus e' wave velocities was higher in the SCA group (7.72 ±1.54 vs. 6.70 ±1.65; p = 0.047). Mitral A wave correlated significantly with hemoglobin levels (r = -0.340; p = 0.032). CONCLUSIONS: There was an increase of left ventricular and left atrial sizes in patients with SCA, compared to patients with OSCD, without changes in systolic or diastolic function in both groups. This could be due to the hyperkinetic state due to the more severe anemia in the SCA subjects.

Interleukin 6 Inhibition and Coronary Artery Disease in a High-Risk Population: A Prospective Community-Based Clinical Study.

BACKGROUND: Atherosclerosis is a chronic inflammatory disease, with interleukin 6 (IL-6) as a major player in inflammation cascade. IL-6 blockade may reduce cardiovascular risk, but current treatments to block IL-6 also induce dyslipidemia, a finding with an uncertain prognosis. METHODS AND RESULTS: We aimed to determine the endothelial function responses to the IL-6-blocking agent tocilizumab, anti-tumor necrosis factor α, and synthetic disease-modifying antirheumatic drug therapies in patients with rheumatoid arthritis in a 16-week prospective study. Sixty consecutive patients with rheumatoid arthritis were enrolled. Tocilizumab and anti-tumor necrosis factor α therapy were started in 18 patients each while 24 patients were treated with synthetic disease-modifying antirheumatic drugs. Forty patients completed the 16-week follow-up period. The main outcome was flow-mediated dilation percentage variation before and after therapy. In the tocilizumab group, flow-mediated dilation percentage variation increased statistically significantly from a pre-treatment mean of (3.43% [95% CI, 1.28-5.58] to 5.96% [95% CI, 3.95-7.97]; P=0.03). Corresponding changes were 4.78% (95% CI, 2.13-7.42) to 6.75% (95% CI, 4.10-9.39) (P=0.09) and 2.87% (95% CI, -2.17 to 7.91) to 4.84% (95% CI, 2.61-7.07) (P=0.21) in the anti-tumor necrosis factor α and the synthetic disease-modifying antirheumatic drug groups, respectively (both not statistically significant). Total cholesterol increased significantly in the tocilizumab group from 197.5 (95% CI, 177.59-217.36) to 232.3 (201.62-263.09) (P=0.003) and in the synthetic disease-modifying antirheumatic drug group from 185.8 (95% CI, 169.76-201.81) to 202.8 (95% CI, 176.81-228.76) (P=0.04), but not in the anti-tumor necrosis factor α group. High-density lipoprotein did not change significantly in any group. CONCLUSIONS: Endothelial function is improved by tocilizumab in a high-risk population, even as it increases total cholesterol and low-density lipoprotein levels.

Correlation between Diastolic Function and Endothelial Function in Patients with Type 2 Diabetes and Hypertension.

BACKGROUND: Endothelial dysfunction may be involved in the pathophysiology of cardiac abnormalities in patients with diabetes mellitus (DM). A correlation between endothelial dysfunction and diastolic dysfunction in patients with type 1 DM has been demonstrated, but this relationship has not been well investigated in type 2 DM. OBJECTIVE: Compare groups of patients with type 2 DM and hypertension with and without diastolic dysfunction using endothelial function indexes, and to assess whether correlations exist between the diastolic function and the endothelial function indexes. METHOD: This was a cross-sectional study of 34 men and women with type 2 DM and hypertension who were aged between 40 and 70 years and were categorized based on assessments of their Doppler echocardiographic parameters as having normal (14 patients) and abnormal (20 patients) diastolic function. Flow-mediated dilatation (FMD) assessments of the brachial artery evaluated the patients' endothelial function. RESULTS: The mean maximum FMD was 7.15 ± 2.80% for the patients with diastolic dysfunction and it was 11.85 ± 4.77% for the patients with normal diastolic function (p = 0.004). Correlations existed between the maximum FMD and the E/e' ratio (p = 0.040, r = -0.354) and the early wave velocity (e') at the lateral mitral annulus (p = 0.002, r = 0.509). CONCLUSION: The endothelial function assessed by FMD was worse in hypertensive diabetic patients with diastolic dysfunction. There were correlations between the diastolic function indexes and the endothelial function indexes in our sample.

Predictive models of six-minute walking distance in adults with sickle cell anemia: Implications for rehabilitation.

BACKGROUND: Sickle cell anemia (SCA) is characterized by a broad spectrum of abnormalities that affect most body organs and systems. To date, there is few data on the influence of these patients' clinical characteristics on the functional exercise capacity. AIM: To investigate the effect of the clinical complications on the functional exercise capacity of adult SCA patients. METHOD: Cross-sectional study, where 45 SCA patients underwent clinical evaluations, echocardiography, pulmonary function testing, and determination of six-minute walking distance (6MWD). RESULTS: A significant correlation (P < 0.001) was found between 6MWD and hemoglobin (Hb) level, tricuspid regurgitation velocity, forced vital capacity, acute chest syndrome, and diffusing capacity for carbon monoxide. The prediction model for 6MWD explained 67% of the 6MWD variability (P < 0.001). CONCLUSIONS: Hemodynamics, cardiovascular function, pulmonary function, and episodes of acute lung injury seem to impact the 6MWD in adults with SCA.

Relationship between pulmonary and cardiac abnormalities in sickle cell disease: implications for the management of patients.

OBJECTIVE: To evaluate the association between clinical, pulmonary, and cardiovascular findings in patients with sickle cell disease and, secondarily, to compare these findings between sickle cell anemia patients and those with other sickle cell diseases. METHODS: Fifty-nine adults were included in this cross-sectional study; 47 had sickle cell anemia, and 12 had other sickle cell diseases. All patients underwent pulmonary function tests, chest computed tomography, and echocardiography. RESULTS: Abnormalities on computed tomography, echocardiography, and pulmonary function tests were observed in 93.5%, 75.0%; and 70.2% of patients, respectively. A higher frequency of restrictive abnormalities was observed in patients with a history of acute chest syndrome (85% vs. 21.6%; p-value<0.0001) and among patients with increased left ventricle size (48.2% vs. 22.2%; p-value=0.036), and a higher frequency of reduced respiratory muscle strength was observed in patients with a ground-glass pattern (33.3% vs. 4.3%; p-value=0.016). Moreover, a higher frequency of mosaic attenuation was observed in patients with elevated tricuspid regurgitation velocity (61.1% vs. 24%; p-value=0.014). Compared to patients with other sickle cell diseases, sickle cell anemia patients had suffered increased frequencies of acute pain episodes, and acute chest syndrome, and exhibited mosaic attenuation on computed tomography, and abnormalities on echocardiography. CONCLUSION: A significant interrelation between abnormalities of the pulmonary and cardiovascular systems was observed in sickle cell disease patients. Furthermore, the severity of the cardiopulmonary parameters among patients with sickle cell anemia was greater than that of patients with other sickle cell diseases.

Implantação de mentoria on-line em uma faculdade de medicina durante a pandemia da Covid-19 / Implementation of online mentoring at a medical school during the Covid-19 pandemic

Resumo: Introdução: Com a interrupção das aulas presenciais nas escolas médicas ocasionada pela pandemia da doença pelo novo coronavírus, verificou-se que os alunos ingressantes no primeiro ano de Medicina de uma faculdade pública brasileira apresentavam maior vulnerabilidade social e psicológica devido aos vínculos pouco consolidados com colegas e com o ambiente acadêmico. Observou-se que os fatores de estresse relacionados às adaptações ao contexto universitário se intensificaram, tornando essa turma prioritária para o desenvolvimento de intervenções emergenciais de suporte e acolhimento. Este trabalho relata um projeto-piloto de mentoria entre professores e alunos em ambiente virtual, visando à sua posterior institucionalização como atividade regular. Descreve etapas de implantação, desenvolvimento, resultados iniciais e perspectivas. Relato de experiência: Foi desenvolvida uma mentoria on-line entre alunos e professores, em que utilizou a dinâmica de grupos de reflexão como estratégia metodológica. Por meio de redes sociais e reuniões on-line, alunos e professores foram convidados a participar do projeto, que contou com seis docentes, um preceptor e 29 alunos, além da equipe coordenadora. Realizou-se uma capacitação on-line de professores com conteúdos teóricos e simulações, objetivando delimitar o papel deles, os objetivos, o enquadre e as especificidades de uma mentoria remota. A avaliação final da atividade foi feita por professores e alunos. Discussão: As medidas de distanciamento social evidenciaram a necessidade de oferecer oportunidades de aprendizagem e de convívio mediadas por plataformas digitais. Comprovou-se a adesão de alunos e professores à mentoria na modalidade on-line, e observou-se a sua potencialidade para fomentar uma relação aluno-professor baseada na troca de ideias, reflexão e suporte social. Constatou-se também um incremento da motivação para a adesão ao curso. Conclusão: A mentoria on-line proporcionou benefícios aos participantes, corroborando resultados de experiências no modelo tradicional presencial, e instigou a realização de pesquisas que aprofundem a investigação sobre a sua eficácia e relevância para a formação médica.

Abstract: Introduction: With the interruption of face-to-face classes in medical schools caused by the Covid-19 pandemic, new first-year medical students at a Brazilian public university showed greater social and psychologic vulnerability due to poorly consolidated ties with colleagues and the academic environment. Intensified stress factors related to adapting to the university environment have been observed, making this group a priority for emergency support and reception interventions. This article reports on a pilot online mentoring project, between teachers and students in a virtual environment, with a view to its subsequent institutionalization as a regular activity. The stages of implementation, development, initial results, and perspectives are described. Experience report: The pilot project aimed to operationalize online mentoring between teachers and students, using reflection group dynamics as a methodological strategy. Through social networks and online meetings, students and teachers were invited to participate in the project, which included six teachers, one preceptor, and twenty-nine students, in addition to the coordination team. Online teacher training with theoretical content and simulations was conducted to outline the teacher's role in the activity, task objectives, framework, and specific characteristics of online mentoring. The final evaluation was performed by teachers and students. Discussion: Social distancing measures have evinced the need for online learning and socializing opportunities. Gathering students and teachers in an online mentoring activity has proven to be feasible and its potential to foster a student-teacher relationship based on exchange of ideas, reflection and social support was observed. Increased motivation to join the course was observed. Conclusion: Online mentoring has brought benefits to the participants, corroborating the results of experiences in the traditional face-to-face model, and has instigated research that deepens investigation into its effectiveness and relevance for medical training.

[Assessing autonomic function in hypertrophic cardiomyopathy]. / Avaliação da função autonômica na cardiomiopatia hipertrófica.

OBJECTIVE: Assess the autonomic function in hypertrophic cardiomyopathy (HCM) through heart rate variability (HRV) and to correlate it to echocardiographic data. METHODS: Two groups were studied, and compared for gender, age and HR: A) Ten (10) patients reporting septal HCM (70% non-obstructive); B) Ten (10) healthy volunteers. HRV was analyzed along four successive stages: at rest, under controlled breathing, while bending, and controlled breathing associated to bending. Variables means were compared between groups and intra-groups in the different stages; in Group A, variables means were correlated to echocardiographic measurements (interventricular septum and left atrial diameter). RESULTS: No HRV difference was reported among groups in the first 3 stages. In the fourth stage vagal activity was shown to be higher in Group A [quadratic mean log between RR intervals (RMSSD) - 1.35+/-0.14 vs 1.17+/-0.16; p=0.019; high frequency component logarithm (LogHF)- 4.89+/-0.22 vs 4.62+/-0.26; p=0.032]. Along the stages, vagal measurements [rate of pairs of consecutive RR intervals whose difference is > or =50 ms (pNN50) and LogHF] also showed lower reduction in the third stage in Group A, while LogHF showed some increase in last stage (p=0.027), thus indicating marked parasympathetic activity in that group. Group A HRV analysis showed no difference among patients reporting larger hypertrophy or atrial diameter. CONCLUSION: 1) Parasympathetic prevalence was shown during autonomic stimulation in HCM patients; 2) No correlation was found between HRV and echocardiographic measurements under analysis.

Renin-Angiotensin System Blockade Associated with Statin Improves Endothelial Function in Diabetics.

BACKGROUND: Studies suggest that statins have pleiotropic effects, such as reduction in blood pressure, and improvement in endothelial function and vascular stiffness. OBJECTIVE: To analyze if prior statin use influences the effect of renin-angiotensin-aldosterone system inhibitors on blood pressure, endothelial function, and vascular stiffness. METHODS: Patients with diabetes and hypertension with office systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 80 mmHg had their antihypertensive medications replaced by amlodipine during 6 weeks. They were then randomized to either benazepril or losartan for 12 additional weeks while continuing on amlodipine. Blood pressure (assessed with ambulatory blood pressure monitoring), endothelial function (brachial artery flow-mediated dilation), and vascular stiffness (pulse wave velocity) were evaluated before and after the combined treatment. In this study, a post hoc analysis was performed to compare patients who were or were not on statins (SU and NSU groups, respectively). RESULTS: The SU group presented a greater reduction in the 24-hour systolic blood pressure (from 134 to 122 mmHg, p = 0.007), and in the brachial artery flow-mediated dilation (from 6.5 to 10.9%, p = 0.003) when compared with the NSU group (from 137 to 128 mmHg, p = 0.362, and from 7.5 to 8.3%, p = 0.820). There was no statistically significant difference in pulse wave velocity (SU group: from 9.95 to 9.90 m/s, p = 0.650; NSU group: from 10.65 to 11.05 m/s, p = 0.586). CONCLUSION: Combined use of statins, amlodipine, and renin-angiotensin-aldosterone system inhibitors improves the antihypertensive response and endothelial function in patients with hypertension and diabetes.

Comparison of benazepril and losartan on endothelial function and vascular stiffness in patients with Type 2 diabetes mellitus and hypertension: A randomized controlled trial.

INTRODUCTION: The purpose of this study was to compare the effects of benazepril and losartan on endothelial function and vascular stiffness, in patients with diabetes mellitus and hypertension. MATERIALS AND METHODS: We included hypertensive diabetic patients with an office systolic blood pressure (BP) ⩾ 130 mmHg and/or diastolic BP ⩾ 80 mmHg. Patients were rolled over to amlodipine for 6 weeks, then we performed C-reactive protein assays, BP measurement and vascular tests; next, patients were randomized to benazepril or losartan. The tests were repeated after 12 weeks. RESULTS: We randomized 14 patients to benazepril and 16 to losartan. There were no differences in systolic (139 versus 134 mmHg, p = 0.618) and diastolic (82 versus 80 mmHg, p = 0.950) BP at the end of the study. C-reactive protein values were lower in the benazepril group (0.38 versus 0.42 mg/dl, p = 0.020). There was a slightly higher flow-mediated vasodilation (FMD) response in the benazepril group (45% increase, p = 0.057) than in the losartan group (19% increase, p = 0.132). Both central systolic BP (129 versus 123 mmHg, p = 0.934) and carotid-femoral pulse wave velocity (cfPWV) (8.5 versus 8.5 m/s, p = 0.280) were the same between groups. CONCLUSIONS: Hypertensive diabetic patients using benazepril had a greater reduction in C-reactive protein, and a slight improvement in FMD, than those taking losartan.

Functional vascular study in hypertensive subjects with type 2 diabetes using losartan or amlodipine.

BACKGROUND: Antihypertensive drugs are used to control blood pressure (BP) and reduce macro- and microvascular complications in hypertensive patients with diabetes. OBJECTIVES: The present study aimed to compare the functional vascular changes in hypertensive patients with type 2 diabetes mellitus after 6 weeks of treatment with amlodipine or losartan. METHODS: Patients with a previous diagnosis of hypertension and type 2 diabetes mellitus were randomly divided into 2 groups and evaluated after 6 weeks of treatment with amlodipine (5 mg/day) or losartan (100 mg/day). Patient evaluation included BP measurement, ambulatory BP monitoring, and assessment of vascular parameters using applanation tonometry, pulse wave velocity (PWV), and flow-mediated dilation (FMD) of the brachial artery. RESULTS: A total of 42 patients were evaluated (21 in each group), with a predominance of women (71%) in both groups. The mean age of the patients in both groups was similar (amlodipine group: 54.9 ± 4.5 years; losartan group: 54.0 ± 6.9 years), with no significant difference in the mean BP [amlodipine group: 145 ± 14 mmHg (systolic) and 84 ± 8 mmHg (diastolic); losartan group: 153 ± 19 mmHg (systolic) and 90 ± 9 mmHg (diastolic)]. The augmentation index (30% ± 9% and 36% ± 8%, p = 0.025) and augmentation pressure (16 ± 6 mmHg and 20 ± 8 mmHg, p = 0.045) were lower in the amlodipine group when compared with the losartan group. PWV and FMD were similar in both groups. CONCLUSIONS: Hypertensive patients with type 2 diabetes mellitus treated with amlodipine exhibited an improved pattern of pulse wave reflection in comparison with those treated with losartan. However, the use of losartan may be associated with independent vascular reactivity to the pressor effect.

Relationship between pulmonary and cardiac abnormalities in sickle cell disease: implications for the management of patients

ABSTRACT Objective: To evaluate the association between clinical, pulmonary, and cardiovascular findings in patients with sickle cell disease and, secondarily, to compare these findings between sickle cell anemia patients and those with other sickle cell diseases. Methods: Fifty-nine adults were included in this cross-sectional study; 47 had sickle cell anemia, and 12 had other sickle cell diseases. All patients underwent pulmonary function tests, chest computed tomography, and echocardiography. Results: Abnormalities on computed tomography, echocardiography, and pulmonary function tests were observed in 93.5%, 75.0%; and 70.2% of patients, respectively. A higher frequency of restrictive abnormalities was observed in patients with a history of acute chest syndrome (85% vs. 21.6%; p-value < 0.0001) and among patients with increased left ventricle size (48.2% vs. 22.2%; p-value = 0.036), and a higher frequency of reduced respiratory muscle strength was observed in patients with a ground-glass pattern (33.3% vs. 4.3%; p-value = 0.016). Moreover, a higher frequency of mosaic attenuation was observed in patients with elevated tricuspid regurgitation velocity (61.1% vs. 24%; p-value = 0.014). Compared to patients with other sickle cell diseases, sickle cell anemia patients had suffered increased frequencies of acute pain episodes, and acute chest syndrome, and exhibited mosaic attenuation on computed tomography, and abnormalities on echocardiography. Conclusion: A significant interrelation between abnormalities of the pulmonary and cardiovascular systems was observed in sickle cell disease patients. Furthermore, the severity of the cardiopulmonary parameters among patients with sickle cell anemia was greater than that of patients with other sickle cell diseases.

Massa Ventricular e Tamanho Atrial em Diabéticos Hipertensos em Uso de Losartana ou Benazepril / Ventricular Mass and Atrial Size in Diabetic Hypertensive Patients Using Losartan or Benazepril

Fundamentos: Diabéticos hipertensos apresentam maior probabilidade de desenvolverem hipertrofia ventricular esquerda e fibrilação atrial. Evidências sugerem que bloqueadores do sistema renina-angiotensina-aldosterona devem ser usado neste grupo de pacientes. Objetivo: Avaliar se há diferença entre os efeitos do inibidor da enzima conversora de angiotensina benazepril e do bloqueador de receptor de angiotensina losartana sobre o tamanho atrial esquerdo, a massa ventricular, quando associados ao tratamento de pacientes hipertensos diabéticos em uso de anlodipino. Métodos: Foram randomizados em dois grupos para associação de losartana ou benazepril 34 pacientes hipertensos e diabéticos tipo 2 do serviço de clínica médica da Universidade do Estado do Rio de Janeiro, após período de 6 semanas apenas com anlodipino. Ao início e ao término do tratamento combinado, os pacientes foram submetidos a ecocardiograma para medidas de cavidades, espessuras parietais e fluxos. Resultados: Houve redução da massa ventricular esquerda indexada no grupo losartana de 81,1 ± 23,5 para 76,9 ± 23,8 g/m² (p = 0,044), sem diferença no grupo benazepril (de 81,8 ± 10,8 para 79,7 ± 12,1; p = 0,520). O diâmetro atrial esquerdo foi menor ao final de 12 semanas (p = 0,034) no grupo losartana, no qual variou de 2,12 ± 0,23 para 2,03 ± 0,22 cm/m² (p = 0,103), quando comparado ao grupo benazepril, no qual variou de 2,12 ± 0,30 para 2,23 ± 0,29 cm/m² (p = 0,064). Conclusão: A combinação losartana e anlodipino foi melhor que a combinação benazepril e anlodipino para redução de massa ventricular esquerda e tamanho do átrio esquerdo nesta amostra de hipertensos diabéticos tipo 2

Background: Hypertensive diabetic patients are more likely to develop left ventricular hypertrophy and atrial fibrillation. Evidence suggests that renin-angiotensin-aldosterone system blockers should be used in this group of patients. Objective: To evaluate if there are differences between the effects of angiotensin-converting enzyme benazepril and the angiotensin-receptor blocker losartan on left atrial size and ventricular mass when associated to the treatment of diabetic hypertensive patients using amlodipine. Methods: 34 hypertensive type-2 diabetic outpatients from the Internal Medicine service of Universidade do Estado do Rio de Janeiro were randomized into two groups, after a period of 6 weeks receiving only amlodipine, to receive losartan or benazepril. At the beginning and end of the combined treatment, patients were submitted to echocardiography for cavity assessment, wall thickness and flow measurements. Results: There was reduction in left ventricular mass index in the losartan group (from 81.1 ± 23.5 to 76.9 ± 23.8 g/m²; p = 0.044), with no difference in the benazepril group (from 81.8 ± 10.8 to 79.7 ± 12.1 g/m²; p = 0.520). The left atrial diameter index was lower at 12 weeks (p=0.034) in the losartan group, which ranged from 2.12 ± 0.23 to 2.03 ± 0.22 cm/m² (p = 0.103) when compared to the benazepril group, which ranged from 2.12 ± 0.30 to 2.23 ± 0.29 cm/m² (p = 0.064). Conclusion: The losartan and amlodipine combination was better than the benazepril and amlodipine combination for left ventricular mass and left atrial size reduction in this sample of type 2 diabetic hypertensive patients

Renin-Angiotensin System Blockade Associated with Statin Improves Endothelial Function in Diabetics / Bloqueio do Sistema Renina-Angiotensina Associado a Estatina Melhora a Função Endotelial em Diabéticos

Abstract Background: Studies suggest that statins have pleiotropic effects, such as reduction in blood pressure, and improvement in endothelial function and vascular stiffness. Objective: To analyze if prior statin use influences the effect of renin-angiotensin-aldosterone system inhibitors on blood pressure, endothelial function, and vascular stiffness. Methods: Patients with diabetes and hypertension with office systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 80 mmHg had their antihypertensive medications replaced by amlodipine during 6 weeks. They were then randomized to either benazepril or losartan for 12 additional weeks while continuing on amlodipine. Blood pressure (assessed with ambulatory blood pressure monitoring), endothelial function (brachial artery flow-mediated dilation), and vascular stiffness (pulse wave velocity) were evaluated before and after the combined treatment. In this study, a post hoc analysis was performed to compare patients who were or were not on statins (SU and NSU groups, respectively). Results: The SU group presented a greater reduction in the 24-hour systolic blood pressure (from 134 to 122 mmHg, p = 0.007), and in the brachial artery flow-mediated dilation (from 6.5 to 10.9%, p = 0.003) when compared with the NSU group (from 137 to 128 mmHg, p = 0.362, and from 7.5 to 8.3%, p = 0.820). There was no statistically significant difference in pulse wave velocity (SU group: from 9.95 to 9.90 m/s, p = 0.650; NSU group: from 10.65 to 11.05 m/s, p = 0.586). Conclusion: Combined use of statins, amlodipine, and renin-angiotensin-aldosterone system inhibitors improves the antihypertensive response and endothelial function in patients with hypertension and diabetes.

Resumo Fundamentos: Estudos sugerem que as estatinas possuem efeitos pleotrópicos, como melhora da função endotelial, da rigidez vascular e redução da pressão arterial. Objetivo: Analisar se o uso prévio de estatina influenciou o efeito sobre a pressão arterial, a função endotelial e a rigidez vascular de drogas inibidoras do sistema renina-angiotensina-aldosterona. Métodos: Pacientes hipertensos e diabéticos com pressão arterial de consultório sistólica ≥ 130 mmHg e/ou diastólica ≥ 80 mmHg tiveram suas medicações anti-hipertensivas substituídas por anlodipino durante 6 semanas. Em seguida, foram randomizados para associação de benazepril ou losartana por mais 12 semanas. Pressão arterial (através da monitorização ambulatorial da pressão arterial), função endotelial (dilatação mediada por fluxo da artéria braquial) e rigidez vascular (velocidade da onda de pulso) foram avaliados antes e após o tratamento combinado. Neste trabalho, uma análise post-hoc foi realizada para comparar pacientes que vinham (grupo CE) ou não (grupo SE) em uso de estatina. Resultados: O grupo CE apresentou maior redução na pressão arterial sistólica nas 24 horas (134 para 122 mmHg, p = 0,007) e na dilatação mediada por fluxo da artéria braquial (6,5 para 10,9%, p = 0,003) quando comparado com o grupo SE (137 para 128 mmHg, p = 0,362, e 7,5 para 8,3%, p = 0,820). Não houve diferença estatisticamente significante na velocidade de onda de pulso (grupo CE 9,95 para 9,90 m/s, p = 0,650 e grupo SE 10,65 para 11,05 m/s, p = 0,586). Conclusão: O uso combinado de estatinas, anlodipino e inibidores do sistema renina-angiotensina-aldosterona melhora a resposta anti-hipertensiva e a função endotelial em pacientes hipertensos e diabéticos.

Functional Vascular Study in Hypertensive Subjects with Type 2 Diabetes Using Losartan or Amlodipine / Estudo Vascular Funcional em Hipertensos com Diabetes Tipo 2 em uso de Losartana ou Anlodipina

Background: Antihypertensive drugs are used to control blood pressure (BP) and reduce macro- and microvascular complications in hypertensive patients with diabetes. Objectives: The present study aimed to compare the functional vascular changes in hypertensive patients with type 2 diabetes mellitus after 6 weeks of treatment with amlodipine or losartan. Methods: Patients with a previous diagnosis of hypertension and type 2 diabetes mellitus were randomly divided into 2 groups and evaluated after 6 weeks of treatment with amlodipine (5 mg/day) or losartan (100 mg/day). Patient evaluation included BP measurement, ambulatory BP monitoring, and assessment of vascular parameters using applanation tonometry, pulse wave velocity (PWV), and flow-mediated dilation (FMD) of the brachial artery. Results: A total of 42 patients were evaluated (21 in each group), with a predominance of women (71%) in both groups. The mean age of the patients in both groups was similar (amlodipine group: 54.9 ± 4.5 years; losartan group: 54.0 ± 6.9 years), with no significant difference in the mean BP [amlodipine group: 145 ± 14 mmHg (systolic) and 84 ± 8 mmHg (diastolic); losartan group: 153 ± 19 mmHg (systolic) and 90 ± 9 mmHg (diastolic)]. The augmentation index (30% ± 9% and 36% ± 8%, p = 0.025) and augmentation pressure (16 ± 6 mmHg and 20 ± 8 mmHg, p = 0.045) were lower in the amlodipine group when compared with the losartan group. PWV and FMD were similar in both groups. Conclusions: Hypertensive patients with type 2 diabetes mellitus treated with amlodipine exhibited an improved pattern of pulse wave reflection in comparison with those treated with losartan. However, the use of losartan may be associated with independent vascular reactivity to the pressor effect. .

Fundamento: A escolha dos fármacos anti-hipertensivos no tratamento de hipertensos diabéticos tem como objetivos o controle da pressão arterial (PA) e a redução das complicações macro/microvasculares. Objetivos: O objetivo deste estudo foi comparar as alterações vasculares funcionais em pacientes hipertensos e diabéticos tipo 2 após seis semanas de anlodipina ou losartana. Métodos: Pacientes com diagnóstico prévio de hipertensão arterial e diabetes melito tipo 2 foram randomizados e divididos em dois grupos, sendo avaliados na sexta semana de uso de losartana 100 mg/dia ou anlodipina 5 mg/dia, com medida da PA, realização de monitoração ambulatorial da pressão arterial e testes para avaliação de parâmetros vasculares, como tonometria de aplanação, velocidade de onda de pulso (VOP) e dilatação mediada por fluxo (DMF) da artéria braquial. Resultados: Foram incluídos 42 pacientes, 21 em cada grupo, com predominância do sexo feminino (71%) nos dois grupos. Os grupos anlodipina e losartana apresentaram média de idade semelhante (54,9 ± 4,5 e 54,0 ± 6,9 anos, respectivamente) e sem diferença estatística na média da PA (145 ± 14/84 ± 8 e 153 ± 19/90 ± 9 mmHg). O augmentation index (30 ± 9% × 36 ± 8%, p = 0,025), assim como a augmentation pressure (16 ± 6 mmHg × 20 ± 8 mmHg, p = 0,045) foram menores no grupo anlodipina que no grupo losartana. Os valores obtidos para VOP e DMF foram semelhantes nos dois grupos. Conclusões: Em hipertensos e diabéticos tipo 2, o uso de anlodipina demonstrou um padrão de reflexão da onda de pulso mais favorável nesse grupo, mas o uso de losartana pode estar associado com ações vasculares independentes do efeito pressórico. .

Metas pressóricas em diabéticos: evidências e recomendações / Blood pressure goals in diabetic patients: evidence and recommendations

Desde que foi estabelecida a relação entre hipertensãoarterial sistêmica (HAS) e maior risco cardiovascular(CV) têm-se realizado esforços no sentido de evitar aocorrência de desfechos cardiovasculares através de um efetivo tratamento anti-hipertensivo. A redução da pressão arterial (PA) é o mais importante objetivo do tratamento da HAS e o alcance das metas pressóricas deve ser perseguido. Um grupo de pacientes diretamente afetados por essa recomendação são os diabéticos. Istos e deve ao notável aumento do risco CV apresentado nos pacientes com coexistência de HAS e diabetes mellitus (DM). Estudos testaram metas variadas de redução da pressão arterial nesse grupo e esse tema permanece sem consenso. A maioria das diretrizes vigentes sugere uma meta pressórica sistólica de130mmHg e diastólica de 80mmHg em pacientes hipertensos com diabetes. Redução mais intensa da PA em diabéticos, além de ser difícil e requerer associação de múltiplos fármacos, não demonstrou benefícios adicionais na redução de desfechos cardiovasculares.Esses dados advêm de trabalhos de meta-análise de vários ensaios clínicos e também de diretrizes de sociedades de cardiologia. PA sistólica (PAS) <130mmHg apresenta resultados heterogêneos em relação à proteção CV, com redução de acidente vascular encefálico (AVE),nenhum benefício adicional sobre outros desfechos cardiovasculares e aumento de efeitos adversos. No presente trabalho, foram revisados os estudos sobre o alcance de metas pressóricas em diabéticos e seu impacto sobre desfechos clínicos relevantes, bem como as recomendações das diretrizes nacional e internacionais sobre o tema.

Since the relationship was established between systemic arterial hypertension (SAH) and increased cardiovascular (CV) risk, efforts have been under way to prevent the occurrence of CV outcomes through effective antihypertensive treatment. Lowering blood pressure (BP) is the most important goal in SAH treatment and blood pressure goals should be pursued. A group directly affected by this recommendation is diabetic patients. This is due to the notable increase in CV risks among patients with coexisting SAH and diabetes mellitus (DM). Studies have tested various blood pressure reduction goals in this group, but this issue is still under discussion. Most guidelines suggest a systolic goal of 130mmHg and 80mmHg for diastolic BP in hypertensive patients with diabetes. Greater BP reductions in diabetics are difficult and require multiple drug combinations, showing no additional benefits in reducing cardiovascular outcomes. These data come from meta analysis studies of several clinical trials and also the guidelines established by cardiology societies. Systolic BP below 130mmHg presents heterogeneous results in terms of CV protection, with a reduction in stroke,no additional benefits for other cardiovascular outcomes and increased adverse effects. This article reviews studies on blood pressure goal achievementin diabetic patients and their impacts on relevant clinical outcomes, as well as the recommendations set forth in Brazilian and international guidelines on this topic.

Avaliação da função autonômica na cardiomiopatia hipertrófica / Assessing autonomic function in hypertrophic cardiomyopathy

OBJETIVO: Avaliar a função autonômica na cardiomiopatia hipertrófica (CMH) através da variabilidade da freqüência cardíaca (VFC) e correlacioná-la com dados ecocardiográficos. MÉTODOS: Foram estudados 2 grupos pareados por sexo, idade e freqüência cardíaca: A) 10 pacientes com CMH septal (70 por cento não obstrutiva); B) 10 voluntários saudáveis. A VFC foi analisada durante quatro estágios sucessivos: repouso, respiração controlada, teste de inclinação e respiração controlada associada ao teste de inclinação. Compararam-se as médias das variáveis entre os grupos, intragrupos durante os estágios, e no grupo A, correlacionando com as medidas ecocardiográficas (septo interventricular e diâmetro atrial esquerdo). RESULTADOS: Não observamos diferença na VFC entre os grupos nos 3 primeiros estágios. No 4° estágio, constatamos que medidas de atividade vagal apresentaram valores maiores no grupo A [logaritmo da raiz média quadrática das diferenças entre intervalos RR (LogRMSSD) - 1,35±0,14 vs 1,17±0,16; p=0,019; logaritmo do componente alta freqüência (LogAF)-4,89±0,22 vs 4,62±0,26; p=0,032]. Durante os estágios, também verificamos que medidas vagais [proporção de pares de intervalos RR consecutivos cuja diferença > 50ms (pNN50) e LogAF] apresentaram menor redução durante o 3° estágio no grupo A, e o LogAF, um aumento no último estágio (p=0,027), indicando marcante atividade parassimpática neste grupo. A análise da VFC do grupo A não revelou diferença entre pacientes com maior hipertrofia ou diâmetro atrial. CONCLUSÃO: 1) ocorreu predomínio parassimpático durante estimulação autonômica nos pacientes com CMH; 2) não encontramos correlação entre VFC e as medidas ecocardiográficas analisadas.