High-density Lipoprotein-cholesterol Subfractions and Coronary Artery Calcium: The ELSA-Brasil Study.

BACKGROUND: Although elevated high-density lipoprotein cholesterol (HDL-C) is considered protective against atherosclerotic cardiovascular disease, no causal relationship has been demonstrated. HDL-C comprises a group of different subfractions that might have different effects on atherosclerosis. Our objective was to investigate the association between HDL-C subfractions with the coronary artery calcium (CAC) score. METHODS: We included 3,674 (49.8 ± 8.3 years, 54% women) participants from the ELSA-Brasil study who had no prior history of CVD and were not currently using lipid-lowering medications. We measured the fasting lipoprotein cholesterol fractions (in mmol/l) by a zonal ultracentrifugation method (VAP). We analyzed the independent predictive values of total HDL-C, HDL2-C, and HDL3-C subfractions and in the HDL2-C/HDL3-C ratio using linear regression to predict Ln(CAC+1) and logistic regression to predict the presence of CAC. RESULTS: Overall 912 (24.8%) of the participants had CAC>0, and 294 (7.7%) had CAC>100. The mean total HDL-C, HDL2-C, and HDL3-C were: 1.42 ± 0.37, 0.38 ± 0.17 and 1.03 ± 0.21 mmol/l, respectively. Individuals with CAC>0 had lower levels of total HDL-C as well as of each subfraction (p < 0.001). When adjusted for age, gender, smoking, hypertension, alcohol use, physical activity, and LDL-C, we observed an inverse association between HDL-C and its subfractions and CAC (p < 0.05). However, by adding triglycerides in the adjustment, neither total HDL-C nor its subfractions remained independently associated with the presence or extent of CAC. CONCLUSION: In this cross-sectional analysis, neither the total HDL-C nor its subfractions (HDL2-C and HDL3-C, as well as HDL2-C/HDL3-C ratio) measured by VAP are independently associated with the presence or extent of coronary calcification.

Relation of Fasting Triglyceride-Rich Lipoprotein Cholesterol to Coronary Artery Calcium Score (from the ELSA-Brasil Study).

Although low-density lipoprotein cholesterol (LDL-C) is widely accepted as the principal lipid fraction associated with atherosclerosis, emerging evidence suggests a causal relation between lifelong elevations in triglyceride-rich lipoprotein cholesterol (TRL-C) and cardiovascular disease (CVD) in genetic studies. To provide further evidence for the potential relevance of TRL-C and atherosclerosis, we have evaluated the relation between TRL-C and coronary artery calcium (CAC) score. We included 3,845 subjects (49.9 ± 8.4 years, 54% women) who had no history of CVD, were not using lipid-lowering medications, and underwent CAC evaluation. We assessed the relation between increasing fasting TRL-C and the graded increase in CAC and to what extent TRL-C were independently associated with CAC over and above LDL-C using logistic regression models. Overall, 973 (25%) of the participants had a CAC >0 and 308 (8%) had a CAC >100. The median TRL-C level was 22 mg/dL (IQR 16 to 32). Subjects with CAC >0 had higher TRL-C levels than those with CAC = 0 (p <0.001). Similarly, subjects with CAC >0 had higher levels of LDL-C, non-high-density lipoprotein cholesterol, and lower high-density lipoprotein cholesterol (all p <0.001). After multivariate adjustment, log-transformed TRL-C remained associated with the presence and severity of CAC (all p <0.05). When TRL-C was added to models that contained demographic factors and conventional lipids, it significantly improved the model to predict the presence of CAC >0 (p = 0.01). In conclusion, in a large cohort of asymptomatic subjects, TRL-C was associated with subclinical atherosclerosis supporting a potentially causal role in CVD.

Age, Gender, and Race-Based Coronary Artery Calcium Score Percentiles in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Coronary artery calcium (CAC) has been demonstrated to independently predict the risk of cardiovascular events and all-cause mortality, especially among White populations. Although the population distribution of CAC has been determined for several White populations, the distribution in ethnically admixed groups has not been well established. HYPOTHESIS: The CAC distribution, stratified for age, gender and race, is similar to the previously described distribution in the MESA study. METHODS: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a prospective cohort study designed to investigate subclinical cardiovascular disease in 6 different centers of Brazil. Similar to previous studies, individuals with self-reported coronary or cerebrovascular disease and those treated for diabetes mellitus were excluded from analysis. RESULTS: Percentiles of CAC distribution were estimated with nonparametric techniques. The analysis included 3616 individuals (54% female; mean age, 50 years). As expected, CAC prevalence and burden were steadily higher with increasing age, as well as increased in men and in White individuals. Our results revealed that for a given CAC score, the ELSA-derived CAC percentile would be lower in men compared with the Multi-Ethnic Study of Atherosclerosis (MESA) and would be higher in women compared with MESA. CONCLUSIONS: In our sample of the Brazilian population, we observed significant differences in CAC by sex, age, and race. Adjusted for age and sex, low-risk individuals from the Brazilian population present with significantly lower CAC prevalence and burden compared with other low-risk individuals from other worldwide populations. Using US-derived percentiles in Brazilian individuals may lead to overestimating relative CAC burden in men and underestimating relative CAC burden in women.

Increase in mortality due to myocardial infarction in the Brazilian city of São Paulo during winter.

OBJECTIVE: To study the seasonal variation in mortality due to myocardial infarction in the city of São Paulo. METHODS: We analyzed the database of PROAIM (Programa de Aprimoramento de Informações de Mortalidade) containing the registrations of the certificates of deaths due to myocardial infarction (International Classification of Diseases, 10th edition, classification I21) of the residents of the municipality of São Paulo during 12 months (from December 1996 to November 1997). The number of deaths was corrected for a standard period of 90 days and then it was divided by the corresponding population to obtain the event rate per 10 thousand inhabitants. The magnitude of the seasonal variation, which was defined by the difference of the relative risks between the seasons with higher and lower mortality, was estimated. RESULTS: A total of 5,615 deaths due to myocardial infarction were included in the study. Sixty-one per cent occurred in the male sex, and the mean age was 68 years. The mortality rate during winter was always higher and that during summer was lower than that during the other seasons (P<0.01), independent from age and sex. Seasonal variations in deaths due to myocardial infarction was 30% in the general group, being 23% in individuals who died younger than 75 years, and 44% in the older ones. CONCLUSION: A marked seasonal variation in mortality due to myocardial infarction was observed in the city of São Paulo, with a significant increase in its magnitude and age distribution during the winter, similar to those reported in regions of North America and Europe with temperate climates.

Subcutaneous tissue thickness is an independent predictor of image noise in cardiac CT.

BACKGROUND: Few data on the definition of simple robust parameters to predict image noise in cardiac computed tomography (CT) exist. OBJECTIVES: To evaluate the value of a simple measure of subcutaneous tissue as a predictor of image noise in cardiac CT. METHODS: 86 patients underwent prospective ECG-gated coronary computed tomographic angiography (CTA) and coronary calcium scoring (CAC) with 120 kV and 150 mA. The image quality was objectively measured by the image noise in the aorta in the cardiac CTA, and low noise was defined as noise < 30 HU. The chest anteroposterior diameter and lateral width, the image noise in the aorta and the skin-sternum (SS) thickness were measured as predictors of cardiac CTA noise. The association of the predictors and image noise was performed by using Pearson correlation. RESULTS: The mean radiation dose was 3.5 ± 1.5 mSv. The mean image noise in CT was 36.3 ± 8.5 HU, and the mean image noise in non-contrast scan was 17.7 ± 4.4 HU. All predictors were independently associated with cardiac CTA noise. The best predictors were SS thickness, with a correlation of 0.70 (p < 0.001), and noise in the non-contrast images, with a correlation of 0.73 (p < 0.001). When evaluating the ability to predict low image noise, the areas under the ROC curve for the non-contrast noise and for the SS thickness were 0.837 and 0.864, respectively. CONCLUSION: Both SS thickness and CAC noise are simple accurate predictors of cardiac CTA image noise. Those parameters can be incorporated in standard CT protocols to adequately adjust radiation exposure.

Association between psoriasis and coronary calcium score.

BACKGROUND: Emerging data suggests that chronic inflammatory disease, such as psoriasis, may be associated to coronary artery disease (CAD). OBJECTIVE: Analyze the association between psoriasis and subclinical atherosclerosis using coronary calcium score (CAC). METHODS: We investigated 221 participants with psoriasis and 718 age- and sex-matched controls without prior known CAD. All participants completed a questionnaire and underwent laboratory tests and a CAC exam. Logistic regression models adjusted for Framingham risk score (FRS) and C-reactive protein (hs-CRP) were built. CAC was included in the models as a binary variable with different cut off values. RESULTS: Body-mass index, race, hypertension, HDL, LDL and hs-CRP were significantly associated with psoriasis presence and severity. Psoriasis severity was significantly associated with CAC (p = 0.04), particularly for very high CAC (>400) (p < 0.01). The OR for severe psoriasis and CAC >400 was 2.45 (95%CI: 1.26-4.75) in unadjusted models. In a model adjusted for the FRS, this association was no longer significant, but a trend was noted (p = 0.09). No significant changes in the association were noted after the inclusion of hs-CRP in the model. CONCLUSION: Psoriasis is associated with higher CAC values, mainly in individuals with severe psoriasis. The current findings also suggest the potential involvement of other mechanisms beyond classical cardiovascular risk factors and inflammation in this association.

Association between postprandial triglycerides and coronary artery disease detected by coronary computed tomography angiography.

BACKGROUND: Studies have demonstrated the association of severe anatomical coronary artery disease (CAD) with postprandial triglycerides (TG) concentrations. Nevertheless the relationship between less severe atherosclerosis plaque burden and postprandial TG is less established. OBJECTIVE: to study the relationship between postprandial TG and CAD detected by coronary computed tomographic angiography (CTA). MATERIAL AND METHODS: 130 patients who underwent an oral fat tolerance test were enrolled (85 with CAD detected by CTA and 45 without). Postprandial lipemia was studied by measuring TG from T0h to T6h with 2-h intervals, and analyzed the TG change over time using a longitudinal multivariable linear mixed effects model with the log normal of the TG as the primary outcome. RESULTS: The majority of individuals with CAD had non-obstructive disease (63.3%) Patients with CAD had a slower clearance of postprandial TG change from 4 h to 6 h (p<0.05) compared to patients without CAD. These results remained significant after adjustment for fasting TG and glucose, age, gender, body mass index, and waist circumference. However, those differences did not reach statistical significance after adjustment for fasting HDL-C. CONCLUSION: Patients with mild (<25% lumen obstruction) and moderate CAD (25-50% lumen obstruction) detected by coronary CTA had an impaired postprandial metabolism, with a delayed TG clearance, when compared to individuals with no CAD. This difference was partially explained by the lower HDL-C. Thus, though postprandial TG may contribute to the development of CAD, this association is partially related to low HDL-C.

Calcium score to evaluate chest pain in the emergency room.

Some authors have suggested that a zero calcium score (CAC) can be used to rule out the diagnosis of acute coronary syndrome. Objective this study is to evaluate the diagnostic accuracy of a zero CAC when compared to the coronary computed tomography angiography (CCTA) at the emergency department. 135 symptomatic patients with no previous coronary heart disease (CHD) who presented to the emergency department were submitted to CAC and CCTA to rule out CHD. All patients had normal electrocardiogram and cardiac biomarkers and were TIMI risk score 0 to 2. The CCTA was considered positive if any obstructive lesion (> 50%) was identified. The mean age was 51.7 ± 13.6 years with 50.6% of men. Seventy-three (54.1%) patients had a calcium score of zero. Of them, 3 (4.1%) had an obstruction > 50 % and underwent invasive coronary angiography. Calcium score showed a sensitivity of 92.9%, specificity of 75.3%, positive and negative predictive values of, respectively, 62.9% and 95.9%. Positive and negative likelihood ratios were respectively of 3.7 and 0.09 to detect lesions greater than 50% in the CCTA. A negative likelihood ratio of 0.09 is very good to rule out most cases of significant coronary obstruction in epidemiologic studies. However, it is important to understand that in a clinical scenario, all evidence including history, clinical examination, data from eletrocardiogram and myocardial biomarkers have to be interpreted together. In our study, three cases with a zero CAC score had coronary obstruction higher than 50% at the CCTA.

Aortic dissection-induced acute flaccid paraplegia treated with cerebrospinal fluid drainage.

Acute aortic dissection is a life-threatening event in which prompt and correct diagnosis is associated with better outcomes. In most cases, there is chest or back pain. However, in rare cases, patients have little or no pain and other symptoms are more conspicuous at presentation. The autors reports the case of a 47-year-old female patient who sought medical attention for sudden-onset paraplegia. The physical examination was normal except for bilateral lower limb flaccid paralysis, with abolition of deep tendon reflexes and paraesthesia in both feet. Computed tomography showed aortic dissection, with partial thrombosis of the false lumen, starting after the emergence of the left subclavian artery and extending, toward the bifurcation of the aorta, to the left iliac artery. After cerebrospinal fluid drainage, the evolution was favorable.

Acute inferolateral ST-elevation myopericarditis diagnosed by delayed enhancement cardiac computed tomography.

A 20-year-old man with no previous medical history presented to the Emergency Department (ED) complaining of 3 h of chest pressure. He denied drug abuse or risk factors for coronary artery disease. He had no symptoms of viral infection. Physical examination was unremarkable. The first electrocardiogram (ECG) showed a 4 mm ST-segment elevation in the inferior leads and no PR depression. His troponin and CK-MB levels were abnormal. Urgent coronary angiography showed no lesions. Echocardiography was normal. The patient was investigated with cardiac computed tomography (CT) and late enhancement imaging. Cardiac anatomy and coronary arteries were normal in the first pass images. Later image acquisition showed an inferolateral enhancement. Since cardiac magnetic resonance (CMR) is the gold standard for myocarditis evaluation, the patient was transferred for CMR evaluation which showed edema and late enhancement in the same myocardial territory diagnosed by CT. The patient was discharged with a diagnosis of myocarditis and presented asymptomatic at 1 month follow-up. This is the first report to show the topographic correlation of the ECG ST elevation with the myocarditis diagnosed by CT and CMR. Since CT is more widely available, its use in myocarditis diagnosis might become part of its routine work up.

Espessura do tecido subcutaneo como preditor independente de ruido em imagem de TC cardiaca / Subcutaneous Tissue Thickness is an Independent Predictor of Image Noise in Cardiac CT

Fundamento: Há poucos dados sobre a definição de parâmetros simples e robustos para predizer artefato de imagem em tomografia computadorizada (TC) cardíaca. Objetivos: Avaliar o valor da simples medida da espessura do tecido subcutâneo (espessura pele-esterno) como preditor de artefato de imagem em TC cardíaca. Métodos: O estudo avaliou 86 pacientes submetidos a angiotomografia computadorizada cardíaca (ATCC) com sincronização prospectiva com ECG e avaliação de escore de cálcio coronário com 120 kV e 150 mA. A qualidade da imagem foi medida objetivamente pelo artefato de imagem na aorta em ATCC, sendo 'artefato baixo' definido como aquele < 30 UH. Os diâmetros torácicos anteroposterior e laterolateral, o artefato de imagem na aorta e a espessura pele-esterno foram medidos como preditores de artefato em ATCC. A associação de preditores e artefato de imagem foi avaliada usando-se correlação de Pearson. Resultados: A dose média de radiação foi 3,5 ± 1,5 mSv. O artefato de imagem médio na ATCC foi de 36,3 ± 8,5 UH, sendo o artefato de imagem médiona fase sem contraste do exame de 17,7 ± 4,4 UH. Todos os preditores foram independentemente associados com artefato em ATCC. Os melhores preditores foram espessura pele-esterno, com correlação de 0,70 (p < 0,001), e artefato de imagem na fases em contraste,com correlação de 0,73 (p < 0,001). Ao avaliar a habilidade de predizer artefato de imagem baixo, as áreas sob a curva ROC para o artefato de imagem na fases em contraste e para a espessura pele-esterno foram 0,837e 0,864, respectivamente. Conclusão: Tanto espessura pele-esterno quanto artefato de escore de cálcio são preditores simples e precisos de artefato de imagem em ATCC. Tais parâmetros podem ser incorporados aos protocolos ...

Background: Few data on the definition of simple robust parameters to predict image noise in cardiac computed tomography (CT) exist. Objectives: To evaluate the value of a simple measure of subcutaneous tissue as a predictor of image noise in cardiac CT. Methods: 86 patients underwent prospective ECG-gated coronary computed tomographic angiography (CTA) and coronary calcium scoring (CAC) with 120 kV and 150 mA. The image quality was objectively measured by the image noise in the aorta in the cardiac CTA, and low noise was defined as noise < 30HU. The chest anteroposterior diameter and lateral width, the image noise in the aorta and the skin-sternum (SS) thickness were measured as predictors of cardiac CTA noise. The association of the predictors and image noise was performed by using Pearson correlation. Results: The mean radiation dose was 3.5 ± 1.5 mSv. The mean image noise in CT was 36.3 ± 8.5 HU, and the mean image noise in non-contrast scan was 17.7 ± 4.4 HU. All predictors were independently associated with cardiac CTA noise. The best predictors were SS thickness, with a correlation of 0.70 (p < 0.001), and noise in the non-contrast images, with a correlation of 0.73 (p < 0.001). When evaluating the ability to predict low image noise, the areas under the ROC curve for the non-contrast noise and for the SS thickness were 0.837 and 0.864, respectively. Conclusion: Both SS thickness and CAC noise are simple accurate predictors of cardiac CTA image noise. Those parameters can be incorporated in standard CT protocols to adequately adjust radiation exposure. .

Influences of the weather and air pollutants on cardiovascular disease in the metropolitan area of São Paulo.

OBJECTIVE: Cardiovascular disease (CVD) has been associated with meteorological variables and pollutant levels. However, these relationships have rarely been studied in São Paulo, Brazil. METHODS: From 1996 to 2000, biometeorological indices including meteorological variables such as temperature, relative humidity, and wind were used to measure thermal comfort in elderly people mortality (>65 years old), and CVD was quantified. RESULTS: Statistical analysis showed a significant negative loading between CVD and meteorological variables as well as thermal comfort indices. The CVD curve was a U-shaped, showing higher value for cold stress than for heat stress. The results clearly show seasonal variations in CVD mortality rates, which were higher in winter. Meteorological variables were found to play an important role as well as through the thermal comfort indices. The air pollutants, PM(10) and SO(2), except ozone, presented positive loadings with CVD, albeit less than statistically significant.

Temperatura ambiente, poluição do ar e infarto agudo do miocárdio / Ambient temperature, air pollution and acute myocardial infarction

Neste artigo, abordaremos a importância dos fatores ambientais como gatilho para a ocorrência do infarto agudo do miocárdio. A crescente atenção com o aquecimento global, efeito estufa e a poluição atmosférica torna oportuno este tema. A temperatura ambiente exerce importante influência sobre o desencadeamento do infarto agudo do miocárdio, ocorrendo aumento tanto das internações como da mortalidade por doença isquêmica do coração nos extremos de temperatura, seja nos dias mais frios ou mais quentes do ano, sendo maior o impacto das baixas temperaturas. A poluição atmosférica, através do material particulado inalável, originado principalmente da queima de combustíveis fósseis, também apresenta efeito deletério sobre esta patologia, tanto nas elevações transitórias como na exposição crônica, ao longo dos anos. Discutiremos os mecanismos biológicos pelos quais estes efeitos se produzem e as medidas que podem ser tomadas para minorar suas consequências em diversos níveis, do planejamento urbano ao atendimento clínico.

Increase in mortality due to myocardial infarction in the Brazilian city of Säo Paulo during winter

OBJECTIVE: To study the seasonal variation in mortality due to myocardial infarction in the city of Säo Paulo. METHODS: We analyzed the database of PROAIM (Programa de Aprimoramento de Informaçöes de Mortalidade) containing the registrations of the certificates of deaths due to myocardial infarction (International Classification of Diseases, 10th edition, classification I21) of the residents of the municipality of Säo Paulo during 12 months (from December 1996 to November 1997). The number of deaths was corrected for a standard period of 90 days and then it was divided by the corresponding population to obtain the event rate per 10 thousand inhabitants. The magnitude of the seasonal variation, which was defined by the difference of the relative risks between the seasons with higher and lower mortality, was estimated. RESULTS: A total of 5,615 deaths due to myocardial infarction were included in the study. Sixty-one per cent occurred in the male sex, and the mean age was 68 years. The mortality rate during winter was always higher and that during summer was lower than that during the other seasons (P<0.01), independent from age and sex. Seasonal variations in deaths due to myocardial infarction was 30 percent in the general group, being 23 percent in individuals who died younger than 75 years, and 44 percent in the older ones. CONCLUSION: A marked seasonal variation in mortality due to myocardial infarction was observed in the city of Säo Paulo, with a significant increase in its magnitude and age distribution during the winter, similar to those reported in regions of North America and Europe with temperate climates

O laboratório digital em ecocardiografia: quando e como implementar / Digital echocardiographic laboratory: when and how to have it

O ambiente digital, com seus recentes desenvolvimentos em termos de eficiência e segurança, traz muitas vantagens ao campo da ecocardiografia. Com esse novo sistema de trabalho, as imagens são transformadas em linguagem de computador, na forma de fotos e filmes curtos, para documentação e armazenamento. A adoção do padrão DICOM (Digital Imaging and Communications in Medicine), pela Associção Americana de Ecocardiografia, possibilita a compatibilidade entre equipamentos de diferentes fabricantes e com sistemas computacionais do hospital, denominado HIS(Hospital Information System) e do setor de imagens, denominado RIS(Radiology Information System). Com esses sistemas integrados, além da identificação, dados clínicos e administrativos podem ser associados às imagens as quais, também, incorporam parâmetros de calibração, permitindo revisão das medidas, controle de qualidade dos exames e um efetivo controle financeiro e do fluxo de pacientes...

Persistência do canal arterial no periodo neonatal / Persistente ductus arteriosus in the newborn

Os autores apresentam uma atualizaçäo no diagnóstico e tratamento da persistência do canal arterial. Säo analisados fatores envolvidos na sua ocorrência e sua relaçäo com a prematuridade. E avaliada a acuracia do diagnóstico clínico isolado e a importância da ecocardiografia na orientaçäo para a melhor terapêutica no momento do diagnóstico. Finalmente, comenta-se os vários tratamentos possiveis, suas complicaçöes e contra-indicaçöes