Autonomic dysfunction in COVID-19 patients receiving mechanical ventilation: A cross-sectional study

ABSTRACT BACKGROUND: Coronavirus disease 2019 (COVID-19) can damage cardiac tissue by increasing troponin levels and inducing arrhythmias, myocarditis, and acute coronary syndrome. OBJECTIVES: To analyze the impact of COVID-19 on cardiac autonomic control in mechanically ventilated intensive care unit (ICU) patients. DESIGN AND SETTING: This cross-sectional analytical study of ICU patients of both sexes receiving mechanical ventilation was conducted in a tertiary hospital. METHODS: Patients were divided into COVID-19-positive (COVID(+)) and COVID-19-negative (COVID(-)) groups. Clinical data were collected and heart rate variability (HRV) records obtained using a heart rate monitor. RESULTS: The study sample comprised 82 subjects: 36 (44%) in the COVID(-) group (58.3% female; median age, 64.5 years) and 46 (56%) in the COVID(+) group (39.1% females; median age, 57.5 years). The HRV indices were lower than the reference values. An intergroup comparison identified no statistically significant differences in the mean normal-to-normal (NN) interval, standard deviation of the NN interval, or root mean square of successive differences in NN intervals. The COVID(+) group had an increased low frequency (P = 0.05), reduced high frequency (P = 0.045), and increased low frequency/high frequency (LF/HF) ratio (P = 0.048). There was a weak positive correlation between LF/HF and length of stay in the COVID(+) group. CONCLUSION: Patients who received mechanical ventilation had lower overall HRV indices. COVID(+) patients who received mechanical ventilation had lower vagal HRV components. These findings likely indicate clinical applicability, as autonomic control impairments are associated with a greater risk of cardiac death.

Alterações Hematológicas durante um Período de Sete Dias de Internação em Pacientes com Infarto Agudo do Miocárdio / Hematological Changes during Seven Days of Hospitalization in Patients with Acute Myocardial Infarction

Resumo Fundamento O infarto agudo do miocárdio é uma das principais causas de mortalidade em todo o mundo e a formação de placa aterosclerótica é o principal mecanismo fisiopatológico, que resulta em inflamação crônica e induz a maturação eritrocitária, podendo causar aumento no índice de amplitude de distribuição dos glóbulos vermelhos (RDW). Objetivo Avaliar o papel do índice de anisocitose em pacientes com infarto agudo do miocárdio em ambos os tipos de infarto como preditor de gravidade. Métodos Os pacientes foram incluídos no estudo de acordo com os critérios de inclusão e exclusão, seguindo a rotina hospitalar baseada na história clínica e laboratorial. As análises estatísticas foram realizadas de acordo com cada variável. Chegou-se a todas as conclusões considerando o nível de significância de 5%. Resultados Durante o período de acompanhamento, nos 349 pacientes analisados, a taxa de mortalidade esteve associada às variáveis RDW (CV) e RDW (SD). Nos pacientes que foram a óbito, notou-se aumento, conforme demonstrado no modelo multivariado, nos efeitos de um infarto agudo do miocárdio com supradesnivelamento do segmento ST e RDW, ajustado para fatores de confusão (valor-p = 0,03 e 0,04). Em contrapartida, o número total de eritrócitos (valor-p = 0,00) e hemoglobina (valor-p = 0,03) apresentou diminuição durante a internação de pacientes graves. Conclusão O índice de anisocitose foi fator preditivo de mortalidade e pode ser utilizado como indicador de pior prognóstico em pacientes com infarto agudo do miocárdio.

Abstract Background Acute myocardial infarction is a major cause of mortality worldwide, and atherosclerotic plaque formation is the main pathophysiological mechanism, which results in chronic inflammation that induces erythrocyte maturation and may cause an increase in the red cell distribution width (RDW) index. Objective Evaluate the role of the anisocytosis index in patients with acute myocardial infarction in both types of infarctions as a predictor of severity. Methods Patients were included in the study according to the inclusion/exclusion criteria, following the hospital routine based on their clinical and laboratory history. Statistical analyzes were performed according to each variable. All conclusions were drawn considering the significance level of 5%. Results During the follow-up period, in the 349 patients analyzed, the mortality rate was associated with the variables RDW (CV) and RDW (SD), in those patients who died, an increase was noted, as demonstrated in the multivariate model, for the effects of an acute ST elevation myocardial infarction and the RDW, adjusted for confounding factors (p-value = 0.03 and 0.04). In contrast, the total number of erythrocytes (p-value = 0.00) and hemoglobin (p-value = 0.03) showed a decrease during severe patients' hospitalization. Conclusion The anisocytosis index was a predictive factor of mortality and can be used as an indicator of worse prognosis in patients with acute myocardial infarction.

Heart rate turbulence assessed through ergometry after myocardial infarction: a feasibility study

ABSTRACT BACKGROUND: Coronary artery disease is an important cause of morbidity and mortality. The impact of ventricular arrhythmias with impaired cardiac vagal activity is one of the most recently studied prognostic factors. However, there are no studies evaluating the phenomenon of heart rate turbulence (HRT) during physical exertion. OBJECTIVE: To study the behavior of HRT during exercise testing, among individuals after myocardial infarction. DESIGN AND SETTING: Feasibility study conducted in a university hospital among individuals 4-6 weeks after myocardial infarction. METHODS: All subjects underwent 24-hour Holter monitoring and ergometric stress testing. We considered that abnormal HRT was present if the turbulence onset was ≥ 0% or turbulence slope was ≤ 2.5 mm/relative risk interval. RESULTS: All 32 subjects were asymptomatic. Their median age was 58 years (interquartile range 12.8) and 70% were male. Abnormal HRT was associated with ventricular dysfunction in this population. We found no differences regarding the behavior of HRT, in relation to age, gender, smoking, systemic arterial hypertension, diabetes mellitus or dyslipidemia. Ergometric stress testing detected premature ventricular beats (PVB) in approximately 44% of the examinations, and these occurred both during the active phase of effort and in the recovery period. The low occurrence of several isolated PVB in beta-blocked subjects made it difficult to perform statistical analysis to correlate HRT between ergometric and Holter testing. CONCLUSION: The data obtained in this study do not support performing HRT through ergometric stress testing among patients who remain on beta-blockers post-myocardial infarction, for the purpose of assessing cardiac vagal activity.

Orthostatic changes in blood pressure and survival in elderly cardiopaths

SUMMARY OBJECTIVE: The objective of this study was to analyze the association between orthostatic changes in blood pressure and mortality in elderly cardiopath patients. METHODS: A cohort of 455 elderly cardiopath patients, monitored at a referral outpatient cardiology clinic in Pernambuco, Brazil, from October 2015 to July 2018. The exposure groups were formed according to their orthostatic changes in blood pressure following the requirements of the Brazilian Guidelines for Hypertension. RESULTS: Orthostatic hypotension was present in 46 patients (10.1%), 91 had orthostatic hypertension (20%), and 318 had no orthostatic alterations (69.9%). There were 52 deaths during follow-up. The results demonstrated that there was no statistically significant association between orthostatic hypotension and overall mortality (HR 1.30; 95%CI 0.53-3.14; p=0.567) nor between orthostatic hypertension and overall mortality (HR 0.95; 95%CI 0.65-1.39; p=0.34). Survival in relation to the exposure groups presented no statistically significant difference (p=0.504). CONCLUSION: There was a low frequency of orthostatic hypotension and a mild high frequency of orthostatic hypertension when compared with previous studies, and no association was observed with overall mortality or with the survival time of elderly patients with heart disease.

Total arterial coronary bypass graft surgery is associated with better long-term survival in patients with multivessel coronary artery disease: a systematic review with meta-analysis

Abstract Introduction: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

The impact of visceral fat and levels of vitamin D on coronary artery calcification

SUMMARY OBJECTIVE: To evaluated calcification of the coronary arteries and its association with visceral fat and 25-hydroxyvitamin D (25(OH)D) serum levels. METHODS: A cross sectional study involving 140 individuals without any previous diagnosis of cardiovascular disease. A biochemical analysis of vitamin D serum levels was carried out, as well as computed tomography to measure coronary artery calcium score and visceral adipose tissue. RESULTS: The mean age of the individuals was 55.9 (±12.4). Coronary artery calcium was observed in 40.7% of the population. Vitamin D presented median serum levels of 30.4 ng/ml (IQ24.5-39.1), with 14,1 and 33.7% of the individuals presenting deficiency and insufficiency, respectively. In the univariate analysis, the calcium score was more prevalent in aged patients (p<0.01), in hypertensive individuals (p<0.01), in diabetics (p=0.02), and in those with a higher concentration of VAT (p=0.02). In the adjusted analysis, it was found that the highest concentration of VAT (OR: 4.0; 95%CI 1.4-11.7), hypertension (OR: 4.8; 95%CI 1.5-15.3), and age (OR: 10.4; 95%CI 3.9-27.6) were predictors of subclinical atherosclerosis, regardless of body mass index, diabetes, and 25OHD. CONCLUSIONS: Excess visceral fat was associated with subclinical atherosclerosis, regardless of other risk factors for cardiovascular disease. Serum levels of 25OHD were not associated with CAD in its early stages.

Performance of a Hematological Scoring System in Predicting All-Cause Mortality in Patients with Acute Myocardial Infarction

Abstract Background: The presence of nucleated red blood cells (NRBCs) and increases in mean platelet volume (MPV) and neutrophil to lymphocyte ratio (NLR) in peripheral circulation are associated with poorer prognosis in patients with acute coronary disease. Objective: We developed a scoring system for in-hospital surveillance of all-cause mortality using hematological laboratory parameters in patients with acute myocardial infarction (AMI). Methods: Patients admitted for AMI were recruited in this prospective study. Exclusion criteria were age younger than 18 years, glucocorticoid therapy, cancer or hematological diseases and readmissions. NRBCs, MPV and NLR were measured during hospitalization. The scoring system was developed in three steps: first, the magnitude of the association of clinical and laboratory parameters with in-hospital mortality was measured by odds ratio (OR), second, a multivariate logistic regression model was conducted with all variables significantly (p < 0.05) associated with the outcome, and third, a β-coefficient was estimated by multivariate logistic regression with hematological parameters with a p < 0.05. Results: A total of 466 patients (mean age were 64.2 ± 12.8 years, 61.6% male) were included in this study. A hematological scoring system ranging from 0 to 49, where higher values were associated with higher risk of in-hospital death. The best performance was registered for a cut-off value of 26 with sensitivity of 89.1% and specificity of 67.2%, positive predictive value of 26.8% (95% CI: 0.204 - 0.332) and negative predictive value of 97.9% (95% CI: 0.962 - 0.996). The area under the curve for the scoring system was 0.868 (95% CI: 0.818 - 0.918). Conclusions: Here we propose a hematological scoring system for surveillance tool during hospitalization of patients with acute myocardial infarction. Based on total blood count parameters, the instrument can evaluate inflammation and hypoxemia due to in-hospital complications and, consequently, predict in-hospital mortality.

Mortality due to congenital heart disease in Pernambuco from 1996 to 2016

SUMMARY BACKGROUND To determine the magnitude and temporal trends of deaths due to congenital heart disease (CHD) in Pernambuco between 1996 and 2016. METHODS This was an ecological, time-series study, involving all cases of deaths from congenital cardiovascular malformations in the state of Pernambuco, from 1996 to 2016, using data from DATASUS, SINASC and SIM. RESULTS There were 3,584 deaths from congenital cardiovascular malformations amongst individuals aged 0 to 14 years, of which 81.94% were concentrated in children aged under one year. The infant mortality rate (IMR) presented a linear growth trend of 0.4645 per year (p <0.01). The cause-of-death code Q24 (other congenital malformations of the heart) was present in 72.54% of the death records and 48.17% of the deaths occurred in infants aged between 28 and 364 days of life. The highest occurrence of deaths was identified in children with low birth weight (500 and 1,499g), male, premature, children of mothers without schooling, in deliveries at home (p <0.05). CONCLUSIONS Congenital heart disease still represents a public health problem as a cause of death, particularly in the first year of life, with IMR in a linear growth trend. Deaths from CHD were more prevalent in male children, born prematurely, with low birth weight, born to mothers with low schooling and deliveries without medical care.

RESUMO OBJETIVO Determinar a magnitude e tendência temporal dos óbitos por doenças cardiovasculares congênitas (DCC) em Pernambuco entre 1996 e 2016. MÉTODOS Trata-se de um estudo ecológico, de série temporal, com todos os casos de óbitos por doenças cardiovasculares congênitas no estado de Pernambuco, entre 1996 e 2016, por meio dos dados do Datasus, Sinasc e SIM. RESULTADOS Ocorreram 3.584 óbitos por DCC entre indivíduos de 0 a 14 anos de idade, dos quais 81,94% foram concentrados em crianças menores de 1 ano de idade. A taxa de mortalidade infantil apresentou tendência linear de crescimento de 0,4645 por ano (p<0,01). A causa Q24 (outras malformações congênitas do coração) esteve presente em 72,54% dos registros de óbitos e 48,17% dos óbitos ocorreram na faixa etária de 28 a 364 dias de vida. Maior ocorrência de óbitos foi identificada entre os nascidos com peso entre 500 e 1.499 g, do sexo masculino, pré-termos, filhos de mães sem escolaridade e em partos domiciliares (p<0,05). CONCLUSÕES As cardiopatias congênitas ainda representam um problema de saúde pública como causa de mortalidade, especialmente no primeiro ano de vida. A taxa de mortalidade por DCC apresentou tendência linear de crescimento. As características gerais demonstraram significância estatística para óbitos entre crianças prematuras, com baixo peso, do sexo masculino, nascidas de mães sem escolaridade e em partos domiciliares.

Demographic and clinical characteristics of pulmonary arterial hypertension caused by schistosomiasis are indistinguishable from other etiologies

Abstract INTRODUCTION: Pulmonary arterial hypertension (PAH) is a serious pulmonary circulation disease caused by several etiologies, including schistosomiasis. The present study retrospectively evaluated the clinical and hemodynamic characteristics of patients with schistosomal PAH (PAH-Sch) compared to those of non-Sch PAH patients (non-Sch PAH). METHODS: Patients treated at the Pronto-Socorro Cardiológico de Pernambuco and diagnosed by right cardiac catheterization were divided into PAH-Sch and non-Sch PAH groups. Their socio-demographic and clinical characteristics, N-terminal-pro B-type natriuretic peptide (NT-proBNP), and echocardiography and hemodynamic parameters were retrospectively reviewed. RESULTS: Among the included 98 patients (mean age, 45 ± 14 years; 68 women [69.4%]), we found 56 PAH-Sch and 42 non-Sch PAH. The age distribution was heterogeneous in the PAH-Sch group, with patients predominantly ranging from 50-59 (p <0.004). Dyspnea was the most common symptom, reported by 92 patients (93.8%), and commonly present for over two years prior to diagnosis. Clinical symptoms were similar in both groups, with no differences in functional class, pulmonary artery systolic pressure (p = 0.102), 6-minute walk test score (p = 0.234), NT-proBNP serum levels (p = 0.081), or hemodynamic parameters. CONCLUSIONS: Patients with PAH-Sch present clinical, laboratory, and hemodynamic profiles similar to those with PAH resulting from other etiologies of poor prognosis. PAH is an important manifestation of schistosomiasis in endemic regions that is often diagnosed late.

Relação da pressão sistólica em artéria pulmonar com gênero, menopausa e gravidez em portadores de hipertensão arterial pulmonar associada à esquistossomose / Pulmonary artery pressure, gender, menopause, and pregnancy in schistosomiasis-associated pulmonary hypertension

FUNDAMENTO: A hipertensão arterial pulmonar associada à esquistossomose (HPAE) é uma grande preocupação no mundo todo. No entanto, o papel de fatores contribuintes específicos do gênero em HPAE é desconhecido. OBJETIVO: Investigamos os valores da pressão arterial pulmonar sistólica (PAPS) e a presença de elevação grave na PAPS relacionado ao gênero, presença de menopausa e histórico de gravidez em pacientes com HPAE. MÉTODOS: Setenta e nove pacientes diagnosticados com HPAE de 2000 a 2009 foram avaliados e 66 foram incluídos no estudo. As informações referentes à idade, status da menopausa, gravidez, PAPS derivada da ecocardiografia, e pressão arterial pulmonar média invasiva (PAPm) foram coletadas de registros médicos. A relação entre os valores de PAPS e PAPm e a correlação para doença grave foram avaliados. Os modelos de regressão avaliaram a associação de gênero, status da menopausa e histórico de gravidez com valores de PAPS e a presença de PAPS severa. RESULTADOS: Houve correlação moderada entre PAPm e PAPS, com boa concordância para classificação de doença grave. Os valores de PAPS foram semelhantes para homens e mulheres. Uma tendência a valores maiores de PAPS foi encontrada para mulheres não menopausadas em comparação a homens. Valores superiores de PAPS foram encontrados para mulheres menopausadas em comparação a mulheres não menopausadas; os valores não foram significativos após o ajuste de idade. O histórico de gravidez não teve relação com a PAPS. Presença de menopausa e passado de gravidez não mostraram associação com valores de PAPS. CONCLUSÃO: Em pacientes com HPAE, nem o gênero, nem o status da menopausa nem o histórico de gravidez apresentou uma correlação independente com valores de HPAE avaliados pela ecocardiografia.

BACKGROUND: Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major concern worldwide. However, the role of gender-specific contributing factors in SPAH is unknown. OBJECTIVE: We investigated how systolic pulmonary artery pressure (SPAP) values and the presence of severe SPAP relate to gender, menopausal status, and pregnancy history in SPAH patients. METHODS: Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66 were enrolled in the study. Information about age, menopausal status, pregnancy, echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP) was collected from medical records. The relation between values of SPAP and mPAP and their agreement for severe disease were assessed. Regression models assessed the association of gender, menopausal status, and pregnancy history with SPAP values and the presence of severe SPAP. RESULTS: Moderate correlation and good agreement for severe disease were found between mPAP and SPAP. Mean SPAP values were similar for men and women. A trend toward higher values of SPAP was found for non-menopausal women compared to men. Higher SPAP values were found for menopausal compared to non-menopausal women; the values were non-significant after adjustment for age. Pregnancy history had no association with SPAP. Menopause and positive pregnancy had no association with severe SPAP. CONCLUSION: In SPAH patients, neither gender, nor menopausal status, nor pregnancy history showed independent correlation with SPAP values assessed by echocardiography.

Recomendações da sociedade brasileira de arritmias cardíacas para serviços de holter / Recommendations of the Brazilian society of cardiac arrhythmias for holter monitoring services

FUNDAMENTOS: Inúmeros indicadores são utilizados para assegurar a qualidade de um serviço; entretanto, a competência médica e o adequado fluxo de realização de um procedimento são determinantes da qualidade final. Nesse contexto, a Sociedade Brasileira de Arritmias Cardíacas pretende recomendar parâmetros mínimos necessários para garantir a excelência dos serviços de monitorização eletrocardiográfica ambulatorial. OBJETIVOS: Recomendar competências médicas mínimas e as informações necessárias para emissão do laudo de Holter. MÉTODOS: O documento foi fundamentado no conceito de medicina baseada em evidência, e nas circunstâncias em que a evidência não estava disponível a opinião de uma comissão de redação foi utilizada para a formulação da recomendação. Essa comissão foi formada por profissionais que apresentam vivência nas dificuldades do método e gestão na prestação de serviços nessa área. RESULTADOS: O profissional responsável pela análise de Holter deve conhecer as patologias cardiovasculares e ter formação consistente em eletrocardiografia, incluindo arritmias cardíacas e seus diagnósticos diferenciais. O laudo deve ser redigido de forma clara e objetiva. Os parâmetros mínimos que devem constar no laudo incluem as estatísticas do exame, assim como quantificação e análise dos distúrbios do ritmo observados durante a monitorização. CONCLUSÃO: A monitorização eletrocardiográfica ambulatorial deve ser realizada por profissionais com vivência em análise eletrocardiográfica e o laudo deve conter os parâmetros mínimos mencionados nesse documento.

BACKGROUND: There are innumerous indicators to assure the quality of a service. However, medical competence and the proper performance of a procedure determine its final quality. The Brazilian Society of Cardiac Arrhythmias recommends minimum parameters necessary to guarantee the excellence of ambulatory electrocardiographic monitoring services. OBJECTIVE: To recommend minimum medical competences and the information required to issue a Holter monitoring report. METHODS: This study was grounded in the concept of evidence-based medicine and, when evidence was not available, the opinion of a writing committee was used to formulate the recommendation. That committee consisted of professionals with experience on the difficulties of the method and management in providing services in that area. RESULTS: The professional responsible for the Holter monitoring analysis should know cardiovascular pathologies and have consistent formation on electrocardiography, including cardiac arrhythmias and their differential diagnoses. The report should be written in a clear and objective way. The minimum parameters that comprise a Holter report should include statistics of the exam, as well as quantification and analysis of the rhythm disorders observed during monitoring. CONCLUSION: Ambulatory electrocardiographic monitoring should be performed by professionals knowledgeable about electrocardiographic analysis, whose report should comprise the minimum parameters mentioned in this document.

Low-intensity resistance exercise does not affect cardiac autonomic modulation in patients with peripheral artery disease

OBJECTIVE: To analyze the effect of a single bout of resistance exercise on cardiac autonomic modulation in patients with peripheral artery disease. METHODS: Fifteen patients with peripheral artery disease (age: 58.3±4.0 years) underwent the following sessions in a random order: resistance exercise (three sets of 10 repetitions of the six resistance exercises with a workload of 5-7 in the OMNI-RES scale) and control (similar to the resistance session; however, the resistance exercises were performed with no load). The frequency domain (low frequency, high frequency and sympathovagal balance) and symbolic analysis (0V, 1V and 2V patterns) of heart rate variability were obtained before and until one hour after the interventions. RESULTS: After the resistance exercise and control sessions, similar increases were observed in the consecutive heartbeat intervals (control: 720.8±28.6 vs. 790.9±34.4 ms; resistance exercise: 712.9±30.1 vs. 756.8±37.9 ms; p<0.05) and in the pattern of the symbolic analysis with no variation (0V) (control: 25.1±3.5 vs. 33.4±4.1%; resistance exercise: 26.1±3.2 vs. 29.7±3.5%; p<0.05) until 50 min after both interventions. The pattern of two variations (2V) decreased similarly (control: 11.2±2.1 vs. 8.3±2.1%; resistance exercise: 9.5±1.7 vs. 7.8±1.7%; p<0.05). In contrast, the pattern of one variation (1V), the low and high frequency bands and sympathovagal balance did not change after the interventions (p>0.05). CONCLUSION: A single bout of resistance exercise did not alter cardiac autonomic modulation in patients with peripheral artery disease. .