Disfunção Ventricular e do Átrio Esquerdo Subclínica em Pacientes com Acromegalia: Um Estudo de Ecocardiograma de Rastreamento de Manchas / Subclinical Left Atrial and Ventricular Dysfunction in Acromegaly Patients: A Speckle Tracking Echocardiography Study

Resumo Fundamento Embora se saiba que a fração de ejeção (FE) do ventrículo esquerdo (VE) medida por eletrocardiograma seja preservada em pacientes com acromegalia, não há informação suficiente sobre deformação longitudinal global e deformação do átrio esquerdo (SLG-VE e SAE). Objetivo O objetivo deste estudo foi avaliar as funções do ventrículo esquerdo (VE) e do átrio esquerdo (AE) por ecocardiograma strain (ES) em pacientes com acromegalia. Métodos Este estudo incluiu 50 pacientes com acromegalia na forma ativa da doença e 50 controles saudáveis com idade, sexo e área de superfície corporal similares. Além dos ecocardiogramas de rotina, medições de SLG-VE e SAE foram realizadas com o ES. Resultados Os valores dos SAE e SLG-VE foram significativamente mais baixos em pacientes com acromegalia (p<0,05 para todos). Na análise bivariada, a pressão arterial sistólica, o pró-hormônio N-terminal do peptídeo natriurético cerebral, o fator de crescimento semelhante à insulina tipo 1, e detectou-se que os níveis de IMVE tinham correlação positiva com SAE e SLG-VE (p<0,05). O nível de IGF-1 tinha forte correlação com SAE e SLG-VE (p<0,001 e β=0,5 vs. p<0,001 e β=0,626, respectivamente); 48% dos pacientes com acromegalia têm SLG-VE reduzido (<20%). O índice de massa do ventrículo esquerdo (IMVE) determina independentemente a presença de SLG-VE reduzido, e cada 1g/m2 de aumento no nível de IMVE aumenta a probabilidade de redução de SLG-VE em 6%. Conclusão Embora a fração de ejeção de VE seja normal em pacientes com acromegalia, os valores de SAE e SLG-VE são significativamente mais baixos. Além do aumento em IMVE, outro achado do envolvimento cardíaco pode ser a redução de SAE e SLG-VE. Portanto, além do ecocardiograma de rotina, SAE e SLG-VE podem ser úteis para avaliar os sinais iniciais de envolvimento cardíaco antes da ocorrência de alterações cardíacas irreversíveis.

Abstract Background Although it is known that the left ventricular (LV) ejection fraction (EF) measured by echocardiography is preserved in patients with acromegaly, there is not enough information about the LV and left atrial strain (LV-GLS and LAS). Objective This study aimed to evaluate the left ventricular (LV) and left atrial (LA) functions with strain echocardiography (SE) in patients with acromegaly. Methods This study included 50 acromegaly patients with active disease and 50 healthy controls with similar age, gender, and body surface area. In addition to routine echocardiography examinations, LV-GLS and LAS measurements were performed with SE. Results LAS and LV-GLS values were significantly lower in patients with acromegaly (p<0.05 for all). In bivariate analysis, systolic blood pressure, N-terminal prohormone of brain natriuretic peptide, Insulin-like growth factor-1, LA diastolic diameter, and LVMI levels were found to be positively correlated with both LAS and LV-GLS (p <0.05). IGF-1 level was strongly correlated with LAS and LV-GLS (p<0.001 and β=0.5 vs. p<0.001 and β=0.626, respectively); 48% of patients with acromegaly have reduced LV-GLS (<20%). Left ventricular mass-index (LVMI) independently determines the presence of reduced LV-GLS and each 1g/m2increase in LVMI level increases the likelihood of reduced LV-GLS by 6%. Conclusion Although LV ejection fraction is normal in patients with acromegaly, LAS and LV-GLS values were significantly reduced. Apart from LVMI increase, another finding of cardiac involvement may be LAS and LV-GLS decrease. Therefore, in addition to routine echocardiography, LAS and LV-GLS may be useful to evaluate early signs of cardiac involvement before the occurrence of irreversible cardiac changes.

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.

Relações entre a Redução de Estrogênio, Obesidade e Insuficiência Cardíaca com Fração de Ejeção Preservada / Crossroads between Estrogen Loss, Obesity, and Heart Failure with Preserved Ejection Fraction

Resumo A prevalência de obesidade e insuficiência cardíaca com fração de ejeção preservada (ICFEP) aumenta significativamente em mulheres na pós-menopausa. Embora a obesidade seja um fator de risco para disfunção diastólica do ventrículo esquerdo (DDFVE), o mecanismo que liga a interrupção da produção de hormônios ovarianos, especialmente o estrogênio, ao desenvolvimento da obesidade, DDFVE, e ICFEP em mulheres em processo de envelhecimento não é claro. Estudos clínicos e epidemiológicos demonstram que mulheres na pós-menopausa com obesidade abdominal (definida pela circunferência de cintura) têm risco maior de desenvolver a ICFEP do que homens ou mulheres sem obesidade abdominal. Este estudo analisa dados clínicos que corroboram a existência de uma ligação de mecanismo entre a perda de estrogênio mais obesidade e o remodelamento ventricular esquerdo com ICFEP. Ele também discute os possíveis mecanismos celulares e moleculares para a proteção mediada por estrogênio contra tipos de células, depósitos de tecidos, função e metabolismo de adipócitos negativos que podem contribuir para a DDFVE e a ICFEP.

Abstract The prevalence of obesity and heart failure with preserved ejection fraction (HFpEF) increases significantly in postmenopausal women. Although obesity is a risk factor for left ventricular diastolic dysfunction (LVDD), the mechanisms that link the cessation of ovarian hormone production, and particularly estrogens, to the development of obesity, LVDD, and HFpEF in aging females are unclear. Clinical, and epidemiologic studies show that postmenopausal women with abdominal obesity (defined by waist circumference) are at greater risk for developing HFpEF than men or women without abdominal obesity. The study presents a review of clinical data that support a mechanistic link between estrogen loss plus obesity and left ventricular remodeling with LVDD. It also seeks to discuss potential cell and molecular mechanisms for estrogen-mediated protection against adverse adipocyte cell types, tissue depots, function, and metabolism that may contribute to LVDD and HFpEF.

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)

Creatina fosfocinasa MB como marcador diagnóstico de disfunción miocárdica en pacientes pediátricos con quemadura eléctrica / Creatine phosphokinase MB levels as a diagnostic marker of myocardial dysfunction in pediatric patients with electrical burns

Resumen Introducción: La disminución de la fracción de eyección ventricular izquierda (FEVI) como consecuencia de una disfunción ventricular se reporta dentro de las alteraciones cardiacas secundarias a una lesión eléctrica. Como complemento de la exploración física, la ecografía cardiaca enfocada (FoCUS) permite una evaluación rápida, no invasiva, que da información para contribuir a tomar mejores decisiones terapéuticas, sobre todo en pacientes en estado crítico. El objetivo de este estudio fue explorar la utilidad de la creatina fosfocinasa MB (CPK-MB) como marcador diagnóstico de disfunción miocárdica en pacientes de 6 a 18 años con quemadura eléctrica. Métodos: Durante el periodo de noviembre de 2018 a agosto de 2019 se llevó a cabo un estudio transversal analítico de 10 pacientes, de 6 a 18 años de edad, con quemadura eléctrica, en quienes se obtuvo el porcentaje de FEVI a través del protocolo FoCUS. Posteriormente, el porcentaje de FEVI se correlacionó con los valores de CPK-MB y el porcentaje de superficie corporal quemada (SCQ) en las primeras 24 horas después de la lesión. Resultados: Se encontraron 10 casos de quemadura eléctrica, ocho de sexo masculino y dos de sexo femenino, con una media de edad de 13 años. El 80% de estos casos presentó disminución leve de la FEVI (45-59%). Al realizar el protocolo FoCUS se reportó hipocinesia miocárdica en siete pacientes. Se encontró una correlación moderada entre la FEVI y los valores de CPK-MB (r = −0.671), aunque no se observó correlación entre la FEVI y la SCQ. Conclusiones: La ecografía cardiaca influye en la toma de decisiones y mejora el pronóstico de estos pacientes.

Abstract Background: The decrease of the left ventricular ejection fraction (LVEF) as consequence of a ventricular dysfunction is reported in cardiac alterations secondary to electrical injury. The focused cardiac ultrasound (FoCUS) helps to complete the clinical examination because it allows a faster non-invasive evaluation, and provides information that contributes to make better therapeutic decisions, especially those for patients in critical condition. The objective of this study was to explore the utility of creatine phosphokinase MB (CPK-MB) as a diagnostic tool of myocardial dysfunction in patients from 6 to 18 years old with electrical burn. Methods: From November 2018 to August 2019, we conducted a transversal analytic study of 10 children with electric burn (6 to 18 years of age), in whom the percentage of LVEF was obtained through the FoCUS protocol in the first 24 hours after injury. Results: We found 10 cases of electrical burn injury, eight males and two females, with an average of 13 years of age. Eighty percent of these cases showed a slight decrease in LVEF (45-59%). When performing the FoCUS protocol, myocardial hypokinesia was reported in seven patients. We observed a moderate correlation between LVEF and CPK-MB levels (r = −0.671), and no correlation between LVEF and body surface area affected by the electrical burn. Conclusions: The cardiac ultrasound influences decision making to improve the prognosis of these patients.

La asincronía ventricular izquierda como resultado de la estimulación apical permanente por dispositivos en el ventrículo derecho / Left ventricular dyssynchrony as result of right ventricular permanent apical pacing

Resumen La estimulación apical permanente del ventrículo derecho (VD) puede producir asincronía del ventrículo izquierdo (VI) desde los puntos de vista eléctrico y mecánico. Este fenómeno es efecto de una alteración de la activación normal del VI que lleva al deterioro de la función sistólica y la aparición de insuficiencia cardíaca y sus efectos deletéreos relacionados. Para el estudio de la asincronía eléctrica del VI se ha propuesto en fecha reciente el nuevo sistema electrocardiográfico no invasivo Synchromax, que puede cuantificar el grado de asincronía eléctrica que causa una subsecuente asincronía mecánica. Esta última se ha estudiado casi siempre mediante la ecocardiografía transtorácica bidimensional (ETT2D) a través del Doppler tisular y la deformación miocárdica y ahora con la ecocardiografía tridimensional transtorácica en tiempo real (E3DTR). La relación entre estos fenómenos ha sido motivo de estudio a fin de identificar a los pacientes que se benefician de la transición a un tratamiento de resincronización cardíaca. Conclusiones: La estimulación artificial permanente del VD produce asincronía eléctrica del VI que puede cuantificarse mediante el nuevo sistema electrocardiográfico Synchromax y desencadenar asincronía mecánica estudiada mediante la ecocardiografía transtorácica para reconocer a los pacientes que pueden beneficiarse de un tratamiento de resincronización cardíaca.

Abstract Permanent apical pacing of right ventricle (RV) can produce dyssynchrony of the left ventricle (LV) from an electrical and mechanical point of view. This phenomenon is caused by an alteration in the normal activation of LV leading to a deterioration of systolic function and the appearance of heart failure and its associated deleterious effects. For the study of the electrical asynchrony of the LV, a new noninvasive electrocardiographic system Synchromax has recently been proposed, being able to quantify the degree of electrical asynchrony that leads to a subsequent mechanical dyssynchrony. The latter has been traditionally studied by two-dimensional transthoracic echocardiography (2DTTE) through tissue Doppler and myocardial deformation and lately by real-time 3-dimensional echocardiography (RT3DE). The relationship between these phenomena has been the subject of study to predict those patients who benefit from an “upgrade” to cardiac resynchronization therapy. Conclusions: Permanent apical pacing of the RV produces electrical dyssynchrony of the LV that can be quantified using a new electrocardiographic system Synchromax and trigger mechanical asynchrony studied through transthoracic echocardiography allowing to predict those patients who benefit from cardiac resynchronization therapy.

Strain segmentario y longitudinal de pacientes cubanos con drepanocitosis / Segmental and longitudinal strain in Cuban patients with sickle cell disease

Introducción: Las strain segmentaria y longitudinal constituyen excelentes parámetros para la cuantificación de la contractilidad miocárdica. Objetivo: Identificar los valores de strain segmentario y longitudinal de pacientes cubanos con drepanocitosis. Material y Método: Estudio descriptivo prospectivo en los 31 pacientes con drepanocitosis y 52 controles que asistieron al Instituto de Cardiología y Cirugía Cardiovascular entre junio de 2017 a enero de 2018, a los que se determinó strain segmentario y longitudinal como variables de estudio. Se compararon medias mediante la prueba t de Student y se realizó un análisis de varianza (ANOVA) con una prueba a posteriori de Tukey para p<0,05. Resultados: En los drepanocíticos las medias de strain segmentario estuvieron entre -17,7±3,4 porciento (p=0,0001*) y -28,6±4,1 por ciento(p=0,0005*) y -29,3±1,1 porciento (p=<0,0002*), fueron homogéneos todos sus segmentos y en el grupo control entre -19,3±2,9 por ciento (p=0,0001*), en general. Independientemente de que en los pacientes drepanocíticos las medias fueron más bajas estuvieron en el rango de lo normal. Los valores de las medias de strain longitudinal global oscilaron entre -19,2±3,3 y -25,2±2,7 fueron más negativos en el grupo control, respecto a los cubanos con drepanocitosis. Conclusiones: Los resultados obtenidos son los primeros de su tipo publicados en Cuba. Las strain segmentaria y longitudinal de los pacientes drepanocíticos cubanos analizados, con resultados significativamente diferentes que los individuos sanos, pero normales, coinciden con lo informado en la literatura internacional(AU)

Introduction: Segmental and longitudinal strains are excellent parameters for the quantification of myocardial contractility. Objective: To identify the values ​​of segmental and longitudinal strain in Cuban patients with sickle cell disease. Material and Method: A prospective descriptive study was conducted in 31 patients with sickle cell disease and 52 controls who attended the Institute of Cardiology and Cardiovascular Surgery between June 2017 and January 2018, to which segmental longitudinal strain was determined as study variable. The means between the two groups were compared using the Student's t-test; an analysis of variance (ANOVA) was performed with a posteriori Tukey test for p <0.05. Results: In the patients with sickle cell disease, the means of segmental strain were between -17,7±3,4 percent (p=0,0001*) and -28,6±4,1 percent (p=0,0005*) and -29,3±1,1 percent (p=<0,0002*) with all segments being homogeneous; in the control group they were between -19,3±2,9 percent (p=0,0001*) in general. Despite the means were the lowest in Cuban patients with sickle cell disease, they were within the normal range. The mean values ​​of global longitudinal strain ranged between -19.2 ± 3.3 and -25.2 ± 2.7, being more negative in the control group with respect to Cuban patients with sickle cell disease. Conclusions: The results obtained are the first of its type published in Cuba. The segmental and longitudinal strain in Cuban patients with sickle cell disease analyzed, which have significantly different results from those obtained in healthy individuals, but normal, coincide with those reported in the international literature(AU)

The Usefulness of Admission Plasma NT-pro BNP Level to Predict Left Ventricular Aneurysm Formation after Acute ST-Segment Elevation Myocardial Infarction / Utilidade do Nível de NT-Pro-BNP no Plasma à Internação em Predizer a Formação de Aneurisma do Ventrículo Esquerdo após Infarto Agudo do Miocárdio com Elevação do Segmento ST

Abstract Background: Left ventricular aneurysm (LVA) is an important complication of acute myocardial infarction. In this study, we investigated the role of N- Terminal pro B type natriuretic peptide level to predict the LVA development after acute ST-segment elevation myocardial infarction (STEMI). Methods: We prospectively enrolled 1519 consecutive patients with STEMI. Patients were divided into two groups according to LVA development within the six months after index myocardial infarction. Patients with or without LVAs were examined to determine if a significant relationship existed between the baseline N- Terminal pro B type natriuretic peptide values and clinical characteristics. A p-value < 0.05 was considered statistically significant. Results: LVA was detected in 157 patients (10.3%). The baseline N- Terminal pro- B type natriuretic peptide level was significantly higher in patients who developed LVA after acute MI (523.5 ± 231.1 pg/mL vs. 192.3 ± 176.6 pg/mL, respectively, p < 0.001). Independent predictors of LVA formation after acute myocardial infarction was age > 65 y, smoking, Killip class > 2, previous coronary artery bypass graft, post-myocardial infarction heart failure, left ventricular ejection fraction < 50%, failure of reperfusion, no-reflow phenomenon, peak troponin I and CK-MB and NT-pro BNP > 400 pg/mL at admission. Conclusions: Our findings indicate that plasma N- Terminal pro B type natriuretic peptide level at admission among other variables provides valuable predictive information regarding the development of LVA after acute STEMI.

Resumo Fundamento: O aneurisma do ventrículo esquerdo (AVE) é uma importante complicação do infarto agudo do miocárdio (IAM). Objetivo: Investigar o papel da porção N-terminal do pró-hormônio do peptídeo natriurético do tipo B (NT-proBNP) para predizer o desenvolvimento de AVE após infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST). Métodos: Incluímos prospectivamente 1519 pacientes consecutivos com IAMCST. Os pacientes foram divididos em dois grupos de acordo com o desenvolvimento de AVE nos seis meses após o infarto do miocárdio. Os pacientes com ou sem AVE foram examinados para determinar se existia uma relação significativa entre os valores basais do NT-proBNP e as características clínicas. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados: O AVE foi detectado em 157 pacientes (10,3%). O nível basal do NT-proBNP foi significativamente maior em pacientes que desenvolveram AVE após IAM (523,5 ± 231,1 pg/mL vs. 192,3 ± 176,6 pg/mL, respectivamente, p < 0,001). Os preditores independentes da formação de AVE após IAM foram idade > 65 anos, tabagismo, classe Killip > 2, cirurgia de revascularização miocárdica anterior, insuficiência cardíaca pós-infarto do miocárdio, fração de ejeção do ventrículo esquerdo < 50%, falha de reperfusão, fenômeno de no-reflow, pico de troponina I e CK-MB e NT-proBNP > 400 pg/mL na internação. Conclusões: Nossos achados indicam que o nível plasmático do fragmento N-terminal do peptídeo natriurético tipo B na admissão, entre outras variáveis, fornece informações preditivas valiosas sobre o desenvolvimento de AVE após o IAMCST agudo.

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters / Correlação entre Risco de Apneia Obstrutiva do Sono e Parâmetros do Ecocardiograma

Abstract Background: Obstructive sleep apnea (OSA) is a chronic progressive disorder with high mortality and morbidity rate, associated with cardiovascular diseases (CVD), especially heart failure (HF). The pathophysiological changes related to OSA can directly affect the diastolic function of the left ventricle. Objectives: To assess the association of the risk of OSA, evaluated by the Berlin Questionnaire (BQ), and echocardiographic (ECHO) parameters related to diastolic dysfunction in individuals without HF assisted in primary care. Methods: A cross-sectional study that included 354 individuals (51% women) aged 45 years or older. All individuals selected were submitted to an evaluation that included the following procedures: consultation, filling out the BQ, clinical examination, laboratory examination and transthoracic Doppler echocardiography (TDE). Continuous data are presented as medians and interquartile intervals, and categoric variables in absolute and relative frequencies. The variables associated with risk of OSA and at the 0.05 level integrated the gamma regression models with a log link function. A value of p < 0.05 was considered an indicator of statistical significance. Exclusion criteria were presence of HF, to fill out the BQ and patients with hypertension and obesity not classified as high risk for OSA by other criteria. All individuals were evaluated on a single day with the following procedures: medical appointment, BQ, laboratory tests and ECHO. Results: Of the 354 individuals assessed, 63% were classified as having high risk for OSA. The patients with high risk for OSA present significantly abnormal diastolic function parameters. High risk for OSA confirmed positive and statistically significant association, after adjustments, with indicators of diastolic function, such as indexed left atrium volume LAV-i (p = 0.02); E'/A' (p < 0.01), A (p = 0.02), E/A (p < 0.01). Conclusion: Our data show that patients at high risk for OSA present worsened diastolic function parameters measured by TDE.

Resumo Fundamento: A apneia obstrutiva do sono (AOS) é um transtorno crônico, progressivo, com alta morbimortalidade e associado às doenças cardiovasculares (DCV), entre elas a insuficiência cardíaca (IC). As alterações fisiopatológicas relacionadas com a AOS podem impactar diretamente a função diastólica do ventrículo esquerdo. Objetivo: Estimar a associação entre risco de AOS, avaliada pelo Questionário de Berlim (QB), e parâmetros do ecocardiograma, relacionados com a função diastólica, em indivíduos sem IC na atenção primária. Métodos: Estudo transversal que incluiu 354 indivíduos (51% mulheres) com idade igual ou superior a 45 anos. Todos os indivíduos selecionados foram submetidos a uma avaliação que constou dos seguintes procedimentos: consulta, preenchimento do QB e exame clínico, realização de exames laboratoriais e ecocardiograma Doppler transtorácico (EDT). Os dados contínuos são apresentados em medianas e intervalos interquartílicos e os categóricos em frequências absolutas e relativas. As variáveis que apresentaram associação ao risco de AOS em nível de 0,05 integraram os modelos de regressão gama com função de ligação log link. Análise bruta: Um valor de p < 0,05 foi considerado como indicador de significância estatística. Resultados: Dos 354 indivíduos analisados, 63% foram classificados como tendo alto risco para AOS. Os pacientes com alto risco para AOS apresentam alterações significativas dos parâmetros que avaliam a função diastólica. Alto risco para AOS confirmou sua associação positiva e estatisticamente significativa, após ajuste, a indicadores de disfunção diastólica - VAE-i (p = 0,02); E'/A' (p < 0,01); A (p = 0,02); E/A (p < 0,01). Conclusão: Nossos dados mostram que pacientes com alto risco de AOS apresentam piora dos parâmetros de função diastólica medidos pelo EDT.

Papel dos peptídeos natriuréticos no controle, nos desfechos e no prognóstico em sepse e choque séptico / The role of natriuretic peptides in the management, outcomes and prognosis of sepsis and septic shock

RESUMO A sepse persiste como importante sobrecarga à saúde pública nos Estados Unidos e em todo o mundo. Com o crescente uso de tecnologias laboratoriais, tem se renovado o interesse na utilização de biomarcadores na sepse, para auxiliar em um processo mais preciso e direcionado para tomadas de decisão. Os peptídeos natriuréticos vem sendo cada vez mais reconhecidos por seu papel que vai além da insuficiência cardíaca. Estes peptídeos estão comumente elevados em pacientes críticos que apresentam condições de disfunção cardiopulmonar e podem ter papel na identificação de pacientes com sepse e choque séptico. São poucos os dados disponíveis em relação ao papel destes biomarcadores no diagnóstico, no controle, nos desfechos e no prognóstico de pacientes sépticos. Esta revisão procura descrever o papel dos peptídeos natriuréticos na ressuscitação volêmica, no diagnóstico de disfunção ventricular, nos desfechos e no prognóstico de pacientes com sepse. Tem sido observado que o peptídeo natriurético tipo B (BNP) e o fragmento N-terminal do peptídeo natriurético tipo B (NT-proBNP) se associam com disfunção ventricular sistólica e diastólica, tanto esquerda quanto direita, em pacientes com cardiomiopatia séptica. O BNP e o NT-proBNP podem predizer a responsividade a volume, e as tendências de medidas seriadas destes peptídeos podem ser importantes na ressuscitação volêmica. A despeito da sugestão de correlação com mortalidade, o papel do BNP nos desfechos de mortalidade e prognóstico, durante a sepse, ainda necessita melhor avaliação.

ABSTRACT Sepsis continues to be a leading public health burden in the United States and worldwide. With the increasing use of advanced laboratory technology, there is a renewed interest in the use of biomarkers in sepsis to aid in more precise and targeted decision-making. Natriuretic peptides have been increasingly recognized to play a role outside of heart failure. They are commonly elevated among critically ill patients in the setting of cardiopulmonary dysfunction and may play a role in identifying patients with sepsis and septic shock. There are limited data on the role of these biomarkers in the diagnosis, management, outcomes and prognosis of septic patients. This review seeks to describe the role of natriuretic peptides in fluid resuscitation, diagnosis of ventricular dysfunction and outcomes and the prognosis of patients with sepsis. B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) have been noted to be associated with left ventricular systolic and diastolic and right ventricular dysfunction in patients with septic cardiomyopathy. BNP/NT-proBNP may predict fluid responsiveness, and trends of these peptides may play a role in fluid resuscitation. Despite suggestions of a correlation with mortality, the role of BNP in mortality outcomes and prognosis during sepsis needs further evaluation.

Left ventricular assessment in patients with mucopolysaccharidosis using conventional echocardiography and myocardial deformation by two-dimensional speckle-tracking method / Avaliação do ventrículo esquerdo em pacientes com mucopolissacaridose através do ecocardiograma convencional e da deformação miocárdica pelo speckle-tracking bidimensional

Abstract Objective: Mucopolysaccharidosis is a rare genetic disease characterized by the intralysosomal deposition of glycosaminoglycans. Cardiovascular impairment is a common feature. Cardiac signs and symptoms are underestimated due to the disease involvement in other organs. Enzyme replacement therapy can be used in mucopolysaccharidosis I, II, IV, and VI. Thus, the knowledge about the use of new echocardiography tools is relevant to improve the care of this population. This study aimed to describe left ventricular function assessment by conventional echocardiography and left ventricular global longitudinal strain analysis and compare the alterations in patients receiving enzyme replacement therapy and who had different ages at the start of therapy. Method: Outpatient-based descriptive study. The patients were submitted to conventional echocardiography and left ventricular global longitudinal strain measurement. Results: Sixteen patients were evaluated; median age of 14.2 years (SD = 5.2 years). Left ventricular hypertrophy was found in nine patients (56.2%). All patients had preserved left ventricular systolic function (Simpson and Teichholz). Nine (56.2%) patients showed alterations in left ventricular global longitudinal strain. The study showed a positive association between left ventricular hypertrophy and alteration in the left ventricular global longitudinal strain, and late start of enzyme replacement therapy and alteration in the left ventricular global longitudinal strain. Conclusion: Echocardiographic alterations in patients with mucopolysaccharidosis were frequently observed, especially alterations in the left ventricular geometry and subclinical dysfunction. Patients who had a late enzyme replacement therapy start showed an association with worse left ventricular global longitudinal strain values, reinforcing the need for early diagnosis and treatment. The use of new echocardiographic tools may improve the follow-up of these patients.

Resumo Objetivo: A mucopolissacaridose é uma doença genética rara, caracterizada por depósito intralisossômico de glicosaminoglicanos. O comprometimento cardiovascular é frequente. Sinais e sintomas cardíacos são subestimados pelo envolvimento da doença em outros órgãos. A terapia de reposição enzimática pode ser usada em mucopolissacaridose I, II, IV e VI. Assim, o conhecimento da aplicação de novas ferramentas de ecocardiografia é relevante para melhorar a assistência dessa população. Este estudo visou descrever a função do ventrículo esquerdo pelo ecocardiograma convencional e pela análise do strain global longitudinal do ventrículo esquerdo e comparar as alterações em pacientes que fazem uso da terapia de reposição enzimática e que tiveram idades distintas de início da terapia. Método: Estudo descritivo de base ambulatorial. Os pacientes foram submetidos à ecocardiografia convencional e medida do strain global longitudinal do ventrículo esquerdo. Resultados: Foram avaliados 16 pacientes; mediana de 14,2 anos (desvio: 5,2 anos). Hipertrofia do ventrículo esquerdo foi encontrada em nove pacientes (56,2%). Todos os pacientes tiveram função sistólica do ventrículo esquerdo preservada (Simpson e Teichholz). Nove (56,2%) pacientes apresentaram alteração no strain global longitudinal do ventrículo esquerdo. O estudo mostrou associação positiva entre hipertrofia do ventrículo esquerdo e alteração no strain global longitudinal do ventrículo esquerdo e início tardio da terapia de reposição enzimática e alteração no strain global longitudinal do ventrículo esquerdo. Conclusão: Alterações ecocardiográficas em pacientes com mucopolissacaridose foram frequentes, especialmente alterações na geometria e disfunção subclínica do ventrículo esquerdo. Pacientes que iniciaram tardiamente a terapia de reposição enzimática apresentaram associação com piores valores de strain global longitudinal do ventrículo esquerdo, o que reforça a necessidade do diagnóstico e tratamento precoces. O uso de novas ferramentas de ecocardiografia pode melhorar o acompanhamento desses pacientes.

Cardiovascular risk in children and adolescents with end stage renal disease

OBJECTIVES: To evaluate cardiovascular involvement in children and adolescents with End Stage Renal Disease (ESRD) and to characterize the main risk factors associated with this outcome. METHODS: Cross-sectional study of 69 children and adolescents at renal transplantation and 33 healthy individuals matched by age and gender. The study outcomes were left ventricular mass z-score (LVMZ) and carotid artery intima-media thickness (CIMT). The potential risk factors considered were age, gender, CKD etiology, use of oral vitamin D and calcium-based phosphate binders, systolic and diastolic blood pressure, body mass index z-score, time since diagnosis, dialysis duration, serum levels of ionic calcium, phosphorus, parathyroid hormone, fibroblast growth factor (FGF 23), uric acid, homocysteine, cholesterol, triglycerides, C-reactive protein (CRP), vitamin D and hemoglobin. RESULTS: In the multivariate analysis, the factors associated with LVMZ were dialysis duration, age, systolic blood pressure, serum hemoglobin and HDL cholesterol levels. Regarding CIMT, in the multivariate analysis, systolic blood pressure was the only factor associated with the outcome. CONCLUSION: Children exhibited important cardiovascular involvement at the time of the renal transplantation. Both of the studied outcomes were independently associated with systolic blood pressure. For this reason, controlling blood pressure seems to be the main therapy to minimize cardiovascular involvement in children with ESRD.

Obstructive Sleep Apnea is Common and Associated with Heart Remodeling in Patients with Chagas Disease / Apneia Obstrutiva do Sono é Comum e está Associada à Remodelação Cardíaca em Pacientes com Doença de Chagas

Abstract Background: Chagas Disease (CD) is an important cause of morbimortality due to heart failure and malignant arrhythmias worldwide, especially in Latin America. Objective: To investigate the association of obstructive sleep apnea (OSA) with heart remodeling and cardiac arrhythmias in patients CD. Methods: Consecutive patients with CD, aged between 30 to 65 years old were enrolled. Participants underwent clinical evaluation, sleep study, 24-hour Holter monitoring, echocardiogram and ambulatory blood pressure monitoring. Results: We evaluated 135 patients [age: 56 (45-62) years; 30% men; BMI: 26 ± 4 kg/m2, Chagas cardiomyopathy: 70%]. Moderate to severe OSA (apnea-hypopnea index, AHI, ≥ 15 events/h) was present in 21% of the patients. OSA was not associated with arrhythmias in this population. As compared to patients with mild or no OSA, patients with moderate to severe OSA had higher frequency of hypertension (79% vs. 72% vs. 44%, p < 0.01) higher nocturnal systolic blood pressure: 119 ± 17 vs. 113 ± 13 vs. 110 ± 11 mmHg, p = 0.01; larger left atrial diameter [37 (33-42) vs. 35 (33-39) vs. 33 (30-36) mm, p < 0.01]; and a greater proportion of left ventricular dysfunction [LVEF < 50% (39% vs. 28% vs. 11%), p < 0.01], respectively. Predictor of left atrial dimension was Log10 (AHI) (b = 3.86, 95% CI: 1.91 to 5.81; p < 0.01). Predictors of ventricular dysfunction were AHI > 15 events/h (OR = 3.61, 95% CI: 1.31 - 9.98; p = 0.01), systolic blood pressure (OR = 1.06, 95% CI: 1.02 - 1.10; p < 0.01) and male gender (OR = 3.24, 95% CI: 1.31 - 8.01; p = 0.01). Conclusions: OSA is independently associated with atrial and ventricular remodeling in patients with CD.

Resumo Fundamento: A doença de Chagas (DC) é uma causa importante de morbimortalidade por insuficiência cardíaca e arritmias malignas em todo o mundo, especialmente na América Latina. Objetivo: Investigar a associação entre apneia obstrutiva do sono (AOS) com remodelação cardíaca e arritmias cardíacas em pacientes com DC. Métodos: Foram incluídos pacientes consecutivos com DC, com idade entre 30 e 65 anos. Os participantes foram submetidos à avaliação clínica, estudo do sono, Holter de 24 horas, ecocardiograma e monitorização ambulatorial da pressão arterial. Resultados: Foram avaliados 135 pacientes [idade: 56 (45-62) anos; 30% homens; IMC: 26 ± 4 kg/m2, cardiomiopatia chagásica: 70%]. AOS moderada a grave (índice de apneia-hipopneia, IAH, ≥ 15 eventos/h) estava presente em 21% dos pacientes. AOS não estava associada a arritmias nessa população. Em comparação com pacientes com AOS leve ou ausente, pacientes com AOS moderada a grave apresentaram maior frequência de hipertensão (79% vs. 72% vs. 44%, p < 0,01) e pressão arterial sistólica noturna mais alta: 119 ± 17 vs. 113 ± 13 vs. 110 ± 11 mmHg, p = 0,01; diâmetro do átrio esquerdo maior [37 (33‑42) vs. 35 (33-39) vs. 33 (30-36) mm, p < 0,01]; e maior proporção de disfunção ventricular esquerda [FEVE < 50% (39% vs. 28% vs. 11%), p < 0,01], respectivamente. O preditor de dimensão do átrio esquerdo foi Log10 (IAH) (β = 3,86, IC 95%: 1,91 a 5,81; p < 0,01). Os preditores de disfunção ventricular foram IAH >15 eventos/h (OR = 3,61, IC 95%: 1,31 - 9,98; p = 0,01), pressão arterial sistólica (OR = 1,06, IC95%: 1,02 - 1,10; p < 0,01) e sexo masculino (OR = 3,24, IC 95%: 1,31 - 8,01; p = 0,01). Conclusões: A AOS está independentemente associada à remodelação atrial e ventricular em pacientes com DC.

Evaluación ecocardiográfica de pacientes pediátricos post-trasplante cardiaco en Chile: Aplicación inicial de un protocolo funcional con Strain longitudinal global / Echocardiographic evaluation after pediatric heart transplant in Chile: initial application of a functional protocol with global longitudinal strain

Resumen: Introducción: La evaluación ecocardiográfica de pacientes post-trasplante cardiaco pediátrico es una herramienta útil. Sin embargo, aún es necesario definir un protocolo óptimo de seguimiento. Obje tivo: Caracterizar los resultados de la aplicación de un protocolo de evaluación ecocardiográfica fun cional en pacientes en control post-trasplante cardiaco pediátrico ortotópico. Pacientes y Método: Posterior al trasplante cardiaco pediátrico se realizó una ecocardiografía con un protocolo funcional que incluyó strain longitudinal global. Se evaluaron además los datos de la biopsia endomiocárdica y del estudio hemodinámico contemporáneos. Resultados: De un total de 9 pacientes sólo 1 presentó disfunción sistólica de ventrículo izquierdo según parámetros clásicos, pero casi la totalidad presentó un strain longitudinal global alterado. No se observaron episodios de rechazo moderado o severo en estos pacientes. Todos los pacientes presentaban disfunción sistólica ventricular derecha. No se ob servó correlación entre estos parámetros y la presión de arteria pulmonar. Conclusiones: Se observó disfunción sistólica biventricular subclínica en la mayoría de los pacientes de esta serie. No hubo aso ciación con episodios de rechazo o con hipertensión pulmonar, lo que podría estar en relación con la ausencia de episodios de rechazo moderado o severo en la biopsia contemporánea y con el reducido tamaño muestral. Sólo el seguimiento a largo plazo de estos pacientes permitirá definir la relevancia clínica de los hallazgos descritos.

Abstract: Introduction: The echocardiographic evaluation of patients after heart transplantation is a useful tool. However, it is still necessary to define an optimal follow-up protocol. Objective: To describe the results of the application of a functional echocardiographic protocol in patients being followed after pediatric heart transplantation. Patients and Method: Alls patients being followed at our institution after pediatric heart transplantation underwent an echocardiographic examination with a functional protocol that included global longitudinal strain. Contemporaneous endomyocardial biopsy results and hemodynamic data were recorded. Results: 9 patients were evaluated with our echocardiographic functional protocol. Of these patients, only 1 showed systolic left ventricular dysfunction according to classic parameters. However, almost all patients had an abnormal global longitudinal strain. Right ventricular systolic dysfunction was observed in all patients. No epidodes of moderate to severe rejectiom were recorded. No correlation was observed between these parameters and pulmonary artery pressure. Conclusions: Subclinical biventricular systolic dysfunction was observed in the majority of the patients in this study. No association with rejection episodes or pulmonary hypertension was observed, which may be related to the absence of moderate or severe rejection episodes during the study period, and to the small sample size. Long term follow-up of these patients may better define the clinical relevance of our findings.

Estimulación eléctrica permanente en región septal en pacientes con insuficiencia cardíaca secundaria a estimulación en ápex de ventrículo derecho / Permanent septal pacing in patients suffering secondary heart failure compared to right ventricular apical pacing

Resumen Introducción: Independientemente de la modalidad de estimulación (VVI o DDD), el mayor porcentaje de estimulación ventricular derecha deteriora la función contráctil izquierda. Por ello se han estudiado diferentes sitios de estimulación. Objetivo: Describir las diferencias electrocardiográficas y ecocardiográficas entre la estimulación en la región apical y la región septal del ventrículo derecho (VD)0. Métodos: Se estudió a 24 pacientes, 2 mujeres y 22 hombres, con fracción de eyección deprimida (≤ 35%) secundaria a estimulación en punta de VD. Se realizó electrocardiograma durante estimulación en ápex de VD y en seguimiento de estimulación septal. También ecocardiografía en ambos momentos. Resultados: La fracción de eyección se incrementó desde 31 ± 3.1% hasta 45 ± 12% (p = 0.0041) con estimulación septal; esta mostró mejor grado de sincronía mecánica. Conclusiones: La estimulación septal puede constituir un sitio de elección en pacientes con disfunción sistólica de ventrículo izquierdo secundaria a estimulación en ápex de VD, los cuales presenten QRS estrecho en su conducción intrínseca, pues en la muestra estudiada produce una mejoría en la sincronía electromecánica, demostrándose incrementos significativos en la fracción de eyección.

Abstract Introduction: Regardless of the type of electrical stimulation (VVI or DDD) the highest percentage of right ventricular apical pacing can cause left ventricular failure. For this reason, studies have been performed in different sites on right ventricle pacing. Objective: To describe differences between electrocardiography and echocardiography variables during right ventricular apical pacing and septal pacing. Methods: A total of 24 patients were studied, 2 women and 22 men, with heart failure due to conventional pacing on right ventricular (ejection fraction ≤ 35%). An electrocardiogram as well as an echocardiogram, was performed during right ventricular apical pacing and when patients were paced on septal area. Results: The ejection fraction increased from 31 ± 3.1% to 45 ± 12% (P=.0041) on septal pacing, showing higher degree of mechanic synchronisation. Conclusions: Pacing on septal area could be a good site for those patients that suffer heart failure due to right ventricular apical pacing. These must show narrow QRS on their intrinsic electrocardiographic conduction. This kind of pacing can produce an improvement in electro- mechanical synchronisation, as well as show an increased left ventricular ejection fraction.

A rare cause of left ventricular assist device (lvad) obstruction: left atrial dissection

Abstract Left atrial dissection is a rare factor that may cause left ventricular assist device obstruction. Prompt diagnosis and surgical repair are essential. This case report describes our experience and a successful surgical management in a patient after HeartMate 3 implantation and mitral valve inflow obstruction due to a left atrial dissection.

Analysis of dyssynchrony and ventricular function in right univentricular stimulation at different positions

Abstract Introduction: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function. Objective: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation. Methods: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode. Results: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9). Conclusion: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Evaluation of Left Ventricular Diastolic Function by Echocardiography with Tissue Doppler in Systemic Sclerosis / Avaliação da Função Diastólica do Ventrículo Esquerdo com Ecocardiografia Associada a Doppler Tecidual na Esclerose Sistêmica

Abstract Background: Systemic sclerosis (SS) is a connective tissue abnormality characterized by fibrosis of the skin and internal organs. Cardiac involvement with consequent myocardial dysfunction in SS is associated with increased morbidity and mortality. Objective: To investigate the left ventricular (LV) diastolic function in patients with SS and preserved systolic function. Methods: Patients with SS were evaluated with two-dimensional echocardiography with tissue Doppler for analysis of chamber diameters, LV mass index (LVMI), indexed left atrial volume (iLAV), systolic function of both ventricles, and presence and degree of diastolic dysfunction (DD). Results: We evaluated 50 patients, divided according to the presence of DD into Group 1 (n = 25; normal diastolic function, E/A ratio ≥ 0.8, deceleration time [DT] > 150 ms and < 200 ms, and septal e' > 8 cm/s) and Group 2 (n = 25; with DD, subdivided into type I DD [E/A < 0.8, DT > 200 ms], type II [E/A ≥ 0.8, septal e' < 8 cm/s, iLAV > 34 mL/m2], and type III [E/A > 2, DT < 150 ms, septal e' < 8 cm/s]). Type I DD was the most frequent (34%), followed by type II DD (16%). LVMI and iLAV were similar in both groups, but septal and lateral e' were reduced only in Group 2. In Group 2, we observed that patients with moderate DD had longer disease duration (p = 0.02). Conclusion: The prevalence of type I DD was elevated in SS and associated with aging. Disease duration emerged as an important factor in moderate DD.

Resumo Fundamento: A esclerose sistêmica (ES) é uma anomalia do tecido conjuntivo caracterizada por fibrose da pele e dos órgãos internos. O envolvimento cardíaco com consequente disfunção miocárdica na ES está associado a uma maior morbimortalidade. Objetivo: Investigar a função diastólica do ventrículo esquerdo (VE) em pacientes com ES e função sistólica preservada. Método: Pacientes com ES foram estudados com ecocardiografia bidimensional com Doppler tecidual para análise dos diâmetros cavitários, índice de massa do VE (IMVE), volume indexado do átrio esquerdo (VAEi), função sistólica biventricular e presença, além de grau de disfunção diastólica (DD) pelo Doppler convencional e tecidual. Resultados: Estudamos 50 pacientes, divididos conforme presença de DD em Grupo 1 (n = 25; função diastólica normal, razão E/A ≥ 0,8, tempo de desaceleração [TD] > 150 ms e < 200 ms e e' septal > 8 cm/s) e Grupo 2 (n = 25; com presença de DD, subdividido em DD tipo I [E/A < 0,8, TD > 200 ms], tipo II [E/A ≥ 0,8, e' septal < 8 cm/s, VAEi > 34 mL/m2] e tipo III [E/A > 2, TD < 150 ms, e' septal < 8 cm/s]. A DD tipo I foi a mais frequente (34%), seguida de DD tipo II (16%). O IMVE e o VAEi foram similares entre os grupos, porém a e' septal e lateral estiveram reduzidas apenas no Grupo 2. No Grupo 2, observamos que os pacientes com DD moderada apresentavam maior duração da doença (p = 0,02). Conclusão: A prevalência de DD tipo I foi elevada na ES e esteve associada ao envelhecimento. No caso da DD moderada, a duração da doença despontou como um fator importante.

Quercetin inhibits left ventricular dysfunction induced by chronic stress in rats / La quercetina inhibe la disfunción ventricular izquierda inducida por el estrés crónico en ratas

Complications of chronic stress including cardiovascular disease are among the common public health problems that affect the lives of millions of people around the globe. We sought to determine whether the anti-oxidant and anti-apoptotic agent, quercetin can inhibit chronic stress-induced left ventricular dysfunction (LVD). Chronic unpredictable stress (CUS) was induced in rats using a variety of stressors in the presence and absence of quercetin (50 mg/kg body weight/day). Harvested tissues from the left ventricles (LV) of these animals were examined using basic histological staining. In addition, LV tissue homogenates were assayed for markers of oxidative and anti-oxidative stress that are known to be modulated in cardiac dysfunction. Furthermore, LV pressure was monitored by a pressure catheter inserted directly into the LV. Histopathological examinations of the LV in the model group (CUS) showed a profound damage to LV compared to the control group as demonstrated by a severe damage of cardiomyocytes and an increase of inflammatory cell infiltration, which was prevented by quercetin. CUS increased LV end-diastolic pressure that was significantly blocked by quercetin. In addition, quercetin significantly (p<0.05) blocked CUS-induced inhibition of the anti-oxidant superoxide dismutase (SOD) and the survival Bcl-2 proteins. Quercetin also significantly (p<0.05) inhibited CUS-induced augmentation of the oxidative stress TBARS and the apoptotic protein caspase-3. We conclude that LVD induced by CUS possibly via activation of oxidative and apoptosis pathways can be inhibited by quercetin; thus may offer therapeutic potential in humans.

Las complicaciones del estrés crónico, incluyendo las enfermedades cardiovasculares, se encuentran entre los problemas comunes de salud pública que afectan la vida de millones de personas en todo el mundo. En este trabajo se buscó determinar si la quercetina, agente antioxidante y antiapoptótico, puede inhibir la disfunción ventricular izquierda (DVI) inducida por estrés crónico. Se indujo estrés crónico impredecible (ECI) en ratas utilizando una variedad de factores de estrés, en presencia y ausencia de quercetina (50 mg / kg de peso corporal / día). Las muestras recolectadas de los ventrículos izquierdos (VI) de estos animales se examinaron usando tinción histológica básica. Además, los homogenados de tejido de VI se utilizaron para detectar marcadores de estrés oxidativo y anti-oxidativo que se conocen están modulados en la disfunción cardíaca. Además, la presión del VI se controló mediante un catéter de presión insertado directamente en el VI. Los exámenes histopatológicos del VI en el grupo modelo (ECI) mostraron un daño profundo al VI en comparación con el grupo control, como lo demuestra un grave daño de los cardiomiocitos y un aumento de la infiltración de células inflamatorias, que fue evitado por la quercetina. El ECI aumentó la presión diastólica final del VI, que fue bloqueada significativamente por la quercetina. Además, la quercetina bloqueó en forma significativa (p <0,05) el ECI inducida por la inhibición de la antioxidante superóxido dismutasa (SOD) y la supervivencia de proteínas Bcl-2. Quercetina también inhibió en forma significativa (p <0,05) el ECI inducido por el aumento de la tensión oxidativa y la proteína apoptótica caspasa-3. Llegamos a la conclusión de que la DVI inducida por ECI, posiblemente a través de la activación de las vía oxidativa y la apoptosis, pueden ser inhibidos por la quercetina, pudiendose ofrecer entonces como un potencial terapéutico en los seres humanos.