Adequacy of Fatty Acids Consumption Among Individuals in Secondary Cardiovascular Prevention. / Adequação do Consumo de Ácidos Graxos entre Pacientes em Prevenção Cardiovascular Secundária.

BACKGROUND: Adhering to a diet adequate in macronutrients is crucial for the secondary prevention of cardiovascular diseases. OBJECTIVE: To assess the prevalence of adherence to recommendations for the consumption of dietary fatty acids for the prevention and treatment of cardiovascular diseases and to estimate whether the presence of certain cardiovascular risk factors would be associated with adherence. METHODS: Cross-sectional study using baseline data from 2,358 participants included in the "Brazilian Cardioprotective Nutritional Program Trial". Dietary intake and cardiovascular risk factors were assessed. Adequate intake of polyunsaturated fatty acids (PUFA) was considered as ≥10% of total daily energy intake; for monounsaturated fatty acids (MUFA), 20%; and for saturated fatty acids (SFA), <7% according to the Brazilian Society of Cardiology. A significance level of 5% was considered in the statistical analysis. RESULTS: No participant adhered to all recommendations simultaneously, and more than half (1,482 [62.9%]) did not adhere to any recommendation. Adherence exclusively to the SFA recommendation was the most prevalent, fulfilled by 659 (28%) participants, followed by adherence exclusively to the PUFA (178 [7.6%]) and MUFA (5 [0.2%]) recommendations. There was no association between the number of comorbidities and adherence to nutritional recommendations (p = 0.269). Participants from the Brazilian Northeast region showed a higher proportion of adherence to SFA consumption recommendations (38.42%) and lower adherence to PUFA intake (3.52%) (p <0.001) compared to other regions. CONCLUSIONS: Among the evaluated sample, there was low adherence to nutritional recommendations for dietary fatty acid consumption.

FUNDAMENTO: A adesão à uma alimentação adequada em macronutrientes é fundamental para a prevenção secundária de doenças cardiovasculares. OBJETIVO: Avaliar a prevalência de adesão às recomendações de consumo de ácidos graxos para prevenção e tratamento de doenças cardiovasculares, e estimar se a presença de determinados fatores de risco cardiovascular estaria associada à adesão. MÉTODOS: Estudo transversal com os dados de linha de base de 2358 participantes do estudo "Brazilian Cardioprotective Nutritional Program Trial". Dados de consumo alimentar, e fatores de risco cardiovascular foram avaliados. Foi considerada, de acordo com a Sociedade Brasileira de Cardiologia, uma ingestão adequada de ácidos graxos poli-insaturados (AGPI) ≥10% do consumo total de energia diária, para ácidos graxos monoinsaturados (AGM), 20% e para ácidos graxos saturados (AGS), <7%. Na análise estatística foi considerando nível de significância de 5%. RESULTADOS: Nenhum participante aderiu a todas as recomendações de forma simultânea e mais da metade (1482 [62,9%]) não aderiu a nenhuma recomendação. A adesão exclusivamente à recomendação de AGS foi a mais prevalente, sendo cumprida por 659 (28%) dos participantes, seguida da adesão exclusivamente à recomendação de AGP (178 [7,6%]) e de AGM (5 [0,2%]). Não houve associação entre o número de comorbidades e a adesão às recomendações nutricionais (p =0,269). Os participantes da região Nordeste do país apresentaram maior proporção de adesão às recomendações para consumo de AGS (38,42%), e menor para ingestão de AGPI (3,52%) (p <0,001) em comparação às demais. CONCLUSÕES: Na amostra avaliada, evidenciou-se baixa adesão às recomendações nutricionais para consumo de ácidos graxos.

Women Physicians: Burnout during the COVID-19 Pandemic in Brazil. / Mulheres Médicas: Burnout durante a Pandemia de COVID-19 no Brasil.

BACKGROUND: COVID-19 has placed a tremendous burden on physicians worldwide, especially women physicians, affected by increased workload and loss of quality of life. OBJECTIVE: To assess the effects of the COVID-19 pandemic on the quality of life, burnout and spirituality of Brazilian women physicians directly or indirectly providing care to COVID-19 patients. METHODS: Prospective, observational study performed from July 28 to September 27, 2020, in Brazil, with women physicians from 47 specialities, the most frequent being cardiology (22.8%), with no age restriction. They voluntarily answered an online survey with questions on demographic and socioeconomic characteristics, quality of life (WHOQOL-brief), spirituality (WHOQOL-SRPB), and statements from the Oldenburg Burnout Inventory. Statistical analysis used the R software, beta regression, classification trees, and polychoric correlation matrix, with a 5% of significance level. RESULTS: Of the 769 respondents, 61.6% reported signs of burnout. About 64% reported wage loss of up to 50% during the pandemic. Some reported lack of energy for daily tasks, frequent negative feelings, dissatisfaction with capability for work, and caring for others not adding meaning to their lives. Negative feelings correlated negatively with satisfaction with sexual life and personal relations, and energy for daily tasks. The inability to remain optimistic in times of uncertainty correlated positively with feeling unsafe daily and not acknowledging that caring for others brings meaning to life. CONCLUSION: This study showed a high frequency of burnout among Brazilian women physicians who answered the survey during the COVID-19 pandemic. Nevertheless, they presented with a relatively good quality of life and believed that spirituality comforted and reassured them in hard times.

FUNDAMENTO: A COVID-19 adicionou um fardo enorme sobre os médicos ao redor do mundo, especialmente as mulheres médicas, que são afetadas pelo aumento da carga de trabalho e pela perda da qualidade de vida. OBJETIVO: Avaliar os efeitos da pandemia de COVID-19 na qualidade de vida, burnout e espiritualidade de médicas brasileiras que atendem pacientes com COVID-19 direta ou indiretamente. MÉTODO: Estudo prospectivo, observacional realizado de 28 de julho a 27 de setembro de 2020, no Brasil, com mulheres médicas de 47 especialidades, a mais frequente sendo a cardiologia (22,8%), sem restrição de idade. Elas responderam voluntariamente um questionário online com questões sobre características demográficas e socioeconômicas, qualidade de vida (WHOQOL-brief) e espiritualidade (WHOQOL-SRPB) e enunciados do Oldenburg Burnout Inventory. A análise estatística utilizou o software R, regressão beta, árvores de classificação e matriz de correlação policórica, com nível de significância de 5%. RESULTADOS: Das 769 respondentes, 61,6% relataram sinais de burnout. Cerca de 64% relataram perda salarial de até 50% durante a pandemia. Algumas relataram falta de energia para as tarefas diárias, sentimentos negativos frequentes, insatisfação com a capacidade para o trabalho, e que cuidar de outras pessoas não agregava sentido às suas vidas. Os sentimentos negativos correlacionaram-se negativamente com a satisfação com a vida sexual, a satisfação com as relações pessoais e a energia para as tarefas diárias. A incapacidade de permanecer otimista em tempos de incerteza correlacionou-se positivamente com a sensação de insegurança no dia a dia e com o não reconhecimento de que cuidar de outras pessoas trouxesse sentido à vida. CONCLUSÃO: O presente estudo mostrou uma alta frequência de burnout entre as médicas brasileiras que responderam ao questionário durante a pandemia de COVID-19. Apesar disso, apresentavam uma qualidade de vida relativamente boa e acreditavam que a espiritualidade trazia-lhes conforto e segurança nos momentos difíceis.

Análise crítica dos estudos que mudaram a prática clínica recente: dislipidemias / Critical analysis of studies that changed recent clinical practice: dyslipidemias

Os eventos isquêmicos continuam a ocorrer em pacientes com fatores de risco mal controlados, como os que têm concentrações elevadas de LDL-colesterol ou de triglicérides, nos que têm diabetes e doença aterosclerótica multivascular, a despeito do tratamento com estatinas. Além dos eventos iniciais, esses pacientes têm risco substancial de eventos recorrentes, possivelmente fatais. A avaliação dos eventos recorrentes traz a perspectiva da carga total de eventos ateroscleróticos a que esses pacientes estão expostos e não apenas dos primeiros eventos. Dois estudos com novas terapêuticas hipolipemiantes abordaram a redução de eventos cardiovasculares e também de eventos totais, de um primeiro evento e de eventos subsequentes. O evolocumabe, um inibidor da pró-proteína convertase subtilisina/quexina tipo 9 e o icosapenta etil, formulação altamente purificada de ácido graxo ômega 3 demonstraram reduções dos eventos cardiovasculares primários e secundários chave, bem como dos eventos totais, dos primeiros eventos e dos eventos subsequentes em pacientes de alto risco e risco muito alto que usam estatinas, mas com um risco elevado de novos eventos cardiovasculares. Pelos benefícios demonstrados, essas estratégias terapêuticas poderão ser incorporadas à prática clínica, desde que avaliadas num contexto de risco e benefício, e com um custo-efetividade aceitável

Ischemic events continue to occur in patients with poorly controlled risk factors, such as those with high concentrations of LDL-cholesterol or triglycerides and those with diabetes and multivascular artherosclerotic disease, in spite of treatment with statins. These patients are at risk not only for the first, but also for recurrent ischemic events, which can be fatal. The evaluation of recurrent events brings a perspective of the total burden of artherosclerotic events to which the patient is exposed and not only of the first one. Two studies using new lipid-lowering therapies addressed the reduction of cardiovascular events and also of total events, of a first event, and of subsequent events. Evolocumab, a proprotein convertase subutilisin kexin type 9 inhibitor, and icosapent ethyl, a highly purified formulation of omega-3 fatty acid, demonstrated reductions in key primary and secondary cardiovascular events, as well as in total events, first events and subsequent events in high and very high risk patients taking statins, but with a high risk of new cardiovascular events. Based on the benefits observed, these therapeutic strategies can be incorporated into clinical practice, provided they are evaluated within a risk benefit context, with an acceptable cost-effectiveness ratio

Abordagem das hipertrigliceridemias graves / Management to severe hypertriglyceridemia

Os níveis de triglicérides plasmáticos são biomarcadores das lipoproteínas ricas em triglicérides circulantes e de seus remanescentes. Formas leves a moderadas de hipertrigliceridemia podem ser secundárias a outras desordens metabólicas, fatores ambientais ou medicamentos, ou ainda poligênicas. Já as formas mais graves são, em geral, monogênicas e resultam de alterações em seis genes. Fatores não genéticos podem exacerbar as hipertrigliceridemias. As hipertrigliceridemias classificam-se quanto à gravidade em leves a moderadas (triglicérides > 200-499 mg/dL) e graves (acima de 500 mg/dL) ou muito graves (> 885 mg/dL, ou > 1000 mg/dL). Quando a hipertrigliceridemia se associa à elevação do LDL-colesterol e/ou à redução do HDL-colesterol, existe risco aumentado de eventos cardiovasculares. No entanto, nas formas graves de hipertrigliceridemia, a pancreatite e as dores abdominais recorrentes são as principais complicações. Estudos prospectivos observacionais, de randomização mendeliana e de intervenção terapêutica mostram não apenas a associação entre marcadores lipídicos e risco de doença cardiovascular, mas podem também evidenciar moléculas que sejam alvos terapêuticos no tratamento de dislipidemias e na redução do risco de eventos cardiovasculares. O tratamento das hipertrigliceridemias tem como objetivos a redução imediata do risco de pancreatite em pacientes com hipertrigliceridemias graves (> 1000 mg/dL) e redução do risco cardiovascular global nas formas leves a moderadas. Dieta restrita em gorduras e carboidratos simples, restrição de álcool, e o uso de fibratos isolados ou associados a ácidos graxos ômega-3 e ácido nicotínico são as principais opções terapêuticas. No entanto, as formas genéticas, que incluem as quilomicronemias familiares, são pouco responsivas à associação de fármacos, havendo necessidade de novas terapias para seu controle

Plasma concentrations of triglycerides are considered biomarkers of circulating triglyceride-rich lipoproteins and their remnants. Mild to moderate hypertriglyceridemia may be secondary to other metabolic disorders, environmental factors, drugs, or polygenic factors. On the other hand, severe forms of hypertriglyceridemia are generally monogenic and the result of six defective genes. Hypertriglyceridemia can be exacerbated by non-genetic factors. It can be classified, according to severity, as mild to moderate (triglycerides >200-499 mg/dL), severe (> 500 mg/dL) or very severe (> 885 mg/dL, or > 1000 mg/dL). When hypertriglyceridemia is associated with LDL-cholesterol elevation and/or a reduction in HDL-cholesterol, there is an increased risk of cardiovascular events. However, in severe forms of hypertriglyceridemia, pancreatitis and recurrent abdominal pain are the main complications. Prospective observational studies, Mendelian randomization studies and intervention studies have not only demonstrated the association between lipid markers and cardiovascular risk, but can also identify molecules as therapeutic targets in the treatment of dyslipidemias and reduction of pancreatitis and cardiovascular risk. Treatment of hypertriglyceridemia has two main objectives: to immediately reduce the risk of pancreatitis in patients with severe hypertriglyceridemia (> 1000 mg/dL), and to reduce global cardiovascular risk in mild to moderate forms. A diet that is low in fat and simple carbohydrates, with alcohol intake, and the use of fibrates, either alone or combined with omega-3 fatty acids, and niacin are the best therapeutic options. However, severe genetic hypertriglyceridemia, including familial chylomicronemia, are less responsive to drug therapy, even in combination, and require new strategies for control of dyslipidemia

Common sources and composition of phytosterols and their estimated intake by the population in the city of São Paulo, Brazil.

OBJECTIVE: Phytosterols have been used alone, or combined with lipid-altering drugs, to reduce cholesterol levels and the burden of cardiovascular disease. Considerable variation in the composition of phytosterols exists and its consumption, in a regular diet, by the Brazilian population is still unknown. Thus, the aim of the present study was to determine the phytosterols content of the most consumed plant foods and to estimate the phytosterols intake by this population. METHODS: Intake of plant foods of a representative population of the city of São Paulo (n = 1609), randomly selected on the basis of the Brazilian Institute for Geography and Statistics census data (2010), was obtained by a food frequency questionnaire (FFQ). Foods were chosen on the basis of the Consume Expenditure Survey (2002-2003) and from answers to the FFQ. Phytosterols composition of most consumed greens, legumes, cereals, and seeds, fruits, and vegetable oils was determined by gas chromatography (flame ionization detection). Daily phytosterols intake was estimated in terms of mg per 100 g (mg/100 g(-1)) of edible portion. Underreporters and overreporters were excluded. RESULTS: Mean (SE) daily phytosterols intake in the diet of the study population was 100.6 (1.2) mg, with ß-sitosterol as the largest sterol component (65.4%), followed by campesterol (23.2%), and stigmasterol (10%). No significant changes in daily phytosterols intake were observed after exclusion of underreporters and overreporters. Considerable variation was observed in phytosterols content among the most consumed plant foods. CONCLUSIONS: Analysis of phytosterols composition in most consumed plant foods has shown that phytosterols content varied among food groups. Dietary intake of phytosterols in a large population of the city of São Paulo is in the same range of some countries.