Mitochondrial and genomic ancestry are associated with etiology of heart failure in Brazilian patients.

There is a high prevalence of heart failure (HF) in the general population, but it is more common in black people. We evaluated the association between genomic ancestry and mitochondrial haplogroups (mt-haplogroups) with HF etiology in 503 Brazilian patients. We elicited Mt-haplogroups by analyzing the control region of mitochondrial DNA, and genomic ancestry, by using 48 autosomal insertion-deletion ancestry informative markers. Hypertensive (28.6%, n=144) and ischemic (28.4%, n=143) etiologies of HF were the most prevalent herein. Our results showed that 233 individuals (46.3%) presented African mitochondrial (mt)-haplogroups, and the major contribution in the genomic ancestry analysis was the European ancestry (57.5% (±22.1%)). African mt-haplogroups were positively associated with a diagnosis of hypertensive cardiomyopathy (odds ratio, OR 1.55, confidence interval, CI 95% 1.04-2.44, P=0.04) when compared with European mt-haplogroups. Regarding the genomic ancestry, the African ancestry variant had higher risks (OR 7.84, 95% CI 2.81-21.91, P<0.001), whereas the European ancestry variant had lower risks (OR 0.14, 95% CI 0.04-5.00, P<0.001) for developing the hypertensive etiology. In addition, European ancestry showed an OR of 4.05 (CI 95% 1.53-10.74, P=0.005), whereas African ancestry showed an OR of 0.17 (CI 95% 0.06-0.48, P=0.001) for developing ischemic etiology. In conclusion, this study supports the importance of using ancestry informative markers and mitochondrial DNA to study the genetics of complex diseases in admixed populations to improve the management, treatment and prevention of these illnesses. Therefore, the ancestry informative markers and mt-haplogroups could provide new biomarkers to be associated with HF etiologies and be used as a premise for more specific management.

Treadmill exercise testing of asymptomatic men and women without evidence of heart disease

The aim of this study was to test the hypothesis of differences in performance including differences in ST-T wave changes between healthy men and women submitted to an exercise stress test. Two hundred (45.4 percent) men and 241 (54.6 percent) women (mean age: 38.7 ¡À 11.0 years) were submitted to an exercise stress test. Physiologic and electrocardiographic variables were compared by the Student t-test and the chi-square test. To test the hypothesis of differences in ST-segment changes, data were ranked with functional models based on weighted least squares. To evaluate the influence of gender and age on the diagnosis of ST-segment abnormality, a logistic model was adjusted; P < 0.05 was considered to be significant. Rate-pressure product, duration of exercise and estimated functional capacity were higher in men (P < 0.05). Sixteen (6.7 percent) women and 9 (4.5 percent) men demonstrated ST-segment upslope ¡Ý0.15 mV or downslope ¡Ý0.10 mV; the difference was not statistically significant. Age increase of one year added 4 percent to the chance of upsloping of segment ST ¡Ý0.15 mV or downsloping of segment ST ¡Ý0.1 mV (P = 0.03; risk ratio = 1.040, 95 percent confidence interval (CI) = 1.002-1.080). Heart rate recovery was higher in women (P < 0.05). The chance of women showing an increase of systolic blood pressure ¡Ü30 mmHg was 85 percent higher (P = 0.01; risk ratio = 1.85, 95 percentCI = 1.1-3.05). No significant difference in the frequency of ST-T wave changes was observed between men and women. Other differences may be related to different physical conditioning.

Treadmill exercise testing of asymptomatic men and women without evidence of heart disease.

The aim of this study was to test the hypothesis of differences in performance including differences in ST-T wave changes between healthy men and women submitted to an exercise stress test. Two hundred (45.4%) men and 241 (54.6%) women (mean age: 38.7 +/- 11.0 years) were submitted to an exercise stress test. Physiologic and electrocardiographic variables were compared by the Student t-test and the chi-square test. To test the hypothesis of differences in ST-segment changes, data were ranked with functional models based on weighted least squares. To evaluate the influence of gender and age on the diagnosis of ST-segment abnormality, a logistic model was adjusted; P < 0.05 was considered to be significant. Rate-pressure product, duration of exercise and estimated functional capacity were higher in men (P < 0.05). Sixteen (6.7%) women and 9 (4.5%) men demonstrated ST-segment upslope >or=0.15 mV or downslope >or=0.10 mV; the difference was not statistically significant. Age increase of one year added 4% to the chance of upsloping of segment ST >or=0.15 mV or downsloping of segment ST >or=0.1 mV (P = 0.03; risk ratio = 1.040, 95% confidence interval (CI) = 1.002-1.080). Heart rate recovery was higher in women (P < 0.05). The chance of women showing an increase of systolic blood pressure

Association of HDL cholesterol and triglycerides with mortality in patients with heart failure

It has been demonstrated that there is an association between serum lipoproteins and survival rate in patients with ischemic cardiomyopathy, as well as in patients with non-ischemic causes of heart failure. We tested the hypothesis of an association between serum lipoprotein levels and prognosis in a cohort of outpatients with heart failure, including Chagas' heart disease. The lipid profile of 833 outpatients with heart failure in functional classes III and IV of the New York Heart Association, with a mean age of 46.9 ± 10.6 years, 655 (78.6 percent) men and 178 (21.4 percent) women, was studied from April 1991 to June 2003. The survival rate was estimated by the Kaplan-Meyer's method and the Cox proportional hazards models. Etiology of heart failure was ischemic cardiomyopathy in 171 (21 percent) patients, Chagas' heart disease in 144 (17 percent), hypertensive cardiomyopathy in 136 (16 percent), and other etiologies in 83 (10 percent). In 299 (36 percent) patients, heart failure was ascribed to idiopathic dilated cardiomyopathy. Variables significantly associated with mortality were age (hazard ratio, HR = 1.02; 95 percentCI = 1.01-1.03; P = 0.0074), male gender (HR = 1.77; 95 percentCI = 1.2-2.62; P = 0.004), idiopathic dilated cardiomyopathy (HR = 1.81; 95 percentCI = 1.16-2.82; P = 0.0085), serum triglycerides (HR = 0.97; 95 percentCI = 0.96-0.98; P < 0.0001), and HDL cholesterol (HR = 0.99; 95 percentCI = 0.99-1.0; P = 0.0280). Therefore, higher serum HDL cholesterol and higher serum triglycerides were associated with lower mortality in this cohort of outpatients with heart failure.

Association of HDL cholesterol and triglycerides with mortality in patients with heart failure.

It has been demonstrated that there is an association between serum lipoproteins and survival rate in patients with ischemic cardiomyopathy, as well as in patients with non-ischemic causes of heart failure. We tested the hypothesis of an association between serum lipoprotein levels and prognosis in a cohort of outpatients with heart failure, including Chagas' heart disease. The lipid profile of 833 outpatients with heart failure in functional classes III and IV of the New York Heart Association, with a mean age of 46.9 +/- 10.6 years, 655 (78.6%) men and 178 (21.4%) women, was studied from April 1991 to June 2003. The survival rate was estimated by the Kaplan-Meyer's method and the Cox proportional hazards models. Etiology of heart failure was ischemic cardiomyopathy in 171 (21%) patients, Chagas' heart disease in 144 (17%), hypertensive cardiomyopathy in 136 (16%), and other etiologies in 83 (10%). In 299 (36%) patients, heart failure was ascribed to idiopathic dilated cardiomyopathy. Variables significantly associated with mortality were age (hazard ratio, HR = 1.02; 95%CI = 1.01-1.03; P = 0.0074), male gender (HR = 1.77; 95%CI = 1.2-2.62; P = 0.004), idiopathic dilated cardiomyopathy (HR = 1.81; 95%CI = 1.16-2.82; P = 0.0085), serum triglycerides (HR = 0.97; 95%CI = 0.96-0.98; P < 0.0001), and HDL cholesterol (HR = 0.99; 95%CI = 0.99-1.0; P = 0.0280). Therefore, higher serum HDL cholesterol and higher serum triglycerides were associated with lower mortality in this cohort of outpatients with heart failure.

Chronic American trypanosomiasis: parasite persistence in endomyocardial biopsies is associated with high-grade myocarditis.

Myocyte diameter, fractional area of collagen, intensity of myocarditis and parasite persistence (explored by immunohistochemistry and PCR) were evaluated in serial sections of endomyocardial biopsies from 29 outpatients with chronic chagasic cardiopathy. The patients, 25 males and four females with a mean (S.D.) age of 43 (9) years, were subsequently followed up for 3-2861 days (median=369 days). During this follow-up, 16 (55%) of the patients died. The biopsies revealed myocarditis in 25 (86%) of the patients and high-grade myocarditis in 14 (56%). Although immunohistochemistry failed to demonstrate Trypanosoma cruzi antigens in any of the samples, five (33%) of the 15 biopsies successfully tested in the PCR-based assay for T. cruzi DNA were found positive, indicating parasite persistence. There was a significant positive association between myocardial parasite persistence and high-grade myocarditis (P=0.014); five (71%) of the seven endomyocardial biopsies with high-grade myocarditis that were successfully tested in the PCR assays showed persistent T. cruzi DNA. The survival time of the patients was not, however, found to be significantly associated with myocardial parasite persistence, any of the morphometric measurements taken, or the presence or intensity of myocarditis.

Bilateral facial pain from cardiac origin. A case report.

A case of a 65-year-old female patient is reported. Her chief complaint was facial pain, so she sought care from her general dental practitioner for evaluation of a suspected temporomandibular disorder, after repeated visits to the emergency department due to excruciating facial pain associated with exertion. The dental examination revealed an edentulous upper and lower jaw. Radiographs of the facial bones revealed no abnormalities. Eventually, she was referred for cardiological evaluation, as her pain radiated to the chest and there was a medical history of myocardial infarction. Cardiac pain may radiate to the face and lead patients to seek dental care. In these settings, dentists may contribute to the diagnosis of ischemic heart disease and refer patients for cardiological evaluation.

Repeated echocardiographic examinations of patients with suspected infective endocarditis.

OBJECTIVE: To study the diagnostic contribution of repeated transthoracic (TTE) and transoesophageal echocardiography (TOE) among patients with suspected infective endocarditis. METHODS: 262 patients with 266 episodes of suspected infective endocarditis were referred for TTE and TOE over three years in a 423 bed university cardiology hospital. Patients were a mean (SD) of 47.6 (17.9) years old. 139 (52.3%) episodes occurred in men and 127 (47.7%) in women. The diagnostic information obtained from repeated TTE and TOE examinations was evaluated relative to the diagnosis of endocarditis. RESULTS: TTE examinations were repeated in 192 (72.2%) and TOE examinations were repeated in 49 (18.4%) of 266 episodes. A mean of 2.4 TTE and 1.2 TOE examinations were performed for each episode of suspected endocarditis. The second and third TTEs added diagnostic information in 34 (26.7%) and the second and third TOEs added diagnostic information in 25 (19.7%) of 127 episodes with definite endocarditis. After the third TTE or TOE no additional diagnostic information was obtained. CONCLUSIONS: The diagnostic contribution of repeated TTE or TOE for the diagnosis of endocarditis decreased as the number of repetitions increased. In this setting, the data do not substantiate more than three TTE or TOE examinations as an efficient strategy to increase the diagnostic yield for all but selected patients with suspected endocarditis.

Hemochromatosis gene variants in patients with cardiomyopathy.

Iron depletion was suggested to be protective against the development of ischemic heart disease. Population studies have led to conflicting results, and such an association has not been addressed in patients with heart failure due to cardiomyopathy. We studied the distribution of hemochromatosis-related mutations in 319 patients with heart failure due to cardiomyopathy of different etiologies. The genotypic distribution showed a significantly higher prevalence of heterozygotes for the C282Y mutation in patients with ischemic cardiomyopathy than in patients with cardiomyopathy of nonischemic etiologies (p = 0.0036). The frequency of the D63 mutation was not significantly different between ischemic versus nonischemic groups. In multiple logistic regression models adjusted for age, sex, ethnicity, and different degrees of disease progression, there was a strong and significant association of the C282Y mutation with ischemic cardiomyopathy compared with the nonischemic group (odds ratio 6.64, 95% confidence interval 1.71 to 25.73, after adjustment). In our sample, genetic variation in the HFE gene was associated with ischemic cardiomyopathy. Such association merits further study regarding its value as a prognostic marker in patients with ischemic heart disease.

Perioperative myocardial infarction in a patient with tuberculous constrictive pericarditis in the absence of coronary artery disease.

A 34-year-old man developed severe heart failure due to constrictive pericarditis. Pericardiectomy was carried on and the patient died 12 hours after surgery. Necropsy revealed an extensive hemorrhagic myocardial infarction involving the lateral free wall of the left ventricle in the absence of coronary artery disease. In addition, necropsy revealed tuberculosis as the etiology of constrictive pericarditis. Thus, myocardial infarction may occur in constrictive pericarditis in the setting of pericardiectomy and absence of coronary artery disease.

Oxygen therapy, continuous positive airway pressure, or noninvasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema.

OBJECTIVE: To compare the effects of 3 types of noninvasive respiratory support systems in the treatment of acute pulmonary edema: oxygen therapy (O2), continuous positive airway pressure, and bilevel positive pressure ventilation. METHODS: We studied prospectively 26 patients with acute pulmonary edema, who were randomized into 1 of 3 types of respiratory support groups. Age was 69+/-7 years. Ten patients were treated with oxygen, 9 with continuous positive airway pressure, and 7 with noninvasive bilevel positive pressure ventilation. All patients received medicamentous therapy according to the Advanced Cardiac Life Support protocol. Our primary aim was to assess the need for orotracheal intubation. We also assessed the following: heart and respiration rates, blood pressure, PaO2, PaCO2, and pH at beginning, and at 10 and 60 minutes after starting the protocol. RESULTS: At 10 minutes, the patients in the bilevel positive pressure ventilation group had the highest PaO2 and the lowest respiration rates; the patients in the O2 group had the highest PaCO2 and the lowest pH (p<0.05). Four patients in the O2 group, 3 patients in the continuous positive pressure group, and none in the bilevel positive pressure ventilation group were intubated (p<0.05). CONCLUSION: Noninvasive bilevel positive pressure ventilation was effective in the treatment of acute cardiogenic pulmonary edema, accelerated the recovery of vital signs and blood gas data, and avoided intubation.

Relapses, recurrences, valve replacements, and mortality during the long-term follow-up after infective endocarditis.

BACKGROUND: Late prognosis after infective endocarditis has not been systematically studied in large series of patients with different underlying heart conditions in recent years. METHODS: We studied an inception cohort study of 420 patients discharged after treatment of endocarditis from a university tertiary care hospital. The patients were aged 34.2+/-17.2 years (mean +/- SD), ranging from 2 months to 83 years; 270 (64.3%) were men and 150 (35.7%) were women. Mean follow-up was 6.1+/-4.3 years for survivors and 3.7+/-3.7 years for the patients who died during the follow-up. We studied the frequency and risk factors for relapses and recurrences of endocarditis, cardiac valve replacements, and deaths during the follow-up. Statistical analysis was performed through comparison of groups, of event-free survival, and risk ratios. RESULTS: Relapses were observed in 14 (3.3%) patients. There was one recurrence of endocarditis in 48 (11.4%) patients, two (0.5%) in 2 patients, three in 1 patient (0.2%), and five (0.2%) in 1 patient. Valve replacement was performed in 83 (19.7%) patients. Ninety-eight (12.3%) patients died. Risk factors for recurrent endocarditis were increasing age (risk ratio 1.02) and male sex (risk ratio 1.61). Risk factors for valve replacement were recurrent endocarditis (risk ratio 1.62) and prosthetic valve endocarditis (risk ratio 1.61). Risk factors for death were increasing age (risk ratio 1.03) and recurrent endocarditis (risk ratio 2.06). CONCLUSIONS: The long-term event-free survival for patients who survived their first episode of endocarditis was low. Recurrent endocarditis, prosthetic valve endocarditis, and increasing age contributed to the high rate of events during the follow-up.

[Publication trends in quarterly, bimonthly and monthly cycles of publication during the five decades of Brazilian Archives of Cardiology]. / Tendências das publicações nas fases trimestral, bimestral e mensal das cinco décadas dos Arquivos Brasileiros de Cardiologia.

OBJECTIVE: To study trends in selected manuscript characteristics of articles published in the Brazilian Archives of Cardiology from March 1948, to February 1998, in the quarterly, bimonthly and monthly cycles of publication. METHODS: A random sample of 25% of all issues of the journal comprised the study sample: 13 issues (11.5%) from the quarterly, 27 (23,5%) from the bimonthly, and 58 (65%) from the monthly publication cycle. We studied the type of manuscript, number of authors, geographical distribution, language of publication and references. RESULTS: A total of 1204 articles were studied, 90 (7.5%) from the quarterly, 238 (19,8%) from the bimonthly, and 876 (72.8%) from the monthly publication cycle. The most frequent published articles were original contributions (353), reviews (350) and case reports (205). No significant difference occurred in the proportion of original articles, reviews and case reports; the number of authors was higher in the monthly period;a geographical concentration of the contributions occurred (72% from three Brazilian States); manuscripts in languages other than Portuguese decreased. The mean number of Brazilian references cited was less than 4.7 and the mean number of international references cited was greater than 16.7. CONCLUSION: The analysis of the trends over five decades of publication revealed the need for further steps to be taken by the Brazilian Archives of Cardiology, to meet international publication standards for biomedical journals as well as authors' and readers' demands.

Peripheral arterial embolism. Report of hospitalized cases.

OBJECTIVE: We analyzed the frequency of peripheral embolisms, the underlying heart disease,triggering factors, the sites of the emboli, and evolution of the patients. METHODS: We analyzed 29 cases of peripheral arterial embolism out of a total of 20,211 hospitalizations in a cardiology center in the city of São Paulo. The age was 51.89+/-18.66 years, and 15 were males. RESULTS: Embolism in the right lower limb occurred in 18 patients (62.0%),in the left lower 11(37.9%) and right upper 3 (10.3%) limbs, and in the left arm (1). Four patients had embolism in two limbs. The heart disease, mitral valvar heart disease (9 patients - 31.0%); infective endocarditis (7- 24.1%); dilated cardiomyopathy (6 - 20.6%); ischemic coronary heart disease (6 patients - 20.6%); and one patient with cor pulmonale. Atrial fibrillation was observed in 20 patients (68.9%), chronic in 12 patients (41.3% ) and acute in 8 (27. 5%). All patients with mitral valvar heart disease had atrial fibrillation, chronic in 8 patients (88.8%); patients with cardiomyopathy and coronary heart disease, 4 in each group had atrial fibrillation, acute in 60% of the patients. Patients with infective endocarditis, 3 had staphylococcus and 2 Gram-negative bacteria. In the follow-up, 2 patients (6.8%) required limbs amputation, and 5 (17.2%) died due to embolism. CONCLUSION: Most of the time, embolism does not cause permanent complications. Our data highlight the importance of anticoagulation for patients acute atrial fibrillation in myocardial dysfunction and for patients with chronic atrial fibrillation in cases of mitral valvar heart disease to prevent peripheral embolism.

Effects of carvedilol in heart failure due to dilated cardiomyopathy. Results of a double-blind randomized placebo-controlled study (CARIBE study).

OBJECTIVE: To assess the effects of carvedilol in patients with idiopathic dilated cardiomyopathy. METHODS: In a double-blind randomized placebo-controlled study, 30 patients (7 women) with functional class II and III heart failure were assessed. Their ages ranged from 28 to 66 years (mean of 43 +/- 9 years), and their left ventricular ejection fraction varied from 8% to 35%. Carvedilol was added to the usual therapy of 20 patients; placebo was added to the usual therapy of 10 patients. The initial dose of carvedilol was 12.5 mg, which was increased weekly until it reached 75 mg/day, according to the patient's tolerance. Clinical assessment, electrocardiogram, echocardiogram, and radionuclide ventriculography were performed in the pretreatment phase, being repeated after 2 and 6 months of medication use. RESULTS: A reduction in heart rate (p = 0.016) as well as an increase in left ventricular shortening fraction (p = 0.02) and in left ventricular ejection fraction (p = 0.017) occurred in the group using carvedilol as compared with that using placebo. CONCLUSION: Carvedilol added to the usual therapy for heart failure resulted in better heart function.

Paroxysmal atrial fibrillation and insidious neck pain.

Paroxysmal atrial fibrillation (AF) is an arrhythmia usually secondary to autonomic imbalance, and it may occur in the absence of any structural heart disease. The case of a patient with paroxysmal AF, in whom the arrhythmia may have been a presenting symptom of a later diagnosed cervical schwannoma, is reported.

Papillary fibroelastoma of the mitral valve 12 years after mitral valve commissurotomy.

A 63 year-old woman who had had mitral valve commissurotomy 12 years earlier was seen because of rheumatic mitral stenosis and left brachial paresis due to cerebral embolism. On clinical evaluation, a diastolic rumble was heard over the mitral area, and the echocardiogram revealed a mass attached to the mitral subvalvular apparatus. The patient was operated on, and both the surgical and histologic findings depicted papillary fibroelastoma. This tumor may occur as an isolated lesion or be associated with mitral valve stenosis or other cardiac abnormalities, and it is an important source of emboli. Early echocardiographic diagnosis, followed by surgical excision, may avoid serious complications such as stroke, myocardial infarction, and sudden death.