Quality of life in patients with stable coronary artery disease submitted to percutaneous, surgical, and medical therapies: a cohort study.

BACKGROUND: Clinical, surgical, and percutaneous strategies similarly prevent major cardiovascular events in patients with stable coronary artery disease (CAD). The possibility that these strategies have differential effects on health-related quality of life (HRQoL) has been debated, particularly in patients treated outside clinical trials. METHODS: We assigned 454 patients diagnosed with CAD during an elective diagnostic coronary angiography to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical treatment (OMT), and followed them for an average of 5.2 ± 1.5 years. HRQoL was assessed using a validated Brazilian version of the 12-Item Short-Form Health Survey questionnaire. The association between therapeutic strategies and quality of life scores was tested using variance analysis and adjusted for confounders in a general linear model. RESULTS: There were no differences in the mental component summary scores in the follow-up evaluation by therapeutic strategies: 51.4, 53.7, and 52.3 for OMT, PCI, and CABG, respectively. Physical component summary scores were higher in the PCI group than the CABG and OMT groups (46.4 vs. 42.9 and 43.8, respectively); however, these differences were no longer different after adjustment for confounding variables. CONCLUSION: In a long-term follow-up of patients with stable CAD, HRQoL did not differ in patients treated by medical, percutaneous, or surgical treatments.

Effect of recreational beach tennis on ambulatory blood pressure and physical fitness in hypertensive individuals (BAH study): rationale and study protocol.

BACKGROUND: Different physical activities are widely recommended as non-pharmacological therapies to reduce blood pressure. However, the effectiveness of exercise programs is associated with its continuity and regularity, and the long-term adherence to traditional exercise interventions is often low. Recreational sports emerge as an alternative, being more captivating and able to retain individuals for longer periods. Besides, sport interventions have demonstrated improvements in physical fitness components that are associated with a lower incidence of hypertension. However, no studies have investigated the effects of recreational sports on 24 h ambulatory blood pressure. The aim of the present study is to evaluate the effect of beach tennis training on ambulatory blood pressure and physical fitness in individuals with hypertension. METHODS: This study will be a randomized, single-blinded, two-arm, parallel, and superiority trial. Forty-two participants aged 35-65 years with previous diagnosis of hypertension will be randomized to 12 weeks of beach tennis training group (two sessions per week lasting 45-60 min) or a non-exercising control group. Ambulatory (primary outcome) and office blood pressures, cardiorespiratory fitness, muscle strength/power and quality of life will be assessed at baseline and after the intervention period. DISCUSSION: Our conceptual hypothesis is that beach tennis training will reduce ambulatory blood pressure and improve fitness parameters in middle-aged individuals with hypertension. The results of this trial are expected to provide evidences of efficacy of recreational beach tennis practice on blood pressure management and to support sport recommendations for clinical scenario in higher risk populations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03909321 . Registered on April 10, 2019.

Role of health determinants in a measles outbreak in Ecuador: a case-control study with aggregated data.

BACKGROUND: In 2011-2012, an outbreak of measles occurred in Ecuador. This study sought to ascertain which population characteristics were associated. METHODS: Case-control study of aggregate data. The unit of analysis was the parish (smallest geographic division). The national communicable disease surveillance database was used to identify 52 case parishes (with at least one confirmed case of measles) and 972 control parishes (no cases of measles). A hierarchical model was used to determine the association of measles with population characteristics and access to health care. RESULTS: Case parishes were mostly urban and had a higher proportion of children under 1 year of age, heads of household with higher educational attainment, larger indigenous population, lower rates of measles immunization, and lower rates of antenatal care visit attendance. On multivariate analysis, associations were found with educational attainment of head of household ≥8 years (OR: 0.29; 95%CI 0.15-0.57) and ≥1.4% indigenous population (OR: 3.29; 95%CI 1.63-6.68). Antenatal care visit attendance had a protective effect against measles (OR: 0.98; 95%CI 0.97-0.99). Measles vaccination was protective of the outbreak (OR: 0.97; 95%CI 0.95-0.98). The magnitude of these associations was modest, but represents the effect of single protective factors, capable of acting at the population level regardless of socioeconomic, biological, and environmental confounding factors. CONCLUSION: In Ecuador, the parishes with the highest percentage of indigenous populations and those with the lowest vaccination coverage were the most vulnerable during the measles outbreak.

Biochemical non-invasive assessment of liver fibrosis cannot replace biopsy in HIV-HCV coinfected patients.

BACKGROUND AND RATIONALE: The liver biopsy has been considered the gold standard for the diagnosis and quantification of fibrosis. However, this method presents limitations. In addition, the non-invasive evaluation of liver fibrosis is a challenge. The aim of this study was to validate the fibrosis cirrhosis index (FCI) index in a cohort of human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients, and compare to AST/ALT ratio (AAR), AST to platelet ratio index (APRI) and FIB-4 scores, as a tool for the assessment of liver fibrosis in coinfected patients. MATERIAL AND METHODS: Retrospective cross sectional study including 92 HIV-HCV coinfected patients evaluated in two reference centers for HIV treatment in the Public Health System in Southern Brazil. Patients who underwent liver biopsy for any indication and had concomitant laboratory data in the 3 months prior to liver biopsy, to allow the calculation of studied noninvasive markers (AAR, APRI, FIB-4 and FCI) were included. RESULTS: APRI < 0.5 presents the higher specificity to detect no or minimal fibrosis, whereas APRI > 1.5 presents the best negative predictive value and FCI > 1.25 the best specificity to detect significant fibrosis. The values of noninvasive markers for each Metavir fibrosis stage showed statistically significant differences only for APRI. In conclusion, until better noninvasive markers for liver fibrosis are developed and validated for HIV-HCV coinfected patients, noninvasive serum markers should be used carefully in this population.

Influence of sleep apnea severity on blood pressure variability of patients with hypertension.

PURPOSE: Obstructive sleep apnea (OSA) is a risk factor for the development of hypertension and cardiovascular disease. Apnea overloads the autonomic cardiovascular control system and may influence blood pressure variability, a risk for vascular damage independent of blood pressure levels. This study investigates the hypothesis that blood pressure variability is associated with OSA. METHODS: In a cross-sectional study, 107 patients with hypertension underwent 24-h ambulatory blood pressure monitoring and level III polysomnography to detect sleep apnea. Pressure variability was assessed by the first derivative of blood pressure over time, the time rate index, and by the standard deviation of blood pressure measurements. The association between the apnea-hypopnea index and blood pressure variability was tested by univariate and multivariate methods. RESULTS: The 57 patients with apnea were older, had higher blood pressure, and had longer duration of hypertension than the 50 patients without apnea. Patients with apnea-hypopnea index (AHI) ≥ 10 had higher blood pressure variability assessed by the standard deviation than patients with AHI < 10 during sleep (10.4 ± 0.7 versus 8.0 ± 0.7, P = 0.02) after adjustment for age, body mass, and blood pressure. Blood pressure variability assessed by the time rate index presented a trend for association during sleep (P = 0.07). Daytime blood pressure variability was not associated with the severity of sleep apnea. CONCLUSION: Sleep apnea increases nighttime blood pressure variability in patients with hypertension and may be another pathway linking sleep abnormalities to cardiovascular disease.

Effect of antihypertensive agents on sleep apnea and ambulatory blood pressure in patients with hypertension: A randomized controlled trial.

BACKGROUND: Obstructive sleep apnea (OSA) and hypertension are common conditions that may be linked through sympathetic activation and water retention. We hypothesized that diuretics, which reduce the body water content, may be more effective than amlodipine, a blood pressure (BP)-lowering agent implicated with edema, in controlling OSA in patients with hypertension. We also aimed to compare the effects of these treatments on ambulatory blood pressure monitoring (ABPM). METHODS: In a randomized, double-blind clinical trial, we compared the effects of chlorthalidone/amiloride 25/5 mg with amlodipine 10 mg on OSA measured by portable sleep monitor and BP measured by ABPM. The study included participants older than 40 who had moderate OSA (10-40 apneas/hour of sleep) and BP within the systolic range of 140-159 mmHg or diastolic range of 90-99 mmHg. RESULTS: The individuals in the experimental groups were comparable in age, gender, and other relevant characteristics. Neither the combination of diuretics nor amlodipine alone reduced the AHI after 8 weeks of treatment (AHI 26.3 with diuretics and 25.0 with amlodipine. P = 0.713). Both treatments significantly lowered office, 24-h, and nighttime ABP, but the two groups had no significant difference. CONCLUSION: Chlorthalidone associated with amiloride and amlodipine are ineffective in decreasing the frequency of sleep apnea episodes in patients with moderate OSA and hypertension. Both treatments have comparable effects in lowering both office and ambulatory blood pressure. The notion that treatments could offer benefits for both OSA and hypertension remains to be demonstrated. TRIAL REGISTRATION CLINICALTRIALS. GOV IDENTIFIER: NCT01896661.

Effects of FTO RS9939906 and MC4R RS17782313 on obesity, type 2 diabetes mellitus and blood pressure in patients with hypertension.

BACKGROUND: Genetic variants of the FTO gene rs9939609 A/T and the MC4R gene rs17782313 C/T have been associated with obesity. Individuals with mutations in MC4R gene have lower blood pressure (BP), independently of obesity. This study aimed to investigate the association of FTO rs9939609 and MC4R rs17782313 with anthropometric indexes, BP, and type 2 diabetes mellitus among hypertensive patients. METHODS: We genotyped 217 individuals (86 men and 131 women) with hypertension (systolic or diastolic BP ≥ 140/90 mmHg or using antihypertensive drugs). Diabetes mellitus was diagnosed according to the American Diabetes Association criteria. Waist and neck circumferences (cm), Body Adiposity Index (BAI,%), Lipid Accumulation Product Index (LAP, cm.mmol.l) and body mass index (BMI, kg/m²) were analyzed using analysis of covariance or modified Poisson's regression. RESULTS: Rare allele frequencies were 0.40 for A for FTO rs9939609 and 0.18 for C for MC4R rs17782313. A positive association of FTO rs9939609 and MC4R rs17782313 with BMI was observed in the overall sample. Among men and women, neck circumference was associated with the FTO genotype and, for women, MC4R genotype. In contrast, in men we found a negative association of MC4R rs17782313 with diastolic BP (TT 90.1 ±12.2, TC/CC 83.2 ±12.1; P = 0.03) and borderline association for systolic BP after controlling for age and BMI. CONCLUSIONS: Common genetic variants of FTO rs9939609 have positive associations with BMI and neck circumference and MC4R rs17782313 in women, but a negative association with diastolic and mean blood pressure in men with hypertension.

Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study.

BACKGROUND: Population aging leads to increased burden of chronic diseases and demand in public health. This study aimed to assess whether the score of Primary Health Care (PHC) is associated with a) the model of care - Family Health Strategy (FHS) vs. traditional care model (the Basic Health Units; BHU); b) morbid conditions such as - hypertension, diabetes mellitus, mental disorders, chronic pain, obesity and central obesity; c) quality of life in elderly individuals who received care in those units. METHODS: A survey was conducted among the elderly between August 2010 and August 2011, in Ilheus, Bahia. We interviewed elderly patients - 60 years or older - who consulted at BHU or FHS units in that day or participated in a group activity, and those who were visited at home by the staff of PHC, selected through a random sample. Demographic and socioeconomic characteristics, services' attainment of primary care attributes, health problems and quality of life were investigated. The Short Form Health Survey (SF-12) was used to assess quality of life and PCATool to generate PHC scores. In addition, weight, height and waist circumference were measured. Trained research assistants, under supervision performed the data collection. RESULTS: A total of 511 elderly individuals were identified, two declined to participate, resulting in 509 individuals interviewed. The health care provided by the FHS has higher attainment of PHC attributes, in comparison to the BHU, resulting in lower prevalence of score below six. Except for hypertension and cardiovascular disease, other chronic problems were not independently associated with low scores in PHC. It was observed an independent and positive association between PHC score and the mental component of quality of life and an inverse association with the physical component. CONCLUSIONS: This study showed higher PHC attributes attainment in units with FHS, regardless of the health problem. The degree of orientation to PHC increased the mental component score of quality of life.

Home blood pressure monitoring is better predictor of cardiovascular disease and target organ damage than office blood pressure: a systematic review and meta-analysis.

The available, albeit rare, evidence indicates the superiority of home- over office blood pressure monitoring (HBPM vs OBP) to predict cardiovascular (CV) outcomes. We performed a systematic review to update the efficacy of HBPM vs OBP as predictors of all-cause mortality, CV death, and target organ damage. Two reviewers independently performed the literature search in various databases. A meta-analysis with a fixed-effect model was conducted, and the heterogeneity and inconsistency indices were assessed. The search identified 291 articles, of which 10 were eligible for inclusion in the study, and five articles published in 2012 were included in the meta-analysis. A previous meta-analysis showed the superiority of HBPM over OBP to predict all-cause mortality, CV mortality, and CV events. The meta-analysis of articles published in 2012 identified that HBPM was also a better predictor of proteinuria than OBP. In conclusion, the results of our systematic review and meta-analysis confirm that HBPM is a better predictor of CV outcomes and target organ damage than OBP.

Association of blood pressure and hypertension with alcohol consumption in HIV-infected white and nonwhite patients.

INTRODUCTION: Although alcohol abuse is associated with hypertension in whites and nonwhites, it has been scarcely investigated in HIV-infected patients. OBJECTIVE: To investigate whether the association of alcohol abuse with hypertension is influenced by skin color in HIV-infected individuals. METHODS: Cross-sectional study in HIV-infected individuals aged 18 years or older. Demographic characteristics, lifestyle, and HIV infection were investigated. Alcohol abuse was defined as ≥ 15 (women) and ≥ 30 g/alcohol/day (men), and binge drinking by the intake of ≥ 5 drinks on a single occasion. Hypertension was defined by blood pressure ≥ 140/90 mmHg or use of blood pressure-lowering agents. RESULTS: We studied 1,240 individuals, with 39.1 ± 10 years, 51% males and 57% whites. Age and body mass index were associated with blood pressure, and there was an independent association of alcohol abuse with hypertension in whites (RR = 1.9, 95% CI 1.1-3.3) and nonwhites (RR = 2.4, 95% CI 1.4 to 4.0). Among nonwhite individuals who were alcohol abusers, systolic (9.3 ± 3.2; P = 0.001) and diastolic blood pressures (6.4 ± 2.1; P = 0.008) were higher than in nonabusers. CONCLUSION: Alcohol abuse is a risk factor for hypertension in white and nonwhite HIV-infected individuals. The association of ethanol consumption with blood pressure is not explained by AIDS-related conditions.

Risk of coronary heart disease among HIV-infected patients: a multicenter study in Brazil.

Cardiovascular disease has emerged as a crescent problem among HIV-infected population. This study aimed to determine the 10-year risk of coronary heart disease using the Framingham risk score among HIV-infected patients from three regions of Brazil. This is a pooled analysis of three cohort studies, which enrolled 3,829 individuals, 59% were men, 66% had white skin color, and mean age 39.0 ± 9.9 years. Comparisons among regions showed that there were marked differences in demographic, socioeconomic, clinical, and HIV-related characteristics. Prevalence of Framingham score ≥10 was 4.5% in the Southern, 4.2% in the Midwest, and 3.9% in the Northeast of Brazil. The Framingham score ≥10 was similar between regions for males, patients aged ≥60 years, with obesity, central obesity, hypertension, and diabetes mellitus. Women were three times more likely to have coronary heart disease in 10 years than men. Hypertension and diabetes increased more than four times the risk of coronary heart disease, followed by central obesity, obesity, and prehypertension. The use of antiretroviral agents and time since HIV diagnosis were not risk factors for coronary artery disease in 10 years. In conclusion, hypertension and diabetes are the strongest independent predictors of 10-year risk of coronary heart disease among HIV-infected population.

Waist-to-Height Ratio: A Sensitive Tool for Assessing the Need for Nutritional Risk Management in Elderly Populations from Brazil.

INTRODUCTION: Nutritional status assessment commonly relies on body mass index (BMI), which overlooks lean mass and adipose tissue distribution. However, waist circumference (WC) and waist-to-height ratio (WHtR) provide additional insights into fat accumulation. By combining these indices, it may be possible to identify older adults needing weight management interventions. OBJECTIVES: To assess the WC and WHtR as strategies for identifying individuals requiring weight management. METHODS: A cross-sectional study was conducted with 509 elderly individuals in Northeast Brazil. Weight, height, hip circumference, and waist circumference were measured, and combined with indices such as BMI WC, WHR, and WHtR to identify those who require weight management. The DeLong test compared areas under the curves using receiver operating characteristic curves and statistical significance. Sensitivity, specificity, and positive and negative predictive values were calculated to verify usefulness for clinical application. A validation sample of 599 elderly individuals from the country's Southern region was used to confirm the results. RESULTS: Both WC and WHtR showed adequate diagnostic accuracy with no statistically significant difference in AUCs. WHtR ≥ 0.50 had 92% sensitivity in identifying men and women requiring nutritional management. WC presented lower sensitivity but 93% specificity, useful for excluding elderly individuals from the nutritional risk category. These results were consistent in the validation sample. CONCLUSION: WHtR is a valuable index for screening nutritional risk management in the elderly population, applicable to men and women. Conversely, WC performs better in excluding individuals who do not need nutritional risk management.

Mortality was predicted by depression and functional dependence in a cohort of elderly adults of Italian descent from southern Brazil.

The older population has an increasing burden of non-communicable disease, which can potentially be associated with physical and mental disabilities and shorten life spam. To investigate whether depression, loss of functionality for activities of daily living, and lower social support are associated with all-cause mortality in the older population of Italian descent. This population-based cohort study was conducted in Veranópolis, a country city from southern Brazil, among individuals aged 60 years or older. Interviews were performed in a systematic random sampling regarding demographic, socioeconomic, and psychosocial variables, in addition to depression (Geriatric Depression Scale), activities of daily living (Barthel Index), and social support (Medical Outcomes Study scale). In the follow-up, participants were reinterviewed or, in case of death, the next of kin, and hospital records were revised. Hierarchical analysis was used to determine characteristics independently associated with all-cause mortality, using Poisson regression with robust variance, expressed as relative risk with 95% confidence intervals (RR; 95%CI). A total of 997 participants were enrolled and 882 participants completed the study, after 7.24 ± 2.41 years; with 581 remaining alive. The mean age was 73.12 ± 8.03 years, 4% were nonagenarians or centennials, and 62% were women. Symptoms of depression (RR: 1.04; 1.01-1.06) and functional dependence for ADL (RR: 1.00; 0.99-1.00) were associated with all-cause mortality, even after controlling for confounding factors. Lower social support was not associated with mortality (RR: 1.00; 0.99-1.01). Depression and functional dependence are independent predictors of all-cause mortality in the older population from Italian descent.

Efficacy of an Educational Intervention for Sodium Restriction in Patients with Hypertension: A Randomized Controlled Trial.

There is sound evidence showing the efficacy of non-pharmacological interventions in lowering blood pressure (BP); however, adherence is usually poor. Interventions to induce behavioral changes aim to improve the ability to read labels, choose foods, and eat low-sodium meals, reinforcing adherence to sodium restriction. In this randomized parallel-controlled trial, we assessed the effectiveness of an educational intervention using the Dietary Sodium Restriction Questionnaire (DSRQ) scores. A follow-up period of 6 months was conducted. Participants were randomized into (1) an educational intervention provided by a registered dietitian on individual visits and dietary planning; (2) a control group with the usual care and dietary recommendations. Patients underwent 24-h ambulatory BP monitoring, 12-h fasting blood tests, spot urine collection, and assessment using DSRQ. We randomized 120 participants (67.5% women and 68.3% Caucasians), and 25 participants were lost to follow-up. The 24-h sodium urinary excretion changed in the control (Δ -1610 mg/day; 95% confidence interval [CI] -1800 to -1410) and intervention groups (Δ -1670 mg/day; 95% CI -1800 to -1450) over time. There was no significant difference in the 24-h estimated sodium between groups. In hypertensive patients, DSRQ-based educational intervention is effective for improving the ability to detect and overcome obstacles to a low-sodium restriction diet but is as effective as dietary recommendations for lowering sodium.

Comparison of Incidence and Prognosis of Myocardial Injury in Patients with COVID-19-Related Respiratory Failure and Other Pulmonary Infections: A Contemporary Cohort Study.

Myocardial injury (MI) is frequent in critically ill patients with COVID-19, but its pathogenesis remains unclear. We hypothesized that MI is not solely due to viral infection by SARS-CoV-2 but rather due to the common pathophysiological mechanisms associated with severe pulmonary infections and respiratory failure. This contemporary cohort study was designed to compare the incidence of MI in patients with acute respiratory failure caused by COVID-19 to patients with other pulmonary infections. In addition, we aimed to investigate whether MI was a distinct risk factor for in-hospital mortality in patients with COVID-19 compared to those with non-COVID-19 infections. This study included 1444 patients with COVID-19 (55.5% men; age 58 (46;68) years) and 182 patients with other pulmonary infections (46.9% men; age 62 (44;73) years). The incidence of MI at ICU admission was lower in COVID-19 patients (36.4%) compared to non-COVID-19 patients (56%), and this difference persisted after adjusting for age, sex, coronary artery disease, heart failure, SOFA score, lactate, and C-reactive protein (RR 0.84 (95% CI, 0.71-0.99)). MI at ICU admission was associated with a 59% increase in mortality (RR 1.59 (1.36-1.86); p < 0.001), and there was no significant difference in the mortality between patients with COVID-19 and those with other pulmonary infections (p = 0.271). We concluded that MI is less frequent in patients with critical COVID-19 pneumonia and respiratory failure compared to those with other types of pneumonia. The occurrence of MI is a significant risk factor for in-hospital mortality, regardless of the etiology of the pulmonary infection.

Effects of chlorthalidone plus amiloride compared with amlodipine on short-term blood pressure variability in individuals with hypertension and obstructive sleep apnea: a randomized controlled trial.

OBJECTIVE: To compare the effects of chlortalidone plus amiloride and amlodipine on blood pressure (BP) variability in patients with hypertension and obstructive sleep apnea syndrome (OSA). METHODS: A randomized, controlled, double-blind trial enrolled men and women aged 40 years or older with a diagnosis of OSA (apnea-hypopnea index 10-40 apneas/h of sleep) confirmed by overnight laboratory polysomnography and systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg. Participants were randomized to receive chlortalidone 25 mg plus amiloride 5 mg daily or amlodipine 10 mg daily for 8 weeks. BP variability was calculated from 24-hour ambulatory BP monitoring at baseline and follow-up using the following indices: SD, coefficient of variation, average real variability (ARV), time-rate index, and variability independent of the mean (VIM). RESULTS: The study included 65 patients, with 33 assigned to the chlortalidone plus amiloride group and 32 to the amlodipine group. Participants in both groups had similar baseline characteristics. Short-term BP variability decreased within groups for SD and ARV indexes for 24-hour systolic BP and daytime systolic BP, but statistically significant time*group interactions were found for sleep systolic SD and VIM, with greater reduction in patients treated with amlodipine. CONCLUSION: In brief, our study has shown that the use of chlorthalidone in combination with amiloride and amlodipine produces comparable effects on short-term BP variability in patients with hypertension and OSA. Therefore, our findings suggest that BP variability may not be a significant factor when choosing between these medications for the treatment of hypertension and OSA.

Secondary Pharmacological Prevention of Coronary Artery Disease among Patients Submitted to Clinical Management, Percutaneous Coronary Intervention, or Coronary Artery Bypass Graft Surgery. / Prevenção Farmacológica Secundária da Doença Arterial Coronariana em Pacientes Submetidos ao Manejo Clínico, Intervenção Coronária Percutânea ou Cirurgia de Revascularização Miocárdica.

BACKGROUND: Secondary prevention is recommended for patients with evidence of coronary artery disease (CAD) regardless of the indication for treatment by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). OBJECTIVES: This study evaluated whether clinical treatment, PCI or CABG had an influence on adherence to the pharmacological secondary prevention in patients with stable CAD. METHODS: This cohort included patients aged ≥40 years with stable CAD confirmed by coronary angiography. The decision for medical treatment alone, or additionally with PCI or CABG, was made by the attending physicians. Adherence to the prescribed drugs recommended by the guidelines for secondary prevention (optimal pharmacological treatment), including antiplatelet agents, lipid-lowering drugs, beta-blockers, and renin-angiotensin-aldosterone system blockers, was assessed at follow-up. Differences were considered significant for p values <0.05. RESULTS: From 928 patients enrolled at baseline, 415 had mild CAD and 66 moderate to severe CAD. The average follow-up was 5.2 ± 1.5 years. Patients submitted to CABG were more likely to receive the optimal pharmacological treatment than those submitted to PCI or treated clinically (63.5% versus 39.1% versus 45.7% respectively, p=0.003). Baseline factors independently associated with greater probability of having a prescription of optimal treatment at follow-up were CABG [39% higher (6% - 83%, p=0.017) and diabetes [25% higher (1% - 56%), p=0.042] than their counterparts treated by other methods and participants without diabetes, respectively. CONCLUSIONS: Patients with CAD submitted to CABG are more commonly treated with optimal pharmacological secondary prevention than patients treated by PCI or exclusively with medical therapy.

FUNDAMENTO: A prevenção secundária é recomendada a pacientes com evidência de doença arterial coronariana (DAC) independentemente da indicação de tratamento por cirurgia de bypass da artéria coronária (CABG) ou intervenção coronária percutânea (ICP). OBJETIVOS: Este estudo avaliou se o tratamento clínico, a ICP ou o CABG teve influência na adesão à prevenção secundária farmacológica em pacientes com DAC estável. MÉTODOS: Esta coorte incluiu pacientes com idade ≥40 anos com DAC estável confirmada por angiografia coronária estável. A decisão por tratamento clínico isolado, ou combinado com ICP ou CABG foi feita por médicos assistentes. A adesão às drogas prescritas recomendadas pelas diretrizes de prevenção secundária (tratamento farmacológico ótimo), incluindo agentes antiplaquetários, drogas hipolipemianetes, betabloqueadores, e bloqueadores do sistema angiotensina aldosterona, foi avaliada no acompanhamento. Diferenças com valores de p < 0,05 foram consideradas estatisticamente significativas. RESULTADOS: Dos 928 pacientes incluídos inicialmente, 415 apresentaram DAC leve e 66 apresentaram DAC leve a moderada. O período médio de seguimento foi 5,2 ± 1,5 anos. Os pacientes submetidos ao CABG apresentaram maior probabilidade de receberem tratamento farmacológico ótimo que aqueles submetidos à ICP ou tratamento clínico (63,5% versus 39,1% versus 45,7% respectivamente, p=0,003). Fatores basais independentemente associados com maior probabilidade de prescrição de tratamento ótimo foram CABG [39% maior (6% - 83%, p=0,017)] em comparação a outros tratamentos e diabetes [25% maior (1% - 56%), p=0,042] em comparação à ausência de diabetes. CONCLUSÕES: Pacientes com DAC submetidos ao CABG são mais frequentemente tratados com prevenção secundária farmacológica ótima que pacientes tratados com ICP ou exclusivamente com tratamento clínico.

Thiazide diuretics alone or combined with potassium-sparing diuretics to treat hypertension: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: The magnitude of blood pressure (BP)-lowering effects and decrease of the adverse effects of thiazide diuretics provided by potassium-sparing diuretics remain uncertain. The aim of this study was to compare the BP-lowering efficacy and the incidence of adverse effects of high (T+) and low-dose (T-) thiazide diuretics, alone or combined with high (PS+) or low-dose (PS-) potassium-sparing diuretics in patients with primary hypertension. METHODS: A systematic literature search was performed in PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus and LILACS. Randomized double-blind placebo or active-controlled trials (RCT) with 3 weeks to 1 year of follow-up were included. Sample size, mean and standard deviation from baseline, follow-up and change from baseline values were extracted by two independent reviewers. Pairwise random effect models and Bayesian network meta-analysis models were used to compare the effects of treatments. The risk of bias in individual studies was assessed using the Rob 1.0 tool. The primary outcome was the mean difference in office SBP. Secondary outcomes were the mean difference in biochemical parameters and the incidence of nonmelanoma skin cancer. RESULTS: Two hundred and seventy-six double-blind RCTs involving 58 807 participants (mean age: 55 years; 45% women) were included. All treatment groups were more effective than placebo in lowering BP, with mean differences (MDs) of change from baseline ranging from -7.66 mmHg [95% credible interval (95% CrI), -8.53 to -6.79] for T- to -12.77 mmHg (95% CrI, -15.22 to -10.31) for T+PS-. T+ alone or combined with potassium-sparing was more effective in reducing BP than T-. The surface under the cumulative ranking curve (SUCRA) estimated ranking showed that the best effectiveness in lowering SBP was found for T+PS- (0.69), T+PS+ (0.65) and T+ (0.54). Compared with placebo, all treatments (except T-PS-) were associated with more potassium reduction and T+ compared with all other treatments and T- when compared with T-PS-. Compared with placebo, all active treatments (except T+PS+) showed higher elevations of uric acid. The increase of plasma glucose promoted by thiazides alone was reduced by potassium-sparing agents. CONCLUSION: Thiazides with potassium-sparing diuretics are associated with increased BP-lowering efficacy compared with thiazides alone while minimizing hypokalaemia and hyperglycaemia. These findings demonstrate that thiazide and potassium-sparing diuretic combination is preferable to thiazide alone in treating hypertension.

Effects of Antihypertensive Treatment on Left and Right Ventricular Global Longitudinal Strain and Diastolic Parameters in Patients with Hypertension and Obstructive Sleep Apnea: Randomized Clinical Trial of Chlorthalidone plus Amiloride vs. Amlodipine.

Hypertension is highly prevalent in patients with obstructive sleep apnea (OSA), and fluid retention with its nighttime rostral distribution is one potential mechanism. We tested whether or not diuretics differ from amlodipine in their impact on echocardiographic parameters. Patients with moderate OSA and hypertension were randomized to receive diuretics (chlorthalidone plus amiloride) or amlodipine daily for 8 weeks. We compared their effects on left and right ventricular global longitudinal strain (LV-GLS and RV-GLS, respectively), on LV diastolic parameters, and on LV remodeling. In the 55 participants who had echocardiographic images feasible for strain analysis, all echocardiographic parameters were within normal ranges. After 8 weeks, the 24 h blood pressure (BP) reduction values were similar, while most echocardiographic metrics were kept unchanged, except for LV-GLS and LV mass. In conclusion, the use of diuretics or amlodipine had small and similar effects on echocardiographic parameters in patients with moderate OSA and hypertension, suggesting that they do not have important effects on mediating the interaction between OSA and hypertension.

Fruits and vegetables intake and characteristics associated among adolescents from Southern Brazil.

BACKGROUND: Increased body weight has been associated with an unhealthy diet, low consumption of fruits and vegetables. Our objective was to investigate whether adolescents had low intake of fruits and vegetables, and whether gender, age and education could affect the feeding patterns. METHODS: A population-based sample of adolescents, aged 12-19 years, were randomly selected in southern Brazil and included in this cross-sectional study. The total daily consumption of fruits, vegetables, rice and beans were investigated in standardized household interviews, using a food frequency questionnaire and questions, being categorized as five or more servings per day as the five-a-day diet. ANOVA, ANCOVA, and modified Poisson regression were used in the analysis. RESULTS: Adolescents (n = 568) were included, 49.5% boys, 14.3% had overweight and 8.8% obesity. Approximately 23% of participants consumed five daily servings of fruits and vegetables. It was observed that 36.7% of boys and 31.0% of girls consumed less than one serving of fruit per day, and 58.4% and 44.6%, respectively, consumed less than one serving of vegetables. The consumption of vegetables, fruits, and rice and beans were not independently associated with gender. Overweight was associated with higher intake of five-a-day, independently of confounding factors. CONCLUSIONS: Adolescents from southern Brazil have lower frequency of consumption of five servings a day of fruits and vegetables combined.