The hypertension-based chronic disease model in a primary care setting.

Background: Driver-based chronic disease models address the public health challenge of cardiometabolic risk. However, there is no data available about the novel Hypertension-Based Chronic Disease (HBCD) model. This study investigates the prevalence, characteristics, and prognostic significance of HBCD Stages in a primary care cohort. Methods: This study included participants aged ≥45 years, randomly selected from the primary care program of a Brazilian medium-sized city. Participants underwent electrocardiogram, tissue Doppler echocardiogram and were followed for a median of 6 years. Participants were classified into HBCD Stages as follows: Stage 1: hypertension risk factors; Stage 2: pre-hypertension; Stage 3: hypertension; and Stage 4: hypertension complications. Results: Overall, 633 participants were included in the cross-sectional analysis and 560 that had follow-up data were included in the prognostic analysis. From 633 participants, 1.3% had no identifiable risk factors for HBCD, 10.0% were Stage 1, 14.7% Stage 2, 51.5% Stage 3, and 22.5% Stage 4. Increasing HBCD stages had worse glomerular filtration rates, echocardiographic markers, and higher body mass index, waist circumference, blood glucose levels, and prevalence of type 2 diabetes. Rates of all-cause mortality or cardiovascular hospitalization increased across HBCD Stages: Stage 1: 3.6%; Stage 2: 4.8%, Stage 3: 7.6%; and Stage 4: 39.5%. Kaplan-Meier curves showed composite outcome worsened across HBCD Stages 1-4 (p < 0.001). Conclusions: HBCD is a conceptually and prognostically valid model. Remarkably, HBCD stages were associated with progressively worsening markers of heart disease, declining kidney function and higher rates of all-cause mortality or cardiovascular hospitalization.

Cardiometabolic-based chronic disease: adiposity and dysglycemia drivers of heart failure.

Heart failure (HF) is a complex clinical syndrome, associated with high rates of mortality, hospitalization, and impairment of quality of life. Obesity and type 2 diabetes are major cardiometabolic drivers, represented as distinct stages of adiposity- and dysglycemia-based chronic disease (ABCD, DBCD), respectively, and leading to cardiometabolic-based chronic disease (CMBCD). This review focuses on one aspect of the CMBCD model: how ABCD and DBCD influence genesis and progression of HF phenotypes. Specifically, the relationships of ABCD and DBCD stages with structural and functional heart disease, HF risk, and outcomes in overt HF are detailed. Also, evidence-based lifestyle, pharmacological, and procedural interventions that promote or reverse cardiac remodeling and outcomes in individuals at risk or with HF are discussed. In summary, driver-based chronic disease models for individuals at risk or with HF can expose prevention targets for more comprehensive interventions to improve clinical outcomes. Future randomized trials that investigate structured lifestyle, pharmacological, and procedural therapies specifically tailored for the CMBCD model are needed to develop personalized care plans to decrease HF susceptibility and improve outcomes.

Characteristics and Temporal Trends in the Mortality of Different Heart Failure Phenotypes in Primary Care. / Características e Tendências na Mortalidade em Diferentes Fenótipos de Insuficiência Cardíaca na Atenção Primária.

BACKGROUND: The classification of heart failure (HF) by phenotypes has a great relevance in clinical practice. OBJECTIVE: The study aimed to analyze the prevalence, clinical characteristics, and outcomes between HF phenotypes in the primary care setting. METHODS: This is an analysis of a cohort study including 560 individuals, aged ≥ 45 years, who were randomly selected in a primary care program. All participants underwent clinical evaluations, b-type natriuretic peptide (BNP) measurements, electrocardiogram, and echocardiography in a single day. HF with left ventricular ejection fraction (LVEF) < 40% was classified as HF with reduced ejection fraction (HFrEF), LVEF 40% to 49% as HF with mid-range ejection fraction (HFmrEF) and LVEF ≥ 50% as HF with preserved ejection fraction (HFpEF). After 5 years, the patients were reassessed as to the occurrence of the composite outcome of death from any cause or hospitalization for cardiovascular disease. RESULTS: Of the 560 patients included, 51 patients had HF (9.1%), 11 of whom had HFrEF (21.6%), 10 had HFmrEF (19.6%) and 30 had HFpEF (58.8%). HFmrEF was similar to HFpEF in BNP levels (p < 0.001), left ventricular mass index (p = 0.037), and left atrial volume index (p < 0.001). The HFmrEF phenotype was similar to HFrEF regarding coronary artery disease (p = 0.009). After 5 years, patients with HFmrEF had a better prognosis when compared to patients with HFpEF and HFrEF (p < 0.001). CONCLUSION: The prevalence of ICFEI was similar to that observed in previous studies. ICFEI presented characteristics similar to ICFEP in this study. Our data show that ICFEi had a better prognosis compared to the other two phenotypes.

FUNDAMENTO: A classificação da insuficiência cardíaca (IC) por fenótipos possui grande relevância na prática clínica. OBJETIVO: O estudo visou analisar a prevalência, as características clínicas e os desfechos entre os fenótipos de IC no contexto da atenção primária. MÉTODOS: Trata-se de uma análise de um estudo de coorte que incluiu 560 indivíduos, com idade ≥ 45 anos, que foram selecionados aleatoriamente em um programa de atenção primária. Todos os participantes foram submetidos a avaliações clínicas, dosagem do peptídeo natriurético tipo B (BNP), eletrocardiograma e ecocardiografia em um único dia. A IC com fração de ejeção do ventrículo esquerdo (FEVE) < 40% foi classificado como IC com fração de ejeção reduzida (ICFEr), FEVE de 40% a 49% como IC com fração de ejeção intermediária (ICFEi) e FEVE ≥ 50% como IC com fração de ejeção preservada (ICFEp). Após 5 anos, os pacientes foram reavaliados quanto à ocorrência do desfecho composto de óbito por qualquer causa ou internação por doença cardiovascular. RESULTADOS: Dos 560 pacientes incluídos, 51 pacientes tinham IC (9,1%), 11 dos quais tinham ICFEr (21,6%), 10 tinham ICFEi (19,6%) e 30 tinham ICFEp (58,8%). A ICFEi foi semelhante à ICFEp nos níveis de BNP (p < 0,001), índice de massa do ventrículo esquerdo (p = 0,037) e índice de volume do átrio esquerdo (p < 0,001). O fenótipo de ICFEi foi semelhante ao de ICFEr em relação à doença arterial coronariana (p = 0,009). Após 5 anos, os pacientes com ICFEi apresentaram melhor prognóstico quando comparados aos pacientes com ICFEp e ICFEr (p < 0,001). CONCLUSÃO: A prevalência de ICFEI foi semelhante ao observado em estudos anteriores. A ICFEI apresentou características semelhantes a ICFEP neste estudo. Nossos dados mostram que a ICFEi teve melhor prognóstico em comparação com os outros dois fenótipos.

Myocardial Injury after Non-cardiac Surgery - State of the Art. / Lesão Miocárdica após Cirurgia Não Cardíaca ­ Estado da Arte.

Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.

Lesão Miocárdica após Cirurgia Não Cardíaca - Estado da Arte / Myocardial Injury after Non-cardiac Surgery - State of the Art

Resumo Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.

Abstract Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

Is lipid accumulation product a better cardiovascular risk predictor in elderly individuals than anthropometric measures?

INTRODUCTION: Population aging is associated with increased prevalence of cardiovascular diseases that have a significant impact on overall morbidity and mortality. Insulin resistance (IR) and visceral obesity are risk factors for vascular damage and cardiometabolic diseases. AIMS: Estimating the correlation between lipid accumulation product (LAP) and IR in elderly individuals and comparing them to traditional anthropometric indices. METHODS: Cross-sectional study comprising 411 individuals >60 years, who were treated in a primary care service. Body mass index (BMI), neck circumference (NC), waist circumference (WC), hip circumference (HC), arm circumference (AC), sagittal abdominal diameter (SAD) and waist-hip ratio (WHR) were recorded. IR was estimated based on HOMA-IR (homeostasis model assessment IR index). LAPa index was calculated as [WC-65]×[triglyceride (TG)] in men, and as [WC-58]×[TG] in women, whereas LAPb was calculated by using the minimum WC values recorded for the current sample, i.e., 61.5 cm for women and 71.5 cm for men. RESULTS: There was correlation among LAPa (0.506), LAPb (0.515) and HOMA-IR. LAP was better correlated to HOMA-IR and showed higher area under the curve than BMI, NC, WHR and SAD. Based on the receiver operating characteristic curve analysis, LAPb≥47.40 and LAPa≥52.5 were the best cut-off values used to identify individuals with IR presenting 68.8% and 68.2% sensitivity, and 68.6% and 68.6% specificity, respectively. CONCLUSION: LAP may be a useful and simple clinical marker to assess cardiometabolic risk factors in the elderly population treated at a primary care service.

Características e tendências na mortalidade em diferentes fenótipos de insuficiência cardíaca na atenção primária / Characteristics and temporal trends in the mortality of different heart failure phenotypes in primary care

Resumo Fundamento: A classificação da insuficiência cardíaca (IC) por fenótipos possui grande relevância na prática clínica. Objetivo: O estudo visou analisar a prevalência, as características clínicas e os desfechos entre os fenótipos de IC no contexto da atenção primária. Métodos: Trata-se de uma análise de um estudo de coorte que incluiu 560 indivíduos, com idade ≥ 45 anos, que foram selecionados aleatoriamente em um programa de atenção primária. Todos os participantes foram submetidos a avaliações clínicas, dosagem do peptídeo natriurético tipo B (BNP), eletrocardiograma e ecocardiografia em um único dia. A IC com fração de ejeção do ventrículo esquerdo (FEVE) < 40% foi classificado como IC com fração de ejeção reduzida (ICFEr), FEVE de 40% a 49% como IC com fração de ejeção intermediária (ICFEi) e FEVE ≥ 50% como IC com fração de ejeção preservada (ICFEp). Após 5 anos, os pacientes foram reavaliados quanto à ocorrência do desfecho composto de óbito por qualquer causa ou internação por doença cardiovascular. Resultados: Dos 560 pacientes incluídos, 51 pacientes tinham IC (9,1%), 11 dos quais tinham ICFEr (21,6%), 10 tinham ICFEi (19,6%) e 30 tinham ICFEp (58,8%). A ICFEi foi semelhante à ICFEp nos níveis de BNP (p < 0,001), índice de massa do ventrículo esquerdo (p = 0,037) e índice de volume do átrio esquerdo (p < 0,001). O fenótipo de ICFEi foi semelhante ao de ICFEr em relação à doença arterial coronariana (p = 0,009). Após 5 anos, os pacientes com ICFEi apresentaram melhor prognóstico quando comparados aos pacientes com ICFEp e ICFEr (p < 0,001). Conclusão: A prevalência de ICFEI foi semelhante ao observado em estudos anteriores. A ICFEI apresentou características semelhantes a ICFEP neste estudo. Nossos dados mostram que a ICFEi teve melhor prognóstico em comparação com os outros dois fenótipos.

Abstract Background: The classification of heart failure (HF) by phenotypes has a great relevance in clinical practice. Objective: The study aimed to analyze the prevalence, clinical characteristics, and outcomes between HF phenotypes in the primary care setting. Methods: This is an analysis of a cohort study including 560 individuals, aged ≥ 45 years, who were randomly selected in a primary care program. All participants underwent clinical evaluations, b-type natriuretic peptide (BNP) measurements, electrocardiogram, and echocardiography in a single day. HF with left ventricular ejection fraction (LVEF) < 40% was classified as HF with reduced ejection fraction (HFrEF), LVEF 40% to 49% as HF with mid-range ejection fraction (HFmrEF) and LVEF ≥ 50% as HF with preserved ejection fraction (HFpEF). After 5 years, the patients were reassessed as to the occurrence of the composite outcome of death from any cause or hospitalization for cardiovascular disease. Results: Of the 560 patients included, 51 patients had HF (9.1%), 11 of whom had HFrEF (21.6%), 10 had HFmrEF (19.6%) and 30 had HFpEF (58.8%). HFmrEF was similar to HFpEF in BNP levels (p < 0.001), left ventricular mass index (p = 0.037), and left atrial volume index (p < 0.001). The HFmrEF phenotype was similar to HFrEF regarding coronary artery disease (p = 0.009). After 5 years, patients with HFmrEF had a better prognosis when compared to patients with HFpEF and HFrEF (p < 0.001). Conclusion: The prevalence of ICFEI was similar to that observed in previous studies. ICFEI presented characteristics similar to ICFEP in this study. Our data show that ICFEi had a better prognosis compared to the other two phenotypes.

Prognosis of Heart Failure with Preserved Ejection Fraction in Primary Care by the H2FPEF Score

Abstract Background: Primary care physicians have difficulty dealing with patients who have HF with preserved LVEF(HFpEF). The prognosis of HFpEF is poor, and difficult to predict on primary care. Objective: The aim of the study is to apply the H2FPEF score to primary care patients and verify its power to assess the risk of death or hospitalization due to cardiovascular disease. Methods: This longitudinal study included 402 individuals, with signs or symptoms of HF, aged≥45 years and, underwent an evaluation which included clinical examination, BNP and echocardiogram. The diagnosis of HFpEF was confirmed by the criteria of the European Society of Cardiology. After five years, the patients were reassessed as to the occurrence of the composite outcome, death from any cause or hospitalization for cardiovascular disease. H2FPEF used six variables: body mass index, medications for hypertension, age, pulmonary artery systolic pressure, atrial fibrillation and E/e' ratio ranged from 0 to 9 points. The level of statistical significance was p<0.05. Results: HFpEF was diagnosed in 58(14.4%). Among patients with H2FPEF≥4, 30% had HFpEF and in those with a score≤4, HFpEF was present in 12%. Patients with HFpEF and H2FPEF≥4 had 53% of outcomes, whereas patients with HFpEF and a score ≤4 had a 21% of outcomes. BNP values were higher in patients with HFpEF compared to those without HFpEF(p<0.0001). Conclusion: H2FPEF≥4 indicated a worse prognosis in patients with HFpEF assisted in primary care. H2FPEF may be a simple and useful tool for risk stratification in patients with HFpEF at the primary care.

Acute Cardiorenal Syndrome: Which Diagnostic Criterion to Use And What is its Importance for Prognosis? / Síndrome Cardiorrenal Aguda: Qual Critério Diagnóstico Utilizar e sua Importância para o Prognóstico?

The absence of a consensus about the diagnostic criteria for acute cardiorenal syndrome (ACRS) affects its prognosis. This study aimed at assessing the diagnostic criteria for ACRS and their impact on prognosis. A systematic review was conducted using PRISMA methodology and PICO criteria in the MEDLINE, EMBASE and LILACS databases. The search included original publications, such as clinical trials, cohort studies, case-control studies, and meta-analyses, issued from January 1998 to June 2018. Neither literature nor heart failure guidelines provided a clear definition of the diagnostic criteria for ACRS. The serum creatinine increase by at least 0.3 mg/dL from baseline creatinine is the most used diagnostic criterion. However, the definition of baseline creatinine, as well as which serum creatinine should be used as reference for critical patients, is still controversial. This systematic review suggests that ACRS criteria should be revised to include the diagnosis of ACRS on hospital admission. Reference serum creatinine should reflect baseline renal function before the beginning of acute kidney injury.

Síndrome Cardiorrenal Aguda: Qual Critério Diagnóstico Utilizar e sua Importância para o Prognóstico? / Acute Cardiorenal Syndrome: Which Diagnostic Criterion to Use And What is its Importance for Prognosis?

Resumo A indefinição de critérios diagnósticos para síndrome cardiorrenal aguda (SCRA) impacta em diferentes resultados prognósticos. Objetivou-se avaliar os critérios diagnósticos da SCRA e o impacto no prognóstico. Procedeu-se à revisão sistemática utilizando-se a metodologia PRISMA e os critérios PICO nas bases MEDLINE, EMBASE e LILACS. A pesquisa incluiu artigos originais do tipo ensaio clínico, coorte, caso-controle e meta-análises publicados no período de janeiro de 1998 até junho de 2018. Não foi encontrada na literatura nem nas diretrizes de insuficiência cardíaca uma definição clara dos critérios diagnósticos da SCRA. O critério diagnóstico mais comumente utilizado é o aumento da creatinina sérica de pelo menos 0,3 mg/dl em relação à basal. Entretanto, existem controvérsias na definição de creatinina basal e de qual deveria ser a creatinina sérica de referência dos pacientes críticos. Esta revisão sistemática sugere que os critérios de SCRA devem ser revistos para que se inclua o diagnóstico de SCRA na admissão hospitalar. A creatinina sérica de referência deve refletir a função renal basal antes do início da injúria renal aguda.

Abstract The absence of a consensus about the diagnostic criteria for acute cardiorenal syndrome (ACRS) affects its prognosis. This study aimed at assessing the diagnostic criteria for ACRS and their impact on prognosis. A systematic review was conducted using PRISMA methodology and PICO criteria in the MEDLINE, EMBASE and LILACS databases. The search included original publications, such as clinical trials, cohort studies, case-control studies, and meta-analyses, issued from January 1998 to June 2018. Neither literature nor heart failure guidelines provided a clear definition of the diagnostic criteria for ACRS. The serum creatinine increase by at least 0.3 mg/dL from baseline creatinine is the most used diagnostic criterion. However, the definition of baseline creatinine, as well as which serum creatinine should be used as reference for critical patients, is still controversial. This systematic review suggests that ACRS criteria should be revised to include the diagnosis of ACRS on hospital admission. Reference serum creatinine should reflect baseline renal function before the beginning of acute kidney injury.

Sagittal abdominal diameter as a marker of visceral obesity in older primary care patients.

BACKGROUND: Longevity, combined with a higher prevalence of obesity, particularly visceral obesity, has been associated with an increased risk of cardiovascular diseases. Insulin resistance (IR) is an important link between visceral obesity and cardiovascular diseases. An important association has been found between sagittal abdominal diameter, visceral obesity and IR. The objective of this study is to evaluate sagittal abdominal diameter as a marker of visceral obesity and correlate it with IR in older primary health care patients. METHODS: A cross-sectional study was performed with 389 patients over 60 years of age (70.6 ± 6.9), of whom 74% were female. Their clinical, anthropometric and metabolic profiles were assessed and their fasting serum insulin level was used to calculate the homeostasis model assessment insulin resistance (HOMA-IR). Sagittal abdominal diameter was measured in the supine position at the midpoint between the iliac crest and the last rib with abdominal calipers. RESULTS: Sagittal abdominal diameter was significantly correlated with anthropometric measures of general and visceral obesity and with HOMA-IR in both genders. There was no change in the association between sagittal abdominal diameter and HOMA-IR after adjusting for age, sex, diabetes and hypertension. CONCLUSION: It is feasible to use sagittal abdominal diameter in older primary care patients as a tool to evaluate visceral obesity, which is an indicator of cardiovascular risk.

Trends in Mortality Rates from Cardiovascular Disease and Cancer between 2000 and 2015 in the Most Populous Capital Cities of the Five Regions of Brazil.

BACKGROUND: In many cities around the world, the mortality rate from cancer (CA) has exceeded that from disease of the circulatory system (DCS). OBJECTIVES: To compare the mortality curves from DCS and CA in the most populous capital cities of the five regions of Brazil. METHODS: Data of mortality rates from DCS and CA between 2000 and 2015 were collected from the Mortality Information System of Manaus, Salvador, Goiania, Sao Paulo and Curitiba, and categorized by age range into early (30-69 years) and late (≥ 70 years), and by gender of the individuals. Chapters II and IX of the International Classification of Diseases-10 were used for the analysis of causes of deaths. The Joinpoint regression model was used to assess the tendency of the estimated annual percentage change of mortality rate, and the Monte Carlo permutation test was used to detect when changes occurred. Statistical significance was set at 5%. RESULTS: There was a consistent decrease in early and late mortality from DCS in both genders in the cities studied, except for late mortality in men in Manaus. There was a tendency of decrease of mortality rates from CA in São Paulo and Curitiba, and of increase in the rates from CA in Goiania. In Salvador, there was a decrease in early mortality from CA in men and women and an increase in late mortality in both genders. CONCLUSION: There was a progressive and marked decrease in the mortality rate from DCS and a maintenance or slight increase in CA mortality in the five capital cities studied. These phenomena may lead to the intersection of the curves, with predominance of mortality from CA (old and new cases).

Left Ventricular Remodeling Patterns in Primary Healthcare.

BACKGROUND: Left ventricular remodeling (LVR) is related to both non-fatal and fatal outcomes. OBJECTIVE: To describe the geometric patterns of the LV and their associations. METHODS: A total of 636 individuals between the ages of 45 and 99 years in Rio de Janeiro, Brazil, were submitted to clinical evaluation, laboratory tests, electrocardiogram, and tissue Doppler echocardiography (TDE). The difference between categories was tested with Kruskall-Wallis with post hoc tests, once all variables studied are non-normally distributed and Pearson's Qui-square (categorical variables). Gross and adjusted ORs were estimated by logistic regression. The level of significance was 5% for all tests. Subjects had LVR characterized as: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH). RESULTS: The prevalence of altered patterns was 33%. Subjects presented NG (n = 423; 67%); EH (n = 186; 29%); CH (n = 14; 2%); and CR (n = 13; 2%). The variables of gender, age, level of education and albumin/creatinine ratio (A/C), showed a relationship with the chance of EH even after adjustment. CONCLUSION: Approximately one third of the studied individuals had LVR and were at risk for developing heart failure. Altered A/C in urine was associated with EH, indicating an early relationship between cardiac and renal dysfunction.

Trends in Mortality Rates from Cardiovascular Disease and Cancer between 2000 and 2015 in the Most Populous Capital Cities of the Five Regions of Brazil / Tendência das Taxas de Mortalidade por Doença Cardiovascular e Câncer entre 2000 e 2015 nas Capitais mais Populosas das Cinco Regiões do Brasil

Abstract Background: In many cities around the world, the mortality rate from cancer (CA) has exceeded that from disease of the circulatory system (DCS). Objectives: To compare the mortality curves from DCS and CA in the most populous capital cities of the five regions of Brazil. Methods: Data of mortality rates from DCS and CA between 2000 and 2015 were collected from the Mortality Information System of Manaus, Salvador, Goiania, Sao Paulo and Curitiba, and categorized by age range into early (30-69 years) and late (≥ 70 years), and by gender of the individuals. Chapters II and IX of the International Classification of Diseases-10 were used for the analysis of causes of deaths. The Joinpoint regression model was used to assess the tendency of the estimated annual percentage change of mortality rate, and the Monte Carlo permutation test was used to detect when changes occurred. Statistical significance was set at 5%. Results: There was a consistent decrease in early and late mortality from DCS in both genders in the cities studied, except for late mortality in men in Manaus. There was a tendency of decrease of mortality rates from CA in São Paulo and Curitiba, and of increase in the rates from CA in Goiania. In Salvador, there was a decrease in early mortality from CA in men and women and an increase in late mortality in both genders. Conclusion: There was a progressive and marked decrease in the mortality rate from DCS and a maintenance or slight increase in CA mortality in the five capital cities studied. These phenomena may lead to the intersection of the curves, with predominance of mortality from CA (old and new cases).

Resumo Fundamento: Em muitas cidades no mundo, a taxa de mortalidade por câncer (CA) ultrapassou aquela por doenças do aparelho circulatório (DAC). Objetivos: Comparar as curvas de mortalidade por DAC e CA nas capitais mais populosas das cinco regiões brasileiras. Métodos: Dados de mortalidade por DAC e CA entre 2000 e 2015 foram coletadas no Sistema de Informações sobre Mortalidade das capitais mais populosas das cinco regiões do Brasil: Manaus, Salvador, Goiânia, São Paulo e Curitiba. Os dados foram categorizados por faixas etárias dos indivíduos em precoce (30-69 anos) e tardia (≥70 anos), e por gênero. Foram considerados os capítulos II e IX da Classificação Internacional de Doenças-10 para análise das causas de óbito. A tendência na estimativa de mudança percentual foi calculada pelo modelo de regressão Joinpoint 4.6.0.0. e a detecção das mudanças das taxas pelo teste de permutação Monte Carlo. Nível de significância estatística de 5%. Resultados: Observou-se queda consistente das mortalidades precoce e tardia por DAC, em ambos os gêneros, nas capitais estudadas, com exceção da mortalidade tardia em homens em Manaus. Houve tendência de queda das taxas de mortalidade por CA em São Paulo e Curitiba, e de aumento da taxa de mortalidade por CA em Goiânia. Em Salvador, houve queda na mortalidade precoce por CA em homens e mulheres e incremento na mortalidade tardia em ambos os gêneros. Conclusão: Houve queda progressiva e expressiva da taxa de mortalidade por DAC nas cinco capitais em oposição à manutenção ou discreta elevação da mortalidade por CA. Tais fenômenos concorrem para o cruzamento das curvas com predomínio da mortalidade por CA (já ocorrido ou casos novos).