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.

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.

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.

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.

Left Ventricular Remodeling Patterns in Primary Healthcare / Padrões de Remodelamento Ventricular Esquerdo na Atenção Primária à Saúde

Abstract 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.

Resumo Fundamento: O remodelamento ventricular esquerdo (RVE) está relacionado a desfechos não fatais e fatais. Objetivo: Descrever os padrões geométricos do VE e suas associações. Métodos: Um total de 636 indivíduos entre 45 e 99 anos no Rio de Janeiro, Brasil, foi submetido a avaliação clínica, exames laboratoriais, eletrocardiograma e ecocardiograma com Doppler tecidual (EDT). A diferença entre as categorias foi testada com Kruskall-Wallis com testes post hoc, uma vez que todas as variáveis estudadas não são normalmente distribuídas e o qui-quadrado de Pearson (variáveis categóricas). As ORs brutas e ajustadas foram estimadas por regressão logística. O nível de significância foi de 5% para todos os testes. Os indivíduos tinham RVE caracterizada como: geometria normal (GN), remodelamento concêntrico (RC), hipertrofia concêntrica (HC) e hipertrofia excêntrica (HE). Resultados: A prevalência de padrões alterados foi de 33%. Os sujeitos apresentaram GN (n = 423; 67%); HE (n = 186; 29%); HC (n = 14; 2%); e RC (n = 13; 2%). As variáveis sexo, idade, escolaridade e razão albumina/creatinina (A/C) mostraram relação com a chance de HE, mesmo após o ajuste. Conclusão: Aproximadamente um terço dos indivíduos estudados apresentavam RVE e corriam risco de desenvolver insuficiência cardíaca. A/C alterada na urina foi associada à HE, indicando uma relação precoce entre disfunção cardíaca e renal.

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

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

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

Increased Left Atrial Volume and Its Relationship to Vitamin D in Primary Care

The study is based on the fact that left atrial (LA) volume measurement is a marker of the presence of diastolic dysfunction and that Vitamin D deficiency may be associated with ventricular remodeling, worsening of left ventricular (LV) diastolic and systolic function, and activation of the renin-angiotensin-aldosterone system. Objective: To evaluate whether LAV changes are related to vitamin D deficiency. Method: A cross-sectional, population-based, unicentric study in which 640 patients over 45 years of age enrolled in the Niterói's Médico de Família program, RJ, were evaluated. Patients were submitted to tissue Doppler echocardiography to evaluate the parameters of diastolic and systolic function and vitamin D dosage. The presence or absence of hypovitaminosis D associated with structural and functional cardiac changes was compared between each group. A p < 0.05 value was considered as an indicator of statistical significance. Results: Of the 640 individuals analyzed, hypovitaminosis D was confirmed in 39.2% of the patients, of whom 34.8% had diastolic dysfunction. The most relevant echocardiographic parameters that were statistically significant were non-indexed AEDs and LAV, E'/A' and E wave deceleration time, which were associated with the presence of hypovitaminosis D (P < 0.01). Conclusion: The study of the association of hypovitaminosis D and the appearance of structural and functional cardiac abnormalities may contribute to the discussion of the adoption of one more criterion to select individuals at risk of developing clinical cardiac insufficiency in primary care since, with the use of echocardiography, the subclinical condition of cardiac involvement, with prognostic and treatment implications for the referred patients with hypovitaminosis D, can be identified early

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters.

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

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care / Prevalência de Risco para Síndrome de Apneia Obstrutiva do Sono e Associação com Fatores de Risco na Atenção Primária

Abstract Background: Obstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women. Objective: To study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied. Methods: Observational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05). Results: Of the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III. Conclusion: BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.

Resumo Fundamento: A síndrome da apneia obstrutiva do sono (SAOS) é uma doença crônica, progressiva, com alta morbimortalidade. Encontra-se subdiagnosticada, principalmente entre mulheres. Objetivo: Estudar a prevalência de alto risco para SAOS globalmente e para as categorias do Questionário de Berlim (QB), e avaliar a confiabilidade do uso do QB na população estudada. Métodos: Estudo observacional, transversal de indivíduos cadastrados no Programa Médico de Família de Niterói, selecionados aleatoriamente, com idade entre 45 e 99 anos, com coleta entre agosto/2011 e dezembro/2012. Variáveis associadas com cada uma das categorias do QB e com o alto risco para SAOS (global) (valor p<0,20) foram incluídas em modelos de regressão logística (valor p<0,05). Resultados: Do total (616), 403 (65,4%) indivíduos disseram roncar. A prevalência de alto risco para SAOS foi de 42,4%, sendo de 49,7% para a categoria I, 10,2% para a categoria II e 77,6% para a categoria III. Conclusão: O QB apresentou uma confiabilidade aceitável quando retiradas as perguntas 'alguém notou que você para de respirar quando está dormindo' e 'cochilar/dormir ao volante', o que deve ser testado em estudos com populações com maioria de mulheres e de baixa escolaridade. Dado o peso das doenças e riscos associados à SAOS, seria importante realizar futuras investigações para validar novos instrumentos ou adaptar o QB para melhor rastreamento da SAOS.

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women. OBJECTIVE: To study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied. METHODS: Observational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05). RESULTS: Of the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III. CONCLUSION: BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.