Acute physical and mental stress resulted in an increase in fatty acids, norepinephrine, and hemodynamic changes in normal individuals: A possible pathophysiological mechanism for hypertension-Pilot study.

Hypertension is often associated with metabolic changes. The sustained increase in sympathetic activity is related to increased blood pressure and metabolic changes. Environmental stimuli may be related to increased sympathetic activity, blood pressure, and metabolic changes, especially in genetically predisposed individuals. The aim of this study was to evaluate the response of fatty acids to physical and mental stress in healthy volunteers and the hemodynamic, hormonal, and metabolic implications of these stimuli. Fifteen healthy individuals with a mean age of 31 ± 7 years, of both sexes, were evaluated. They were assessed at baseline and after combined physical and mental stress (isometric exercise test, Stroop color test). Blood samples were collected at baseline and after stimulation for glucose, insulin, fatty acid, and catecholamine levels. Blood pressure, heart rate, cardiac output, systemic vascular resistance, and distensibility of the large and small arteries were analyzed. The data obtained at baseline and after stimuli were from the same individual, being the control itself. Compared to baseline, after physical and mental stress there was a statistically significant increase (p < .05) in free fatty acids, norepinephrine, diastolic blood pressure, peripheral vascular resistance, and distensibility of the large and small arteries. In conclusion, the combination of physical and mental stress raised fatty acids, norepinephrine, diastolic blood pressure, and peripheral vascular resistance in healthy individuals.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Desempenho físico e qualidade de vida de pacientes hipertensos em um programa de orientação educacional / Physical performance and quality of life of hypertense patients in an educational guidance program

INTRODUÇÃO: Intervenções educacionais, que incluem aumento no nível de atividade física e controle da hipertensão arterial, podem ser estratégias eficazes e de baixo custo. OBJETIVO: Avaliar os efeitos de um programa educacional no controle da pressão arterial (PA), desempenho físico e qualidade de vida (QV) de hipertensos. MATERIAIS E MÉTODOS: Estudo de intervenção, controlado, não randomizado, com adultos hipertensos, ambos os gêneros, acompanhados ambulatoriamente. O programa multiprofissional constituiu-se de 12 encontros com orientações sobre DCV e mudanças no estilo de vida. Aplicou-se o teste de caminhada dos seis minutos (TC6M), questionários QV Minnesota e Internacional de Atividade Física (IPAQ) e medidas de PA. Utilizou-se os testes t-Student pareado ou de Wilcoxon e ANOVA para medidas repetidas. RESULTADOS: Participaram 20 pacientes, 82% mulheres, 62±11 anos. Houve redução da pressão arterial sistólica (147,0 vs126,0) e diastólica (85,0 vs 70,0), aumento na distância percorrida (458±83 vs 499±77 p<0,001), redução nos sintomas de fadiga (4±3 vs 2±3 p<0,001) e dispneia (4±2 vs 2±2 p<0,05) aos esforços e referência de maior nível de AF (sedentários 2 vs 0; irregularmente ativos 12 vs 5; ativos 8 vs 11; muito ativos 0 vs 4). Redução na pontuação de todos os domínios na QV foi significante: Físico (14,5±11,7 vs 8,9±9,9 p=0,004); Emocional (8,4±6,5 vs 5,3±6,6 p=0,004); Outros (9,5±8,5 vs 6,6 p<0,001); Total (32,5±25,5 vs 19,7±23,5 p<0,001). CONCLUSÃO: Programas educacionais, envolvendo aumento da atividade física, são eficazes no controle da PA, aumento no desempenho físico e melhora na QV de pacientes hipertensos.

INTRODUCTION: Educational interventions, including increased physical activity and control of hypertension, can be effective and cost-effective strategies. OBJECTIVE: To evaluate the effects of an educational program on the control of blood pressure (BP), physical performance and quality of life (QOL) of hypertensive patients. MATERIALS AND METHODS: Non-randomized controlled intervention study with hypertensive adults, both genders, followed up on an outpatient basis. The multiprofessional program consisted of 12 meetings with guidance on CVD and lifestyle changes. The six-minute walk test (6MWT), the QL Minnesota and International Physical Activity Questionnaires (IPAQ) and BP measurements were applied. The paired Student t test or Wilcoxon and ANOVA tests were used for repeated measures. RESULTS: Twenty patients participated, 82% women, 62 ± 11 years old. There was a reduction in systolic (147.0 vs 126.0) and diastolic (85.0 vs 70.0) blood pressure, increased distance covered (458 ± 83 vs 499 ± 77 p <0.001), reduction in symptoms of fatigue (4 ± 3 vs 2 ± 3 p <0.001) and dyspnea (4 ± 2 vs 2 ± 2 p <0.05) on exertion and reference of higher PA level (sedentary 2 vs 0; irregularly active 12 vs 5; active 8 vs 11; very active 0 vs 4). Reduction in the score of all domains in QOL was significant: Physical (14.5 ± 11.7 vs 8.9 ± 9.9 p = 0.004); Emotional (8.4 ± 6.5 vs 5.3 ± 6.6 p = 0.004); Others (9.5 ± 8.5 vs 6.6 p <0.001); Total (32.5 ± 25.5 vs 19.7 ± 23.5 p <0.001). CONCLUSION: Educational programs involving increased physical activity are effective in controlling BP, increasing physical performance and improving QoL of hypertensive patients.

Is hepatojugular reflux a good predictor of heart failure with preserved ejection fraction?

Hypertension may occur with left ventricular (LV) diastolic dysfunction, and the consequence may be symptoms and signs of heart failure (HF). Hepatojugular reflux (HJR), described as a sign of regurgitation of the tricuspid valve, may reflect structural and functional changes of the LV in the hypertensive patient. The signal may be present in the presence of HF. Case: male, 49 years old with uncontrolled blood pressure. Physical examination showed jugular turgescence, HJR, and elevated blood pressure. Complementary exams showed signs of atrial and left ventricular overload in the electrocardiogram and, the echocardiogram showed left atrium volume increase, concentric LV hypertrophy and signs of grade I diastolic dysfunction. DISCUSSIO: The HJR present correlates with pulmonary artery pressure and probably reflect the increase in central blood volume.

Is hepatojugular reflux a good predictor of heart failure with preserved ejection fraction?

SUMMARY Hypertension may occur with left ventricular (LV) diastolic dysfunction, and the consequence may be symptoms and signs of heart failure (HF). Hepatojugular reflux (HJR), described as a sign of regurgitation of the tricuspid valve, may reflect structural and functional changes of the LV in the hypertensive patient. The signal may be present in the presence of HF. Case: male, 49 years old with uncontrolled blood pressure. Physical examination showed jugular turgescence, HJR, and elevated blood pressure. Complementary exams showed signs of atrial and left ventricular overload in the electrocardiogram and, the echocardiogram showed left atrium volume increase, concentric LV hypertrophy and signs of grade I diastolic dysfunction. DISCUSSIO: The HJR present correlates with pulmonary artery pressure and probably reflect the increase in central blood volume.

RESUMO A hipertensão pode cursar com disfunção diastólica de ventrículo esquerdo (VE) e a consequência disso pode ser sintomas e sinais de insuficiência cárdica (IC). O refluxo hepatojugular (RHJ), descrito como sinal de regurgitação da valva tricúspide, pode refletir alterações estruturais e funcionais do VE no paciente hipertenso. O sinal pode estar presente na vigência de IC. Caso: homem, 49 anos compressão arterial não controlada. Ao exame físico apresentou turgência jugular, RHJ e pressão arterial elevada. Os exames complementares mostraram sinais de sobrecarga atrial e de ventrículo esquerdo no eletrocardiograma, e no ecocardiograma foi evidenciado aumento do volume do átrio esquerdo, hipertrofia concêntrica do VE e sinais de disfunção diastólica grau I. DISCUSSÃO: RHJ presente correlaciona-se com a pressão da artéria pulmonar e provavelmente reflete o aumento do volume sanguíneo central.

Dysregulation of insulin levels in Chagas heart disease is associated with altered adipocytokine levels.

Metabolic, inflammatory, and autonomic nervous system (ANS) dysfunction are present in patients with heart failure. However, whether these changes are due to left ventricular dysfunction or heart failure etiology is unknown. We evaluated metabolism and inflammatory activity in patients with idiopathic dilated cardiomyopathy (IDC) and Chagas cardiomyopathy (CHG) and their correlation with the ANS. Forty-six patients were divided into 3 groups: IDC, CHG, and control. We evaluated adiponectin, leptin, insulin, interleukin-6, and tumor necrosis factor-alpha. ANS were analyzed by heart rate variability in time and frequency domains on a 24-hour Holter monitor. Levels of glucose, cholesterol, leptin, and adiponectin did not show differences between groups. Insulin levels were lower in CHG group (5.4 ± 3.3 µU/mL) when compared with control (8.0 ± 4.9 µU/mL) and IDC (9.9 ± 5.0 µU/mL) groups (p = 0.007). Insulin was positively associated with LFr/HFr ratio (r = 0.562; p = 0.029) and with the LFr component (r = 0.562; p = 0.029) and negatively associated with adiponectin (r = -0.603; p = 0.017) in CHG group. The addition of an adiponectin unit reduced average insulin by 0.332 µg/mL. Insulin levels were decreased in the CHG group when compared with the IDC group and were associated with ANS indexes and adiponectin levels.

Metabolic Syndrome-Related Features in Controlled and Resistant Hypertensive Subjects.

BACKGROUND: Metabolic syndrome (MetS) is widespread among hypertensive patients. Clinical features and potential biomarkers of MetS in the presence of hypertension and resistant hypertension (RHTN) represent a great area of interest for investigation. OBJECTIVE: The purpose of this study was to evaluate the prevalence of MetS and the clinical features associated with it in resistant and mild to moderate hypertensives. METHODS: This cross-sectional study included 236 patients, (i) 129 mild to moderate hypertensive patients and (ii) 107 patients with RHTN. We measured blood pressure (BP) and adipokines levels, and performed bioelectrical impedance analysis. Microalbuminuria (MA), cardiac hypertrophy and arterial stiffness were also assessed. The significance level of alpha = 0.05 was adopted. RESULTS: We found a MetS prevalence of 73% in resistant and 60% in mild-to-moderate hypertensive patients. In a multiple regression analysis, MA (odds ratio = 8.51; p = 0.01), leptin/adiponectin ratio (LAR) (odds ratio = 4.13; p = 0.01) and RHTN (odds ratio = 3.75; p = 0.03) were independently associated with the presence of MetS apart from potential confounders. CONCLUSIONS: Our findings suggest that both resistant and controlled hypertensive subjects have a high prevalence of MetS. In addition, MetS-related metabolic derangements may cause early renal and hormonal changes. Finally, LAR may be useful as a reliable biomarker for identifying those hypertensive subjects who are at risk for developing MetS.

Metabolic Syndrome-Related Features in Controlled and Resistant Hypertensive Subjects / Características Relacionadas à Síndrome Metabólica em Indivíduos com Hipertensão Controlada e Hipertensão Resistente

Abstract Background: Metabolic syndrome (MetS) is widespread among hypertensive patients. Clinical features and potential biomarkers of MetS in the presence of hypertension and resistant hypertension (RHTN) represent a great area of interest for investigation. Objective: The purpose of this study was to evaluate the prevalence of MetS and the clinical features associated with it in resistant and mild to moderate hypertensives. Methods: This cross-sectional study included 236 patients, (i) 129 mild to moderate hypertensive patients and (ii) 107 patients with RHTN. We measured blood pressure (BP) and adipokines levels, and performed bioelectrical impedance analysis. Microalbuminuria (MA), cardiac hypertrophy and arterial stiffness were also assessed. The significance level of alpha = 0.05 was adopted. Results: We found a MetS prevalence of 73% in resistant and 60% in mild-to-moderate hypertensive patients. In a multiple regression analysis, MA (odds ratio = 8.51; p = 0.01), leptin/adiponectin ratio (LAR) (odds ratio = 4.13; p = 0.01) and RHTN (odds ratio = 3.75; p = 0.03) were independently associated with the presence of MetS apart from potential confounders. Conclusions: Our findings suggest that both resistant and controlled hypertensive subjects have a high prevalence of MetS. In addition, MetS-related metabolic derangements may cause early renal and hormonal changes. Finally, LAR may be useful as a reliable biomarker for identifying those hypertensive subjects who are at risk for developing MetS.

Resumo Fundamentos: A síndrome metabólica (SM) é comum em pacientes hipertensos. As características clínicas e os potenciais biomarcadores da SM na presença de hipertensão e hipertensão resistente (HR) representam uma ampla área de interesse a ser investigada. Objetivo: O objetivo deste estudo foi avaliar a prevalência de SM e as características clínicas associadas à síndrome em indivíduos com hipertensão resistente e leve a moderada. Métodos: Este estudo transversal incluiu 236 pacientes, (i) 129 pacientes com hipertensão leve a moderada e (ii) 107 pacientes com HR. Medimos a pressão arterial (PA), parâmetros bioquímicos e os níveis de adipocinas dos pacientes, além de microalbuminúria (MA), hipertrofia cardíaca e rigidez arterial. Foi adotado o nível de significância de alfa 0,05. Resultados: A SM esteve presente em 73% dos pacientes com HR e 60% daqueles com hipertensão leve a moderada. Na análise de regressão múltipla, a MA (odds ratio = 8,51; p = 0,01), a razão leptina/adiponectina (RLA) (odds ratio = 4,13; p = 0,01) e a HR (odds ratio = 3,75; p = 0,03) foram independentemente associadas com a presença de SM, excluindo-se potenciais fatores de confusão. Conclusões: Nossos resultados sugerem que tanto hipertensos resistentes como hipertensos controlados apresentam alta prevalência de SM. Além disso, distúrbios metabólicos relacionados à SM podem causar alterações precoces renais e hormonais, e a RLA parece ser útil como biomarcador confiável para identificar indivíduos hipertensos em risco de desenvolverem SM.

Dysregulation of Autonomic Nervous System in Chagas' Heart Disease Is Associated with Altered Adipocytokines Levels.

BACKGROUND: Chagas disease (CD) induces autonomic dysfunction and inflammatory activity, which may promote metabolic abnormalities. We studied metabolism and his correlation with Autonomic Nervous System (ANS) and inflammation in CD. METHODS AND RESULTS: Sixty subjects were divided into 4 groups: control group (CG), IF (indeterminate form) group; ECG group (ECG abnormalities and normal left ventricular systolic function), and LVD group (left ventricular sistolic dysfunction). Levels of adiponectin, leptin, insulin, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) were assayed in serum samples by ELISA. ANS was assessed by heart rate variability in frequency domain in 24-hour Holter and postural tilt test (rest and orthostatic position). High frequency (HFr) component values were used to estimate parasympathetic activity and low frequency (LFr) component, sympathetic activity. Analyzes were made of the correlations of each of the metabolic parameters (leptin and adiponectin) with the inflammatory cytokines (interleukin-6 and TNF- alpha) and with the ANS assessment measurements. No significant differences were observed in leptin and insulin levels. Adiponectin was higher in ECG and LVD groups: [CG = 4766.5 (5529.5), IF = 4003.5 (2482.5), ECG = 8376.5 (8388.5), LVD = 8798 (4188.0) ng/mL, p<0.001)]. IL-6 and TNF-alpha were higher in LVD group: [IL-6: CG = 1.85 (6.41); IF = 1.58 (1.91); ECG = 1.0 (1.57); LVD= 31.44 (72.19) pg/ml; p = 0.001. TNF-alpha: CG = 22.57 (88.2); IF = 19.31 (33.16); ECG = 12.45 (3.07); LVD = 75.15 (278.57) pg/ml; p = 0.04]. Adiponectin levels had a positive association with the HFr component (r = 0.539; p = 0.038) and an inverse association with the LFr component (r = - 0.539; p = 0.038) in ECG group. Leptin levels had a negative association with the HFr component (r= - 0.632; p = 0.011) and a positive association with the LFr component (r = 0.632; p = 0.011) in LVD group. CONCLUSIONS: We found increased adiponectin levels in Chagas' heart disease with systolic dysfunction and in patients with ECG abnormalities and normal systolic function at rest. Adipocytokines levels (adiponectin and leptin) were associated with ANS parameters in Chagas' heart disease.

Prevalence of cardiovascular risk factors among truck drivers in the South of Brazil.

BACKGROUND: Truck drivers work under conditions that predispose them to a high prevalence of risk factors for the development of cardiovascular disease (CVD); however, these factors have not been fully evaluated and are not usually considered to be within the scope of health or labor services. METHODS: An observational cross-sectional study was conducted on 250 long-distance truck drivers; the drivers were all male and were aged 18-60 years. The clinical evaluation consisted of an assessment of social habits and demographic data and an evaluation of risk factors for CVD at 3 time points separated by a one-week interval. To assess the associations with risk factors were used univariate and multivariate analysis. The suitability of the final model fit was assessed via the Hosmer-Lemeshow test. The significance level was set at 5%. RESULTS: Among all of the subjects, the prevalence of physical inactivity was 72.8%; consumption of alcoholic beverages, 66.8%; routine use of some type of stimulant during work activities, 19.2%; and smoking, 29%. Only 20.8% had a healthy weight, and 58.2% had an abdominal circumference greater than 102 cm. A diagnosis of arterial hypertension was confirmed in 45.2%, and abnormal glucose levels were detected in 16.4%. Although some of the truck drivers were aware of these conditions, most were not taking specific medications. The logistic regression analysis shows that the odds of hypertension and abnormal glucose levels were increased in truck drivers with abdominal obesity. Age and the family history of premature CVD also increased the chances of hypertension and the abnormal blood glucose levels were related to II or III grade obesity. CONCLUSION: Long-distance truck drivers showed a high prevalence of a cluster of cardiovascular risk factors; these risk factors make the drivers highly susceptible to the development of CVD. The associated risk factors, low compliance with drug treatment, and unique features of this profession suggest that traditional precautions are not sufficient to change this scenario.

Genética e hipertensão arterial / Genetic and hypertension

A hipertensão arterial tem alta prevalência no mundo e, no Brasil, a taxa de prevalência vem aumentando progressivamente. Na grande maioria das vezes, a causa da hipertensão arterial é desconhecida. O componente genético é importante como causa para uma pequena parte dos hipertensos e a interação da genética com o meio ambiente é responsável pela maioria dos casos de hipertensão arterial. Em um pequeno percentual de hipertensos, é possível diagnosticar uma causa renal, endócrina ou de origem cardiovascular que pode ser tratada. Nos casos de hipertensão secundária a uma herança genética, pode-se destacar a síndrome de Liddle, síndrome do excesso aparente de mineralocorticoide, hipertensão exacerbada pela gravidez, síndrome de Gordon, aldosteronismo suprimível por glicocorticoide, hiperaldosteronismo familiar tipo 2 e hiperplasia adrenal congênita. Nos casos em que existe uma predisposição genética e a hipertensão se instala de acordo com a interação com o meio ambiente, pode-se destacar como mecanismos mais importantes o aumento da atividade simpática, a participação do sistema renina-angiotensina e um defeito na excreção renal do sódio. A exposição ao estresse e a ingestão exagerada de sal contribuem sobremaneira para a ativação desses sistemas e a instalação da hipertensão arterial nos indivíduos geneticamente predispostos.

Arterial hypertension prevalence is high all over the world and, in Brasil, this prevalence has been increasing progressively. In the majority of patients, the hypertension cause is unknown. Gentic component is important as a cause of hypertension in a small number of hypertensive patients and the interaction between genetic an environment is responsible for the majority of hypertension cases. In a small number of hypertensive patients, it is possible to find a renal, endocrine or cardiovascular cause which is possible to treat. In those cases of hypertension secondary to genetic inheritance, we can mention Liddle syndrome, apparent mineralocorticoid excess syndrome, hypertension exacerbated by pregnancy, Gordon syndrome, corticosteroid remediable hypertension, familial hyperaldosteronism type 2, and congenital adrenal hyperplasia. When there is a genetic predisposition to hypertension and this disease occurs according to the interaction with environment, we can highlight the increase in sympathetic activity, the participation of renin-angiotensin system and a impairment in renal sodium excretion. The stress exposition and high salt ingestion will contribute to the activation of these systems and to hypertension initiation in genetically predisposed subjects.

Implante Valve-in-Valve: uma opção / Valve-in-valve implant: an option

Os relatos de implante de valve-in-valve no Brasil são escassos, mas têm aumentado de frequência nos países desenvolvidos. Relata-se o caso de paciente feminina, 73 anos, que se submeteu a implante transcutâneo de prótese aórtica valve-in-valve há quatro anos. A paciente havia implantado bioprótese aórtica por cirurgia há 24 anos, evoluindo com degeneração da prótese, tendo recusado a troca valvar por nova cirurgia aberta. Após avaliação de equipe multidisciplinar foi indicado o implante transcutâneo de prótese aórtica valve-in-valve. Após quatro anos, a paciente apresentou melhora da classe funcional de insuficiência cardíaca e a durabilidade da prótese tem sido satisfatória.

Although valve-in-valve implantation reports are still sparse in Brazil, they are becoming more frequent in the developed countries. This case report addresses a 73-year-old female patient who underwent a transcutaneous aortic valve-in-valve prosthesis implant four years ago, subsequent to an aortic bioprosthesis implant operation 24 years earlier that degenerated, with the patient refusing to replace the valve through a further open surgery. After evaluation, a multidisciplinary team recommended a transcutaneous aortic valve-in-valve prosthesis implant. Four years later, the functional class of her heart failure has improved and the durability of the prosthesis has been satisfactory.