Classification System for Cardiorespiratory Fitness Based on a Sample of the Brazilian Population

Peak oxygen consumption (VO2peak) is an important prognostic marker and its classification helps the cardiologist in the therapeutic decision-making process. The most commonly used cardiorespiratory fitness (CRF) classification has not been validated for the Brazilian population. Objective: To elaborate a CRF classification using a Brazilian sample and to compare it with the American Heart Association (AHA), Cooper and UNIFESP classifications. Methods: A total of 6,568 healthy subjects were analyzed through cardiopulmonary exercise testing (CPET). They were distributed by sex and the following age groups (years): 7-12, 13-19, 20-79 (per decades) and > 80 years. After measurement of the VO2peak, participants were distributed into quintiles of CRF in very poor, poor, moderate, high and very high (AEMA Table). The CRF classifications by AEMA, AHA, Cooper, and UNIFESP were compared using the Wilcoxon, Kappa and concordance percentages. Results: VO2peak presented an inverse and moderate correlation with age considering both sexes (R = -0.488, p < 0.001). All paired comparisons between CRF classification systems showed differences (p < 0.001) and disagreement percentage - AEMA versus AHA (k = 0.291, 56.7%), AEMA versus Cooper (k = 0.220, 62.4%) and AEMA versus UNIFESP (k = 0.201, 63.9 %). Conclusion: The AEMA table showed important discrepancies in the classification of CRF when compared to other tables widely used in our setting. Because it was obtained from a large sample of the Brazilian population, the AEMA table should be preferred over other classification systems in our population

Yoga and breathing technique training in patients with heart failure and preserved ejection fraction: study protocol for a randomized clinical trial.

BACKGROUND: Current therapies for heart failure (HF) are followed by strategies to improve quality of life and exercise tolerance, besides reducing morbidity and mortality. Some HF patients present changes in the musculoskeletal system and inspiratory muscle weakness, which may be restored by inspiratory muscle training, thus increasing respiratory muscle strength and endurance, maximal oxygen uptake (VO2), functional capacity, respiratory responses to exercise, and quality of life. Yoga therapies have been shown to improve quality of life, inflammatory markers, and peak VO2 mostly in HF patients with a reduced ejection fraction. However, the effect of different yoga breathing techniques in patients showing HF with a preserved ejection fraction (HFpEF) remain to be assessed. METHODS/DESIGN: A PROBE (prospective randomized open blinded end-point) parallel-group trial will be conducted at two specialized HF clinics. Adult patients previously diagnosed with HFpEF will be included. After signing informed consent and performing a pre-test intervention, patients will be randomized into three groups and provided with either (1) active yoga breathing techniques; (2) passive yoga breathing techniques (pranayama); or and (3) control (standard pharmacological treatment). Follow-up will last 8 weeks (16 sessions). The post-intervention tests will be performed at the end of the intervention period for analysis of outcomes. Interventions will occur continuously according to patients' enrollment. The main outcome is respiratory muscular resistance. A total of 33 enrolled patients are expected. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist. DISCUSSION: This trial is probably the first to assess the effects of a non-pharmacological intervention, namely yoga and specific breathing techniques, to improve cardiorespiratory function, autonomic system, and quality of life in patients with HFpEF. TRIAL REGISTRATION: REBEC Identifier: RBR-64mbnx (August 19, 2012). Clinical Trials Register: NCT03028168 . Registered on 16 January 2017).

Effect of acute inspiratory muscle exercise on blood flow of resting and exercising limbs and glucose levels in type 2 diabetes.

To evaluate the effects of inspiratory loading on blood flow of resting and exercising limbs in patients with diabetic autonomic neuropathy. Ten diabetic patients without cardiovascular autonomic neuropathy (DM), 10 patients with cardiovascular autonomic neuropathy (DM-CAN) and 10 healthy controls (C) were randomly assigned to inspiratory muscle load of 60% or 2% of maximal inspiratory pressure (PImax) for approximately 5 min, while resting calf blood flow (CBF) and exercising forearm blood flow (FBF) were measured. Reactive hyperemia was also evaluated. From the 20 diabetic patients initially allocated, 6 wore a continuous glucose monitoring system to evaluate the glucose levels during these two sessions (2%, placebo or 60%, inspiratory muscle metaboreflex). Mean age was 58 ± 8 years, and mean HbA1c, 7.8% (62 mmol/mol) (DM and DM-CAN). A PImax of 60% caused reduction of CBF in DM-CAN and DM (P<0.001), but not in C, whereas calf vascular resistance (CVR) increased in DM-CAN and DM (P<0.001), but not in C. The increase in FBF during forearm exercise was blunted during 60% of PImax in DM-CAN and DM, and augmented in C (P<0.001). Glucose levels decreased by 40 ± 18.8% (P<0.001) at 60%, but not at 2%, of PImax. A negative correlation was observed between reactive hyperemia and changes in CVR (Beta coefficient = -0.44, P = 0.034). Inspiratory muscle loading caused an exacerbation of the inspiratory muscle metaboreflex in patients with diabetes, regardless of the presence of neuropathy, but influenced by endothelial dysfunction. High-intensity exercise that recruits the diaphragm can abruptly reduce glucose levels.

Effects of diaphragmatic contraction on lower limb venous return and central hemodynamic parameters contrasting healthy subjects versus heart failure patients at rest and during exercise.

The main objective was to assess the effects of abdominal breathing (AB) versus subject's own breathing on femoral venous blood flow (Qfv) and their repercussions on central hemodynamics at rest and during exercise contrasting healthy subjects versus heart failure (HF) patients. We measured esophageal and gastric pressure (PGA), Qfv and parameters of central hemodynamics in eight healthy subjects and nine HF patients, under four conditions: subject's own breathing and AB ( ∆: PGA ≥ 6 cmH2O) at rest and during knee extension exercises (15% of 1 repetition maximum) until exhaustion. Qfv and parameters of central hemodynamics [stroke volume (SV), cardiac output (CO)] were measured using Doppler ultrasound and impedance cardiography, respectively. At rest, healthy subjects Qfv, SV, and CO were higher during AB than subject's breathing (0.11 ± 0.02 vs. 0.06 ± 0.00 L·min(-1), 58.7 ± 3.4 vs. 50.1 ± 4.1 mL and 4.4 ± 0.2 vs. 3.8 ± 0.1 L·min(-1), respectively, P ≤ 0.05). ∆SV correlated with ∆PGA during AB (r = 0.89, P ≤ 0.05). This same pattern of findings induced by AB was observed during exercise (SV: 71.1 ± 4.1 vs. 65.5 ± 4.1 mL and CO: 6.3 ± 0.4 vs. 5.2 ± 0.4 L·min(-1); P ≤ 0.05); however, Qfv did not reach statistical significance. The HF group tended to increase their Qfv during AB (0.09 ± 0.01 vs. 0.07 ± 0.03 L·min(-1), P = 0.09). On the other hand, unlike the healthy subjects, AB did not improve SV or CO neither at rest nor during exercise (P > 0.05). In healthy subjects, abdominal pump modulated venous return improved SV and CO at rest and during exercise. In HF patients, with elevated right atrial and vena caval system pressures, these findings were not observed.

Effects of vildagliptin compared with glibenclamide on glucose variability after a submaximal exercise test in patients with type 2 diabetes: study protocol for a randomized controlled trial, DIABEX VILDA.

BACKGROUND: Cardiovascular disease, endothelial dysfunction, and oxidative stress are common complications among patients with type 2 diabetes (T2DM). In addition to the average blood glucose concentration, glycemic variability may be an important factor for the development of chronic diabetes complications. Patients with T2DM are treated with various types of oral glucose-lowering drugs. Exercise is considered to benefit the health of both healthy and unhealthy individuals, which has been confirmed by a number of scientific research studies in which the participants' health improved. Our general aim in this study will be to evaluate glucose variability after submaximal exercise test in patients receiving treatment with either vildagliptin or glibenclamide. The specific aims of this study are to evaluate the oxidative stress, endothelial function, and metabolic and cardiovascular responses to exercise under treatment with vildagliptin or glibenclamide. All these responses are important in patients with T2DM. METHODS/DESIGN: This study is a PROBE (Prospective, Randomized, Open-label, Blinded-Endpoint) design clinical trial. The estimated sample needed is 20 patients with T2DM. In addition to the routine treatment (metformin), patients will receive a second drug orally for 12 weeks: the METV group will receive metformin plus vildagliptin (50 mg twice daily), and the METG group will receive metformin plus glibenclamide (5 to 10 mg twice daily.). Before and after intervention, evaluation of glycemic variability, endothelial function, oxidative stress, and metabolic and cardiovascular response will be performed at rest, during and after a submaximal exercise test (30 minutes, with an intensity based at 10% under the heart rate at the second threshold). DISCUSSION: In addition to drug treatment, exercise is recommended for treatment of glycemic control in patients with T2DM, especially for its beneficial effects on blood glucose and HbA1c. Few studies have determined the effects of the association between exercise and oral glucose-lowering drugs. The study will be conducted to assess the metabolic and cardiovascular responses at rest, and during and after submaximal exercise in patients receiving one of two oral glucose-lowering drugs (vildagliptin or glibenclamide). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01867502 study release date: May-17-2013.

An equation for the prediction of oxygen consumption in a Brazilian population.

BACKGROUND: The equations predicting maximal oxygen uptake (VO2max or peak) presently in use in cardiopulmonary exercise testing (CPET) softwares in Brazil have not been adequately validated. These equations are very important for the diagnostic capacity of this method. OBJECTIVE: Build and validate a Brazilian Equation (BE) for prediction of VO2peak in comparison to the equation cited by Jones (JE) and the Wasserman algorithm (WA). METHODS: Treadmill evaluation was performed on 3119 individuals with CPET (breath by breath). The construction group (CG) of the equation consisted of 2495 healthy participants. The other 624 individuals were allocated to the external validation group (EVG). At the BE (derived from a multivariate regression model), age, gender, body mass index (BMI) and physical activity level were considered. The same equation was also tested in the EVG. Dispersion graphs and Bland-Altman analyses were built. RESULTS: In the CG, the mean age was 42.6 years, 51.5% were male, the average BMI was 27.2, and the physical activity distribution level was: 51.3% sedentary, 44.4% active and 4.3% athletes. An optimal correlation between the BE and the CPET measured VO2peak was observed (0.807). On the other hand, difference came up between the average VO2peak expected by the JE and WA and the CPET measured VO2peak, as well as the one gotten from the BE (p = 0.001). CONCLUSION: BE presents VO2peak values close to those directly measured by CPET, while Jones and Wasserman differ significantly from the real VO2peak.

Relevance to home blood pressure monitoring protocol of blood pressure measurements taken before first- morning micturition and in the afternoon.

BACKGROUND: The importance of measuring blood pressure before morning micturition and in the afternoon, while working, is yet to be established in relation to the accuracy of home blood pressure monitoring (HBPM). OBJECTIVE: To compare two HBPM protocols, considering 24-hour ambulatory blood pressure monitoring (wakefulness ABPM) as gold-standard and measurements taken before morning micturition (BM) and in the afternoon (AM), for the best diagnosis of systemic arterial hypertension (SAH), and their association with prognostic markers. METHODS: After undergoing 24-hour wakefulness ABPM, 158 participants (84 women) were randomized for 3- or 5-day HBPM. Two variations of the 3-day protocol were considered: with measurements taken before morning micturition and in the afternoon (BM+AM); and with post-morning-micturition and evening measurements (PM+EM). All patients underwent echocardiography (for left ventricular hypertrophy - LVH) and urinary albumin measurement (for microalbuminuria - MAU). RESULT: Kappa statistic for the diagnosis of SAH between wakefulness-ABPM and standard 3-day HBPM, 3-day HBPM (BM+AM) and (PM+EM), and 5-day HBPM were 0.660, 0.638, 0.348 and 0.387, respectively. The values of sensitivity of (BM+AM) versus (PM+EM) were 82.6% × 71%, respectively, and of specificity, 84.8% × 74%, respectively. The positive and negative predictive values were 69.1% × 40% and 92.2% × 91.2%, respectively. The comparisons of intraclass correlations for the diagnosis of LVH and MAU between (BM+AM) and (PM+EM) were 0.782 × 0.474 and 0.511 × 0.276, respectively. CONCLUSIONS: The 3 day-HBPM protocol including measurements taken before morning micturition and during work in the afternoon showed the best agreement with SAH diagnosis and the best association with prognostic markers.

Relevance to Home Blood Pressure Monitoring Protocol of Blood Pressure Measurements Taken Before First- Morning Micturition and in the Afternoon / Relevância das Medidas da Pressão Arterial Pré-Micção Matinal e à Tarde em Protocolo de Monitorização Residencial da Pressão Arterial

Background: The importance of measuring blood pressure before morning micturition and in the afternoon, while working, is yet to be established in relation to the accuracy of home blood pressure monitoring (HBPM). Objective: To compare two HBPM protocols, considering 24-hour ambulatory blood pressure monitoring (wakefulness ABPM) as gold-standard and measurements taken before morning micturition (BM) and in the afternoon (AM), for the best diagnosis of systemic arterial hypertension (SAH), and their association with prognostic markers. Methods: After undergoing 24-hour wakefulness ABPM, 158 participants (84 women) were randomized for 3- or 5-day HBPM. Two variations of the 3-day protocol were considered: with measurements taken before morning micturition and in the afternoon (BM+AM); and with post-morning-micturition and evening measurements (PM+EM). All patients underwent echocardiography (for left ventricular hypertrophy - LVH) and urinary albumin measurement (for microalbuminuria - MAU). Result: Kappa statistic for the diagnosis of SAH between wakefulness-ABPM and standard 3-day HBPM, 3-day HBPM (BM+AM) and (PM+EM), and 5-day HBPM were 0.660, 0.638, 0.348 and 0.387, respectively. The values of sensitivity of (BM+AM) versus (PM+EM) were 82.6% × 71%, respectively, and of specificity, 84.8% × 74%, respectively. The positive and negative predictive values were 69.1% × 40% and 92.2% × 91.2%, respectively. The comparisons of intraclass correlations for the diagnosis of LVH and MAU between (BM+AM) and (PM+EM) were 0.782 × 0.474 and 0.511 × 0.276, respectively. Conclusions: The 3 day-HBPM protocol including measurements taken before morning micturition and during work in the afternoon showed the best agreement with SAH diagnosis and the best association with prognostic markers. .

Fundamentos: A importância das medidas da pressão arterial antes do ato miccional matinal e no período da tarde, durante atividades laborativas, na acurácia da monitoração residencial da pressão arterial (MRPA) não foi estabelecida. Objetivo: Comparar dois protocolos de MRPA, tendo como padrão-ouro a monitoração ambulatorial da pressão arterial de 24 horas (MAPA-vigília) e avaliando-se as medidas antes do ato miccional e à tarde, para o melhor diagnóstico de hipertensão arterial (HAS), e sua associação com marcadores prognósticos. Métodos: Após realizarem MAPA de 24 horas, os 158 participantes (84 mulheres) foram randomizados para realizar MRPA de três ou cinco dias com posterior crossover. Analisou-se o protocolo de três dias nas seguintes situações: aferições antes do ato miccional matinal e à tarde (AM+MT); e aferições após o ato miccional matinal e à noite (PM+MN). Todos os pacientes foram submetidos a ecocardiografia (hipertrofia ventricular esquerda - HVE) e a dosagem de albumina urinária (microalbuminúria - MAU). Resultados: A estatística kappa para diagnóstico de HAS entre MAPA-vigília e MRPA de três dias padrão, MRPA de três dias (AM + MT) e (PM + MN), e MRPA de cinco dias foi de 0,660, 0,638, 0,348 e 0,387, respectivamente. Os valores de sensibilidade de AM+MT versus PM+MN foram 82,6% × 71%, respectivamente, e os de especificidade foram 84,8% × 74%, respectivamente. Os valores preditivos positivos e negativos foram 69,1% × 40% e 92,2% × 91,2%, respectivamente. As comparações das correlações intraclasse para diagnósticos de HVE e MAU, entre AM+MT e PM+MN, foram 0,782 × 0,474 e 0,511 × 0,276, respectivamente. Conclusões: O protocolo de MRPA de três dias ...

Efficiency of twice weekly concurrent training in trained elderly men.

This study compared the effects of different weekly training frequencies on the cardiovascular and neuromuscular adaptations induced by concurrent training in previously trained elderly. After 20weeks of combined strength and endurance training, twenty-four healthy elderly men (65±4 years) were randomly placed into two frequency training groups: strength and endurance training performed twice a week (SE2, n=12); or, strength and endurance training performed three times per week (SE3, n=12). The interventions lasted 10 weeks and each group performed identical exercise intensity and volume per session. Before and after the exercise training, one maximum repetition test (1RM), isometric peak torque (PT), maximal surface electromyographic activity (EMG), as well as muscle thickness (MT) were examined. Additionally, peak oxygen uptake (VO(2peak)), maximum aerobic workload (W(max)), first and second ventilatory thresholds (VT1 and VT2) were evaluated. There were significant increases in upper and lower-body 1RM, MT, VO(2peak), VT1 and VT2, with no differences between groups. There were no changes after training in maximal EMG and isometric peak torque. W(max) was improved only in SE3. After 10 weeks of training, twice weekly combined strength and endurance training leads to similar neuromuscular and cardiovascular adaptations as three times per week, demonstrating the efficiency of lower frequency of concurrent training in previously trained elderly men.

TP53 p.R337H is a conditional cancer-predisposing mutation: further evidence from a homozygous patient.

BACKGROUND: Adrenocortical carcinomas (ACCs) are among the most common childhood cancers occurring in infants affected with the Li-Fraumeni and Li- Fraumeni-like (LFS/LFL) syndromes, which are caused by dominant germline mutations in the TP53 gene. In Brazil, a particular mutation, occurring in the tetramerisation domain of the gene, p.R337H, is exceedingly common due to a founder effect and is strongly associated with ACC. In this report, we describe the phenotype and long-term clinical follow-up of a female child diagnosed with ACC and homozygous for the TP53 p.R337H founder mutation. CASE PRESENTATION: At age 11 months, the patient was diagnosed with a virilising anaplastic adrenal cortical tumour, which was completely excised without disturbing the adrenal capsule. Family history was consistent with an LFL tumour pattern, and genotyping identified the TP53 p.R337H mutation in both alleles in genomic DNA from lymphocytes and fibroblasts. Haplotype analysis confirmed the occurrence of the mutation in the same founder haplotype previously described in other Brazilian patients. No other germline or somatic TP53 mutations or rearrangements were identified. At age 9 years, the child was asymptomatic and had no evidence of endocrine derangements. Full body and brain magnetic resonance imaging (MRI) failed to detect any suspicious proliferative lesions, and cardiopulmonary exercise testing results were within the normal reference for the child's age, ruling out a major exercise capacity deficiency. CONCLUSION: This is the first clinical and aerobic functional capacity documentation of a patient who carries two mutant TP53 alleles and no wild-type allele. Our results support the hypothesis that TP53 p.R337H, the most common TP53 mutation ever described in any population, is a conditional mutant. Furthermore, our observations over a long period of clinical follow-up suggest that TP53 p.R337H homozygotes do not have a more severe disease phenotype than do heterozygote carriers of the same mutation. Patients with the homozygous TP53 p.R337H genotype will require careful surveillance for lifetime cancer risk and for effects on metabolic capacity later in life.

[The influence of food preparation methods on atherosclerosis prevention]. / Influência do modo de preparo de alimentos na prevenção da aterosclerose.

OBJECTIVE: To analyze the influence of food preparation methods on the composition of fatty acids and cholesterol in foods. METHODS: The chemical composition of cholesterol and fatty acids was analyzed in eight different types of meat and feijoada in relation to different methods of preparation. RESULTS: Feijoada, when prepared with the beans and meats in separate pots, has less cholesterol (12.1 vs. 16.1mg, respectively, p=0.005) and saturated fat (1.4 vs. 1.9mg, p=0.046) than when it is prepared in a single pot. Broiled chicken without the skin has less saturated fat when compared with skinless fried chicken (1,505 vs. 7,645mg, p=0.049). Broiled shrimp also has a lower saturated fat content than fried shrimp (532 vs. 1,262mg, p=0.049). Broiled ribeye steak without fat has a lower cholesterol content when compared with the fried steak (102 vs. 114mg, p=0.049). CONCLUSION: The analysis indicates that the method of food preparation influences the fat content of foods, with potential impact on the prescription of low-fat and low-cholesterol diets.

Influência do modo de preparo de alimentos na prevenção da aterosclerose / The influence of food preparation methods on atherosclerosis prevention

OBJETIVO: Analisar a influência do modo de preparo na composição de ácidos graxos e colesterol em alimentos. MÉTODOS: Foi analisada a composição química do colesterol e ácidos graxos de oito tipos diferentes de carnes e da feijoada, em relação a diferentes métodos de preparo. RESULTADOS: A feijoada preparada com as carnes em separado tem menos colesterol (12,1 e 16,1 mg, respectivamente; p = 0,005) e gordura saturada (1,4 e 1,9 mg; p = 0,046) do que quando preparada junto. O frango grelhado sem pele apresenta menor quantidade de gordura saturada quando comparado com o frango frito sem pele (7645 e 1505 mg; p = 0,049). O camarão grelhado também apresenta menor conteúdo de gordura saturada quando comparado com o frito (532 e 1262 mg; p = 0,049). O contrafilé grelhado sem gordura apresenta menor conteúdo de colesterol quando comparado com o frito (102 e 114 mg; p = 0,049). CONCLUSÃO: As análises aqui realizadas indicam que a forma de preparo influencia no teor de gordura dos alimentos, com potencial impacto na prescrição de dietas com baixo teor de gordura e colesterol.

OBJECTIVE: To analyze the influence of food preparation methods on the composition of fatty acids and cholesterol in foods. METHODS: The chemical composition of cholesterol and fatty acids was analyzed in eight different types of meat and feijoada in relation to different methods of preparation. RESULTS: Feijoada, when prepared with the beans and meats in separate pots, has less cholesterol (12.1 vs. 16.1 mg, respectively, p = 0.005) and saturated fat (1.4 vs. 1.9 mg, p = 0.046) than when it is prepared in a single pot. Broiled chicken without the skin has less saturated fat when compared with skinless fried chicken (1,505 vs. 7,645 mg, p = 0.049). Broiled shrimp also has a lower saturated fat content than fried shrimp (532 vs. 1,262 mg, p = 0.049). Broiled ribeye steak without fat has a lower cholesterol content when compared with the fried steak (102 vs. 114 mg, p = 0.049). CONCLUSION: The analysis indicates that the method of food preparation influences the fat content of foods, with potential impact on the prescription of low-fat and low-cholesterol diets.

Effects of L-arginine supplementation on blood flow, oxidative stress status and exercise responses in young adults with uncomplicated type I diabetes.

BACKGROUND AND AIMS: Vascular disease is the principal cause of death and disability in patients with diabetes, and endothelial dysfunction seems to be the major cause in its pathogenesis. Since L-arginine levels are diminished in conditions such as type 1 and type 2 diabetes, in this work we aimed to verify the effects of L-arginine supplementation (7 g/day) over the endothelial function and oxidative stress markers in young male adults with uncomplicated type 1 diabetes. We also investigated the influences of L-arginine administration on vascular/oxidative stress responses to an acute bout of exercise. METHODS: Ten young adult male subjects with uncomplicated type 1 diabetes and twenty matched controls volunteered for this study. We analysed the influence of L-arginine supplementation (7 g/day during 1 week) over lower limb blood flow (using a venous occlusion plethysmography technique), oxidative stress marker (TBARS, Carbonyls), anti-oxidant parameters (uric acid and TRAP) and total tNOx in rest conditions and after a single bout of submaximal exercise (VO2 at 10 % below the second ventilatory threshold). Data described as mean ± standard error (SE). Alpha level was P < 0.05. RESULTS: Glycaemic control parameters were altered in type 1 diabetic subjects, such as HbA1c (5.5 ± 0.03 vs. 8.3 ± 0.4 %) and fasted glycaemia (94.8 ± 1.4 vs. 183 ± 19 mg/dL). Oxidative stress/damage markers (carbonyls and TBARS) were increased in the diabetic group, while uric acid was decreased. Rest lower limb blood flow was lower in type 1 diabetic subjects than in healthy controls (3.53 ± 0.35 vs. 2.66 ± 0.3 ml 100 ml⁻¹ min⁻¹). L-Arginine supplementation completely recovered basal blood flow to normal levels in type 1 diabetics' subjects (2.66 ± 0.3 to 4.74 ± 0.86 ml 100 ml⁻¹ min⁻¹) but did not interfere in any parameter of redox state or exercise. CONCLUSION: Our findings highlight the importance of L-arginine for the improvement of vascular function in subjects with diabetes, indicating that L-arginine supplementation could be an essential tool for the treatment for the disease complications, at least in non-complicated diabetes. However, based on our data, it is not possible to draw conclusions regarding the mechanisms by which L-arginine therapy is inducing improvements on cardiovascular function, but this important issue requires further investigations.

Obstructive sleep apnea, detected by the Berlin Questionnaire: an associated risk factor for coronary artery disease.

Obstructive sleep apnea (OSA), a risk factor for coronary artery disease, remains under diagnosed. We investigated if OSA identified by the Berlin Questionnaire (BQ) is associated with the risk of coronary artery disease. Cases were patients referred for elective coronariography. The cases were classified with significant coronary lesions (stenosis ≥ 50% in an epicardial coronary) or without significant coronary lesions. Controls were selected from a population-based sample. Positive BQ results were identified in 135 (41.2%) of 328 cases, in contrast with 151 (34.4%) of 439 control subjects (p = 0.03). In a multinomial logistic analysis, the risk for OSA identified by the BQ was independently associated with coronary artery disease in cases with lesions of at least 50% (OR = 1.53; 95%CI: 1.02-2.30; p = 0.04). The risk from OSA identified by the BQ was higher in younger subjects (40-59 years) (OR = 1.76; 95%CI: 1.05-2.97; p = 0.03) and in women (OR = 3.56; 95%CI: 1.64-7.72; p = 0.001). In conclusion, OSA identified by the BQ greatly increases the risks of coronary artery disease in patients having significant coronary artery lesions indicated by anangiogram, particularly in younger individuals and in women.

Obstructive sleep apnea, detected by the Berlin Questionnaire: an associated risk factor for coronary artery disease / Risco de apneia obstrutiva do sono detectado pelo Questionário de Berlim está associado com doença arterial coronariana

Obstructive sleep apnea (OSA), a risk factor for coronary artery disease, remains under diagnosed. We investigated if OSA identified by the Berlin Questionnaire (BQ) is associated with the risk of coronary artery disease. Cases were patients referred for elective coronariography. The cases were classified with significant coronary lesions (stenosis > 50% in an epicardial coronary) or without significant coronary lesions. Controls were selected from a population-based sample. Positive BQ results were identified in 135 (41.2%) of 328 cases, in contrast with 151 (34.4%) of 439 control subjects (p = 0.03). In a multinomial logistic analysis, the risk for OSA identified by the BQ was independently associated with coronary artery disease in cases with lesions of at least 50% (OR = 1.53; 95%CI: 1.02-2.30; p = 0.04). The risk from OSA identified by the BQ was higher in younger subjects (40-59 years) (OR = 1.76; 95%CI: 1.05-2.97; p = 0.03) and in women (OR = 3.56; 95%CI: 1.64-7.72; p = 0.001). In conclusion, OSA identified by the BQ greatly increases the risks of coronary artery disease in patients having significant coronary artery lesions indicated by anangiogram, particularly in younger individuals and in women.

Síndrome da apneia obstrutiva do sono (SAOS), fator de risco para doença arterial coronariana, permanece subdiagnosticada. Investigou-se se o risco de SAOS pelo Questionário de Berlim (QB) associa-se com doença arterial coronariana. Casos foram pacientes encaminhados para coronariografia eletiva, classificados em casos com lesão significativa (estenose > 50%) ou sem lesões significativas. Controles foram selecionados em amostra populacional. QB foi positivo em 135 (41,2%) de 328 casos, em contraste com 151 (34,4%) de 439 controles (p = 0,03). Em análise logística multinomial, o risco de SAOS identificado pelo QB associou-se com doença arterial coronariana exclusivamente nos casos com lesões de pelo menos 50% (OR: 1,53; IC95%: 1,02-2,30; p = 0,04). Em indivíduos com lesões significativas, o risco de SAOS pela QB foi maior entre os que têm 40-59 anos (OR: 1,76; IC95%: 1,05-2,97; p = 0,03) e em mulheres (OR: 3,56; IC95%: 1,64-7,72; p = 0,001). Em conclusão, alto risco para a SAOS identificados pela QB associa-se a risco de lesões coronarianas significativas na angiografia, particularmente em indivíduos mais jovens e em mulheres.

Highlights from the IV International Symposium of Thrombosis and Anticoagulation (ISTA), October 20-21, 2011, Salvador, Bahia, Brazil.

To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Fourth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, from October 20-21, 2011. This scientific program was developed by clinicians for clinicians and was promoted by three major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, and Hospital do Coração Research Institute. Comprising 2 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.

Bloqueio completo do ramo esquerdo esforço-induzido: prevalência e prognóstico / Exercise-induced left bundle branch block: prevalence and prognosis / Bloqueo completo de la rama izquierda esfuerzo-inducido prevalencia y pronóstico

FUNDAMENTO: O bloqueio completo do ramo esquerdo esforço-induzido (BCRE E-I) é um achado infrequente ao teste de exercício e sua prevalência e significado prognóstico não são claros. OBJETIVO: Avaliar de forma longitudinal a prevalência e o significado prognóstico do BCRE E-I em homens americanos veteranos de guerra. MÉTODOS: Avaliamos 9.623 pacientes que realizaram ergometria em esteira (TE) entre 1987 e 2007. Os desfechos foram comparados entre aqueles com TE NL, os com BCRE E-I e os que apresentaram Dep ST anormal. A mortalidade e a causa das mortes foram identificadas de forma cega para os resultados do TE. RESULTADOS: Nesta coorte prospectiva, 6922 indivíduos apresentaram TE NL (57,2 ± 11,4 anos), 1.739 apresentaram Dep ST anormal (62,7 ± 9,8 anos) e 38 casos de BCRE E-I foram identificados (65,2 ± 11,9 anos). A prevalência do BCRE E-I foi 0,38 por cento. Após 8,8 anos, ocorreram 1.699 mortes por todas as causas e 610 mortes cardiovasculares (CV). Doença arterial coronária e insuficiência cardíaca foram mais prevalentes nos pacientes com BCRE E-I. Pacientes com BCRE E-I tiveram razão de azar de 2,37 (p = 0,002) para mortalidade por todas as causas, mas a mesma não foi significativa quando ajustada para idade ou quando a mortalidade cardiovascular foi o desfecho avaliado. CONCLUSÃO: BCRE E-I é um achado raro. Indivíduos com BCRE E-I apresentam maior mortalidade por todas as causas quando comparados aqueles com TE NL. No entanto, tal fato é explicado por esses pacientes serem significativamente mais velhos e por apresentarem mais enfermidades cardiovasculares associadas.

BACKGROUND: Exercise-induced left bundle branch block (EI-LBBB) is an infrequent finding. Its prevalence and prognostic significance are not clear. OBJECTIVE: To evaluate, in a longitudinal study, the prevalence and prognostic significance of EI-LBBB in American war veterans. METHODS: We evaluated 9,623 patients submitted to an exercise test (ET) in treadmill between 1987 and 2007. The outcomes were compared between those with normal TE, the ones with EI-LBBB and the ones with down-sloping ST-segment. Mortality and causes of death were identified while blinded to the ET results. RESULTS: In this prospective cohort, 6,922 individuals had normal ET results (57.2 ± 11.4 years), 1,739 had abnormal ST-segment depression (62.7 ± 9.8 years), and 38 had EI-LBBB (65.2 ± 11.9 years). The prevalence of EI-LBBB was 0.38 percent. After 8.8 years, there were 1,699 deaths due to all-cause mortality and 610 cardiovascular (CV) deaths; coronary artery disease and heart failure were more prevalent in patients with EI-LBBB. Patients with EI-BCRE had a hazard ratio of 2.37 (p = 0.002) for all-cause mortality, but it was not significant when adjusted for age or when the CV death was the assessed outcome. CONCLUSION: EI-LBBB is a rare clinical finding. Individuals with BCRE-EI have higher all-cause mortality when compared to those with normal ET results. However, this fact is explained by the fact that these patients are significantly older and have more associated cardiovascular diseases.

FUNDAMENTO: El bloqueo completo de rama izquierda esfuerzo-inducido (BCRI E-I) es un hallazgo infrecuente en el test de ejercicio y su prevalencia y significado pronóstico no son claros. OBJETIVO: Evaluar de forma longitudinal la prevalencia y el significado pronóstico del BCRI E-I en los hombres norteamericanos veteranos de guerra. MÉTODOS: Evaluamos 9.623 pacientes que realizaron ergometría en cinta (TE) entre 1987 y 2007. Los resultados fueron comparados entre aquellos con TE normal (TE NL), los con BCRI E-I y los que presentaron infradesnivel del segmento ST (Dep ST) anormal. La mortalidad y la causa de las muertes fueron identificadas de forma ciega para los resultados del TE. RESULTADOS: En esta cohorte prospectiva y después de las exclusiones, 6.922 individuos presentaron EC NL (57,2 ± 11,4 años), 1739 tuvieron Dep ST anormal (62,7 ± 9,8 años), y 32 casos de BCRI E-I fueron identificados (65,2 ± 11,9 años). La prevalencia del BCRI E-I fue del 0,38 por ciento. Después de 8,8 años, ocurrieron 1699 muertes por todas las causas y 610 muertes cardiovasculares (CV). La enfermedad arterial coronaria y la insuficiencia cardíaca fueron las más prevalentes en los pacientes con BCRI E-I. Los pacientes con BCRI E-I presentaron azar de 2,37 (p = 0,002) para la mortalidad por todas las causas, pero ella no fue significativa cuando se ajustó para la edad o cuando la mortalidad cardiovascular fue el desenlace evaluado. CONCLUSIÓN: BCRI E-I es un hallazgo raro. Los individuos con BCRI E-I presentan una mayor mortalidad por todas las causas cuando se les compara con los de EC NL. Sin embargo, ese hecho se explica porque esos pacientes son significativamente más viejos y por presentar más enfermedades cardiovasculares asociadas.

Exercise-induced left bundle branch block: prevalence and prognosis.

BACKGROUND: Exercise-induced left bundle branch block (EI-LBBB) is an infrequent finding. Its prevalence and prognostic significance are not clear. OBJECTIVE: To evaluate, in a longitudinal study, the prevalence and prognostic significance of EI-LBBB in American war veterans. METHODS: We evaluated 9,623 patients submitted to an exercise test (ET) in treadmill between 1987 and 2007. The outcomes were compared between those with normal TE, the ones with EI-LBBB and the ones with down-sloping ST-segment. Mortality and causes of death were identified while blinded to the ET results. RESULTS: In this prospective cohort, 6,922 individuals had normal ET results (57.2 ± 11.4 years), 1,739 had abnormal ST-segment depression (62.7 ± 9.8 years), and 38 had EI-LBBB (65.2 ± 11.9 years). The prevalence of EI-LBBB was 0.38%. After 8.8 years, there were 1,699 deaths due to all-cause mortality and 610 cardiovascular (CV) deaths; coronary artery disease and heart failure were more prevalent in patients with EI-LBBB. Patients with EI-BCRE had a hazard ratio of 2.37 (p = 0.002) for all-cause mortality, but it was not significant when adjusted for age or when the CV death was the assessed outcome. CONCLUSION: EI-LBBB is a rare clinical finding. Individuals with BCRE-EI have higher all-cause mortality when compared to those with normal ET results. However, this fact is explained by the fact that these patients are significantly older and have more associated cardiovascular diseases.

Chemical food composition: implications for atherosclerosis prevention.

OBJECTIVE: To compare the fatty acid and cholesterol content in food acquired in Brazil with the composition found in the most frequently used reference tables in the country. METHODS: The fatty acid and cholesterol content in 41 food items frequently used in our country and the various directions to prepare them were reviewed by using specific methodology and the information was compared to the tables adopted by Unicamp and UNIFESP. RESULTS: According to Unicamp table, the cholesterol content found in parmesan cheese was 100.7 mg/100 g, while it was 68 mg/100 g in UNIFESP table, that is, a 48% (p < 0.05), higher content in the former. This study table found a cholesterol content 31% lower (94 mg/100 g vs. 123 mg/100 g, p < 0.05) for yellow cheese. For whole milk, we found a 52% difference regarding cholesterol content, while the difference for saturated fat ranged from 1.4 g/100 g in Unicamp table to 2.130 g/100 g in our study table (p < 0.05). For some food items, no statistically significant differences were found among the tables. However, when a 1,800-calorie diet was prescribed, the discrepancies among the tables and lack of information resulted in clinically relevant differences in dietary recommendations. CONCLUSION: There are important differences in food fat content between the fatty acid and cholesterol content formally analyzed and the content shown on commonly used tables, and this can compromise our recommendations on preventing atherosclerosis. One possible explanation for the differences would be the fact that the UNIFESP table is American in origin.

Composição química de alimentos: implicações na prevenção da aterosclerose / Chemical food composition: implications for atherosclerosis prevention

OBJETIVO: Comparar a composição de ácidos graxos e colesterol de alimentos adquiridos no mercado brasileiro, com tabelas de referência mais usadas no Brasil. MÉTODOS: Foi analisada a composição de ácidos graxos e colesterol de 41 alimentos mais usados na alimentação em nosso meio e modos de preparo, utilizando-se metodologias específicas e comparadas com as informações das tabelas adotadas pela Unicamp e UNIFESP. RESULTADOS: O conteúdo de colesterol encontrado no queijo parmesão foi de 100,7 mg/100 g; já na tabela da UNIFESP foi de 68 mg/100 g (p < 0,05), ou seja, 48 por cento a mais. Para o queijo tipo prato, a tabela deste estudo apresentou medida 31 por cento menor de colesterol (94 mg/100 g versus 123 mg/100 g, p < 0,05). Para o leite integral, a variação é de 52 por cento com relação ao colesterol, enquanto a gordura saturada variou de 1,4 g/100 g, na tabela da Unicamp, a 2,130 g/100 g, na tabela do estudo (p < 0,05). Para alguns alimentos, não foram encontradas diferenças estatisticamente significativas entre as tabelas avaliadas. Entretanto, quando foi prescrita uma dieta de 1.800 calorias, as discrepâncias entre as tabelas e a falta de informações resultaram em diferenças clinicamente relevantes nas recomendações dietéticas. CONCLUSÃO: Existem importantes diferenças no teor das gorduras nos alimentos avaliados quando comparados com as tabelas mais usadas em nosso meio, o que pode comprometer as recomendações para a prevenção da aterosclerose. Uma das explicações seria o fato de a tabela da UNIFESP ser de origem americana.

OBJECTIVE: To compare the fatty acid and cholesterol content in food acquired in Brazil with the composition found in the most frequently used reference tables in the country. METHODS: The fatty acid and cholesterol content in 41 food items frequently used in our country and the various directions to prepare them were reviewed by using specific methodology and the information was compared to the tables adopted by Unicamp and UNIFESP. RESULTS: According to Unicamp table, the cholesterol content found in parmesan cheese was 100.7 mg/100 g, while it was 68 mg/100 g in UNIFESP table, that is, a 48 percent (p < 0.05), higher content in the former. This study table found a cholesterol content 31 percent lower (94 mg/100 g vs. 123 mg/100 g, p < 0.05) for yellow cheese. For whole milk, we found a 52 percent difference regarding cholesterol content, while the difference for saturated fat ranged from 1.4 g/100 g in Unicamp table to 2.130 g/100 g in our study table (p < 0.05). For some food items, no statistically significant differences were found among the tables. However, when a 1,800-calorie diet was prescribed, the discrepancies among the tables and lack of information resulted in clinically relevant differences in dietary recommendations. CONCLUSION: There are important differences in food fat content between the fatty acid and cholesterol content formally analyzed and the content shown on commonly used tables, and this can compromise our recommendations on preventing atherosclerosis. One possible explanation for the differences would be the fact that the UNIFESP table is American in origin.