Tratamento atual da hipercolesterolemia e novas perspectivas / Current dyslipidemia treatments and new perspectives

Novos fármacos para o tratamento da hipercolesterolemia foram desenvolvidos, que poderão ser incorporadas nas diretrizes, resultantes de estudos clínicos robustos que demonstraram redução de desfechos cardiovasculares adicionais aos resultados obtidos com a otimização terapêutica disponível com as estatinas. O objetivo deste artigo é atualizar o conhecimento para o tratamento das dislipidemias baseado nas melhores evidências e as novas opções terapêuticas para reduzir o risco de eventos cardiovasculares em pacientes com dislipidemia refratária à otimização do tratamento atual.

New drugs for dyslipidemia treatment have been developed in solid clinical studies, which demonstrated an additional reduction of cardiovascular outcomes compared to therapeutic treatment with statins, and might be incorporated in new treatment guidelines. The aim of this article is to update the knowledge for the treatment of dyslipidemias based on the best evidences and the new therapeutic options incorporated to reduce the risk of cardiovascular events in patients with dyslipidemia refractory to treatment optimization.

Cardiotoxicidade induzida por quimioterapia / Chemotherapy-induced cardiotoxicity

Introdução: A cardiotoxicidade resulta de efeitos diretos do tratamento do câncer na estrutura e função cardíaca, bem como na aceleração do desenvolvimento de doenças cardiovasculares em pacientes com fatores predisponentes. Isso tem levado a uma preocupação crescente no que concerne à morbidade prematura e óbito de pacientes sobreviventes ao câncer, uma vez que esse impacto negativo no prognóstico ocorre também em pacientes assintomáticos. Trata-se de um estudo de revisão da literatura com objetivo de explorar brevemente o tema sobre cardiotoxicidade. Métodos: Dados foram obtidos a partir de artigos e diretrizes atuais. Resultados: A sobrevida do câncer tem aumentado significativamente nas últimas décadas devido ao desenvolvimento de um maior número de agentes quimioterápicos. Entretanto, a área da Cardio-Oncologia carece ainda de protocolos bem estabelecidos que definam o manejo ideal no que tange à cardiotoxicidade induzida por terapia do câncer. Conclusões: A cardiotoxicidade permanece uma preocupação com impacto no prognóstico deste universo crescente de pacientes.

Introduction: Cardiotoxicity results from direct effects on cardiac structure and function in patients undergoing cancer treatment, as well as on accelerating the development of cardiovascular disease in patients with predisposing factors. This subject has led to a growing concern regarding the early morbidity and death of cancer survivors since there is negative impact on prognosis even in asymptomatic patients. This is a review of the literature which explores briefly the subject of cardiotoxicity. Methods: Our data were taken from current articles and guidelines. Results: Cancer survival has increased over time due to the development of a greater number of chemotherapeutic agents. However, Cardio-Oncology field still lacks of well-defined protocols to define the best management for cardiotoxicity. Conclusions: Cardiotoxicity remains a concern with an impact on the prognosis of this growing universe of patients.

Marcador de risco hemostático associado a eventos cardiovasculares em síndrome metabólica / Hemostatic risk marker associated with cardiovascular events in metabolic syndrome

Fundamentos: A doença cardiovascular (DCV) é a principal causa de morte nos países em desenvolvimento. Os indivíduos com síndrome metabólica (SM) apresentam risco elevado para DCV. Os fatores de risco tradicionais em conjunto, não explicam todos os eventos cardiovasculares. O fator von Willebrand (FvW), envolvido na agregação plaquetária e trombose, tem sido investigado nesse contexto. Objetivo: Investigar a relação entre FvW e DCV, em pacientes portadores de SM, com e sem eventos cardiovasculares prévios. Métodos: Estudados 77 pacientes ambulatoriais, ≥18 anos, portadores de SM de acordo com os critérios estabelecidos pela NCEP-ATP III. Mediu-se o nível plasmático do FvW e comparou-se os valores médios entre os grupos com DCV prévia (n=30) e sem DCV documentada (n=47). Resultados: Da população estudada, 66,0% eram do sexo feminino, 78,0% de etnia branca, média de idade 63,7±8,9 anos, peso médio 82,9±14,9 kg e índice de massa corpórea 32,2±4,8 kg/m2. O nível plasmático médio do FvW foi similar nos pacientes com e sem DCV prévia, com valores de 154,5±52,1 e 155,47±41,4, respectivamente. Observou-se associação entre o diabetes mellitus (DM) e DCV estabelecida, que permaneceu significativa após ajuste para as demais variáveis incluídas no modelo multivariado. Conclusões: Não houve diferença no nível plasmático médio do FvW entre os pacientes portadores de SM, com e sem DCV documentada. A presença de DM, entretanto, esteve associada de forma independente com DCV nesta população.

Background: Cardiovascular disease (CVD) is the leading cause of death in developing countries. Individuals with metabolic syndrome (MS) are at increased risk for CVD. The traditional risk factors, altogether, do not explain all cardiovascular events. The von Willebrand factor (vWF), involved in platelet aggregation and thrombosis, has been investigated in this context. Objective: To investigate the relationship between the vWF and CVD in patients with MS, with and without previous cardiovascular events. Methods: The study included 77 outpatients, ≥18 years, with MS, according to the criteria established by NCEP-ATP III. The plasma level of vWF was measured and the mean values were compared between the groups with prior CVD (n=30) and without documented CVD (n=47). Results: In the study population, 66.0% were female, 78.0% were white, mean age 63.7±8.9, mean weight 82.9±14.9 kg, and body mass index 32.2±4.8 kg/m2. The average plasma level of vWF was similar in patients with and without previous CVD, with values of 154.5±52.1 and 155.47±41.4, respectively. There was an association between diabetes mellitus (DM) and established CVD, which remained significant after adjusting for other variables included in the multivariate model. Conclusions: There was no difference in the mean plasma level of vWF among patients with MS, with and without documented CVD. The presence of DM, however, was independently associated with CVD in this population.

Abordagem inicial da taquicardia na emergência / Tachycardia first approach in the emergency room

A taquicardia, comumente causadora de sintomas que levam o paciente a buscar setores de emergência, necessita de avaliação e manejo adequados por qualquer profissional de medicina pelo seu potencial risco iminente à vida.

Tachycardia, a common cause of symptoms that encourage patients to search for emergency sectors, needs to be properly evaluated and managed by any physician considering its imminent life threat potential.

Cardiomyopathy induced by artificial cardiac pacing: myth or reality sustained by evidence?

Implantable cardiac pacing systems are a safe and effective treatment for symptomatic irreversible bradycardia. Under the proper indications, cardiac pacing might bring significant clinical benefit. Evidences from literature state that the action of the artificial pacing system, mainly when the ventricular lead is located at the apex of the right ventricle, produces negative effects to cardiac structure (remodeling, dilatation) and function (dissinchrony). Patients with previously compromised left ventricular function would benefit the least with conventional right ventricle apical pacing, and are exposed to the risk of developing higher incidence of morbidity and mortality for heart failure. However, after almost 6 decades of cardiac pacing, just a reduced portion of patients in general would develop these alterations. In this context, there are not completely clear some issues related to cardiac pacing and the development of this cardiomyopathy. Causality relationships among QRS widening with a left bundle branch block morphology, contractility alterations within the left ventricle, and certain substrates or clinical (previous systolic dysfunction, structural heart disease, time from implant) or electrical conditions (QRS duration, percentage of ventricular stimulation) are still subjects of debate. This review analyses contemporary data regarding this new entity, and discusses alternatives of how to use cardiac pacing in this context, emphasizing cardiac resynchronization therapy.

Cardiomyopathy induced by artificial cardiac pacing: myth or reality sustained by evidence? / Miocardiopatia dilatada induzida por estimulação cardíaca artificial: mito ou realidade sustentada pelas evidências?

Implantable cardiac pacing systems are a safe and effective treatment for symptomatic irreversible bradycardia. Under the proper indications, cardiac pacing might bring significant clinical benefit. Evidences from literature state that the action of the artificial pacing system, mainly when the ventricular lead is located at the apex of the right ventricle, produces negative effects to cardiac structure (remodeling, dilatation) and function (dissinchrony). Patients with previously compromised left ventricular function would benefit the least with conventional right ventricle apical pacing, and are exposed to the risk of developing higher incidence of morbidity and mortality for heart failure. However, after almost 6 decades of cardiac pacing, just a reduced portion of patients in general would develop these alterations. In this context, there are not completely clear some issues related to cardiac pacing and the development of this cardiomyopathy. Causality relationships among QRS widening with a left bundle branch block morphology, contractility alterations within the left ventricle, and certain substrates or clinical (previous systolic dysfunction, structural heart disease, time from implant) or electrical conditions (QRS duration, percentage of ventricular stimulation) are still subjecte of debate. This review analyses contemporary data regarding this new entity, and discusses alternatives of how to use cardiac pacing in this context, emphasizing cardiac resynchronization therapy.

A estimulação cardíaca artificial (ECA) é o tratamento mais seguro e eficaz para a bradicardia sintomática irreversível. Nas indicações propícias, pode trazer grande benefício clínico. Contudo, as evidências mostram que a ação da ECA geraria, em alguns casos, efeitos deletérios à estrutura e fisiologia cardíacas. Este potencial efeito negativo da ECA convencional poderia ser mais acentuado principalmente em pacientes com comprometimento prévio da função ventricular esquerda e, sobretudo, quando o eletrodo é colocado em posição apical do ventrículo direito (VD). Intrigante é, contudo, que após quase 6 décadas de ECA do VD, apenas uma reduzida parcela de pacientes apresenta esta condição clinicamente manifesta. Os determinantes do surgimento ou não da cardiopatia por ECA não estão totalmente esclarecidos. Ainda é motivo de debate a existência de uma relação de causalidade entre o padrão de BRE artificial secundário à ativação antifisiológica ventricular, alterações da dinâmica contrátil ventricular, e condições clínicas (disfunção sistólica prévia, cardiopatia estrutural preexistente, tempo desde o implante) ou elétricas (duração do intervalo QRS, dose percentual de estimulação ventricular). Esta revisão aborda dados contemporâneos sobre esta nova entidade e discute alternativas de como utilizar a ECA neste contexto, com ênfase na terapia de ressincronização cardíaca.

O uso dos novos anticoagulantes no tratamento do tromboembolismo pulmonar / The use of new anticoagulants in the treatment of pulmonary thromboembolism

O tromboembolismo pulmonar é uma doença potencialmente grave, de difícil diagnóstico devido a apresentações diversas, exigindo diagnóstico rápido e a implementação de tratamento adequado. Torna-se importante a discussão sobre as novas alternativas no manejo medicamentoso contemporâneo desta patologia.

Pulmonary thromboembolism is a potentially serious disease, difficult to diagnose due to various presentations, requiring rapid diagnosis and implementation of appropriate treatment. It is important to discuss about new alternatives in contemporary medical management of this condition.

Long-term effectiveness of non-drug recommendations to treat hypertension in a clinical setting.

BACKGROUND: Nonpharmacological interventions have been efficacious to control blood pressure (BP) in clinical trials, but their long-term effectiveness in clinical practice was still not documented. METHODS: This is a prospective cohort study of 825 patients who received repeated nonpharmacological recommendations to treat hypertension. The outcomes were BP change and rate of BP control by pattern of adherence (informed by the patients) to the recommendations to follow low-salt and low-calorie diets and to do physical activities. RESULTS: Patients were followed for 23.1 ± 8.4 months. Between group deltas of BP change in patients with and without adherence to the low-salt diet, adjusted for baseline BP, body mass index (BMI), age, and number of drugs in use, were 5.1 (95% confidence interval: 1.7-8.6) mm Hg for systolic (P = 0.003) and 2.1 (0.2-3.9) mmHg for diastolic BP (P = 0.02). For adherence to low-calorie diet, the deltas were 6.6 (2.9-10.2) mm Hg (P < 0.001) and 2.0 (0.1-3.9) mm Hg (P = 0.045). Adherence to physical activities was not associated with a BP-lowering effect. Relative risks for a fall of 10 mm Hg in systolic or 5 mm Hg in diastolic BP, with adjustment for confounding, were 0.69 (95% confidence interval: 0.55-0.87) for adherence to the low-salt diet, 0.83 (0.66-1.05) for low-calorie diet, and 0.99 (0.79-1.24) for exercise. CONCLUSIONS: Adherence to low-salt and low-calorie diets is associated with clinically relevant long-term BP reduction and better hypertension control in a clinical setting.

Efficacy of isolated home blood pressure monitoring for blood pressure control: randomized controlled trial with ambulatory blood pressure monitoring - MONITOR study.

BACKGROUND: Rates of control of hypertension remain unsatisfactory worldwide and simple methods to encourage patients to adhere to treatments are still necessary. In this randomized controlled trial, we evaluated the efficacy of a protocol of home blood pressure monitoring (HBPM), without medication titration, to improve BP assessed by ambulatory BPM (ABPM). METHODS: Patients with hypertension under drug treatment and with uncontrolled BP at office and by 24-h ABPM were randomly assigned to HBPM or usual care. The treatment was not modified during the trial. Follow-up visits were conducted at 7 and 30 days after randomization, and at 60 days to assess the outcome. Deltas between baseline and final ABPM measurements were calculated for 24-h, nightly and daily ambulatory SBP and DBP. RESULTS: Of 558 patients screened, 136 fulfilled the eligibility criteria and were randomized, and 121 (89%) completed the trial. The between groups deltas (95% confidence interval) of variation of 24 h, nightly and daily SBP were 5.4 (0.9-9.8) (P = 0.018), 10.9 (2.9-18.9) (P = 0.012) and 4.4 mmHg (-0.1 to 8.8) (P = 0.055), respectively; the corresponding deltas for DBP were 4.5 (1.6-7.4) (P = 0.003), 3.4 (0.4-6.3) (P = 0.025) and 5.8 mmHg (2.5-9.0) (P = 0.001), respectively. At the end of the trial, 32.4% of patients of the HBPM groups and 16.2% of the control group had 24-h SBP less than 130/80 mmHg (P = 0.03). CONCLUSION: A protocol of HBPM without medication titration enhances the control of BP assessed by ABPM.

Marcadores inflamatórios e anticorpos anti-chlamydia em pacientes com síndrome metabólica / Inflammatory markers and antichlamydial antibodies in patients with metabolic syndrome / Marcadores inflamatorios y anticuerpos anti-chlamydia en pacientes con síndrome metabólico

FUNDAMENTO: A síndrome metabólica está associada ao aumento de risco de eventos cardiovasculares. Marcadores inflamatórios e anticorpos anti-Chlamydia têm sido relacionados ao desenvolvimento e à progressão da aterosclerose e dos eventos cardiovasculares. OBJETIVO: Avaliar os marcadores inflamatórios interleucina-6 (IL-6) e fator de necrose tumoral-alfa (TNF-α) e os anticorpos anti-Chlamydia pneumoniae em pacientes com síndrome metabólica (SM), com e sem eventos cardiovasculares. MÉTODOS: Estudo transversal constituído por 147 indivíduos. Desses, 100 (68 por cento) com SM e sem eventos cardiovasculares; e 47 (32 por cento) com SM e com eventos cardiovasculares. Dos indivíduos que sofreram eventos cardiovasculares, 13 (6,11 por cento) apresentam infarto agudo do miocárdio (IAM), e dez (4,7 por cento), acidente vascular cerebral (AVC). O diagnóstico da SM foi determinado pelos critérios do NCEP-ATPIII. RESULTADOS: A média de idade dos sujeitos com eventos cardiovasculares foi de 61,26 ± 8,5 e de 59,32 ± 9,9 nos indivíduos sem esses eventos (p=0,279), havendo predomínio do sexo feminino. O grupo com SM e sem evento apresentou maior peso, altura, IMC e circunferência abdominal. Para os indivíduos com eventos cardiovasculares (p=0,001), os marcadores inflamatórios IL-6 e TNF-α e a doença vascular periférica foram significativamente maiores. Obtiveram-se níveis elevados de anticorpos IgG para Chlamydia pneumoniae no grupo SM, sem eventos e de IgA no grupo com eventos quando comparados os dois grupos. Com relação ao IAM e ao AVC, os anticorpos anti-Chlamydia pneumoniae não demonstraram significância estatística, comparados ao grupo sem eventos cardiovasculares. Associação foi observada com o uso de estatinas, hipoglicemiantes orais, injetáveis e anti-inflamatórios não esteroidais no grupo com esses eventos. CONCLUSÃO: Marcadores inflamatórios encontram-se significativamente elevados em pacientes com SM, com IAM e AVC. Anticorpos anti-Chlamydia não mostraram diferença significativa em pacientes com SM, com e sem eventos.

BACKGROUND: The metabolic syndrome is associated with increased risk of cardiovascular events. Inflammatory markers and antichlamydial antibodies have been linked to the development and progression of atherosclerosis and cardiovascular events. OBJECTIVE: To evaluate the inflammatory markers interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), as well as anti-chlamydia pneumoniae antibodies, in patients with metabolic syndrome (MS), with and without cardiovascular events. METHODS: Cross sectional study consisting of 147 individuals. Out of these, 100 (68 percent) with MS and without cardiovascular events; and 47 (32 percent) with MS and with cardiovascular events. Among the individuals who had had cardiovascular events, 13 (6.11 percent) had acute myocardial infarction (AMI) and ten (4.7 percent) had cerebrovascular accident (CVA). The diagnosis of MS was determined by the criteria of NCEP-ATPIII. RESULTS: The mean age of subjects with cardiovascular events was 61.26 ± 8.5 and 59.32 ± 9.9 in subjects without such events (p = 0.279), with a predominance of females. The weight, height, BMI and waist circumference of the group with MS and without event was greater. Among individuals with cardiovascular events (p = 0.001), the inflammatory markers IL-6 and TNF-α and the peripheral vascular disease were significantly greater. There were high levels of IgG antibodies to C. pneumoniae in the SM group, without events, and of IgA antibodies in the group with events, when the two groups were compared. With respect to AMI and stroke, the anti-chlamydia pneumoniae antibodies showed no statistical significance, compared to the group without cardiovascular events. An association was observed with the use of statins, nonsteroidal anti-inflammatory drugs and injectable, oral hypoglycemic agents, in the group with these events. CONCLUSION: The inflammatory markers were significantly elevated in patients with MS, with acute myocardial infarction and stroke. There was no significant difference in anti-chlamydial antibodies in patients with MS, with and without events.

FUNDAMENTO: El síndrome metabólico está asociado al aumento de riesgo de eventos cardiovasculares. Marcadores inflamatorios y anticuerpos anti-Chlamydia han sido relacionados al desarrollo y a la progresión de la aterosclerosis y de los eventos cardiovasculares. OBJETIVO: Evaluar los marcadores inflamatorios interleucina-6 (IL-6) y factor de necrosis tumoral-alfa (TNF-α) y los anticuerpos anti-Chlamydia pneumoniae en pacientes con síndrome metabólico (SM), con y sin eventos cardiovasculares. MÉTODOS: Estudio transversal constituido por 147 individuos. De estos, 100 (68 por ciento) con SM y sin eventos cardiovasculares; y 47 (32 por ciento) con SM y con eventos cardiovasculares. De los individuos que habían sufrido eventos cardiovasculares, 13 (6,11 por ciento) presentan infarto agudo de miocardio (IAM), y diez (4,7 por ciento), accidente cerebro vascular (ACV). El diagnóstico del SM fue determinado por los criterios del NCEP-ATPIII. RESULTADOS: La media de edad de los sujetos con eventos cardiovasculares fue de 61,26 ± 8,5 y de 59,32 ± 9,9 en los individuos sin esos eventos (p=0,279), habiendo predominio del sexo femenino. El grupo con SM y sin evento presentó mayor peso, altura, IMC y circunferencia abdominal. Para los individuos con eventos cardiovasculares (p=0,001), los marcadores inflamatorios IL-6 y TNF-α y la enfermedad vascular periférica fueron significativamente mayores. Se obtuvieron niveles elevados de anticuerpos IgG para Chlamydia pneumoniae en el grupo SM, sin eventos y de IgA en el grupo con eventos cuando fueron comparados los dos grupos. Con relación al IAM y al ACV, los anticuerpos anti-Chlamydia pneumoniae no demostraron significación estadística, comparados al grupo sin eventos cardiovasculares. Asociación fue observada con el uso de estatinas, hipoglicemiantes orales, inyectables y antiinflamatorios no esteroides en el grupo con esos eventos. CONCLUSIÓN: Marcadores inflamatorios se encuentran significativamente elevados en pacientes con SM, con IAM y ACV. Anticuerpos anti-Chlamydia no mostraron diferencia significativa en pacientes con SM, con y sin eventos.

Inflammatory markers and antichlamydial antibodies in patients with metabolic syndrome.

BACKGROUND: The metabolic syndrome is associated with increased risk of cardiovascular events. Inflammatory markers and antichlamydial antibodies have been linked to the development and progression of atherosclerosis and cardiovascular events. OBJECTIVE: To evaluate the inflammatory markers interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), as well as anti-chlamydia pneumoniae antibodies, in patients with metabolic syndrome (MS), with and without cardiovascular events. METHODS: Cross sectional study consisting of 147 individuals. Out of these, 100 (68%) with MS and without cardiovascular events; and 47 (32%) with MS and with cardiovascular events. Among the individuals who had had cardiovascular events, 13 (6.11%) had acute myocardial infarction (AMI) and ten (4.7%) had cerebrovascular accident (CVA). The diagnosis of MS was determined by the criteria of NCEP-ATPIII. RESULTS: The mean age of subjects with cardiovascular events was 61.26 ± 8.5 and 59.32 ± 9.9 in subjects without such events (p = 0.279), with a predominance of females. The weight, height, BMI and waist circumference of the group with MS and without event was greater. Among individuals with cardiovascular events (p = 0.001), the inflammatory markers IL-6 and TNF-α and the peripheral vascular disease were significantly greater. There were high levels of IgG antibodies to C. pneumoniae in the SM group, without events, and of IgA antibodies in the group with events, when the two groups were compared. With respect to AMI and stroke, the anti-chlamydia pneumoniae antibodies showed no statistical significance, compared to the group without cardiovascular events. An association was observed with the use of statins, nonsteroidal anti-inflammatory drugs and injectable, oral hypoglycemic agents, in the group with these events. CONCLUSION: The inflammatory markers were significantly elevated in patients with MS, with acute myocardial infarction and stroke. There was no significant difference in anti-chlamydial antibodies in patients with MS, with and without events.

Accuracy of anthropometric indexes of obesity to predict diabetes mellitus type 2 among men and women with hypertension.

BACKGROUND: Anthropometric measurements and indexes that assess excess of adiposity are associated with cardiovascular risk factors, and predict diabetes mellitus. METHODS: This cross-sectional study reported the performance of adiposity indexes to detect or turn diabetes unlikely in patients with hypertension. Patients with hypertension (blood pressure (BP) ≥140/90 mm Hg or antihypertensive drug use) aged 18-80 years, being 150 men and 332 women, had weight, height, waist circumference (WC), hip circumference, body mass index (BMI), waist-hip ratio (WHR), waist-to-height ratio (WHtR), and waist-to-square height ratio (WHt(2)R) calculated. Diabetes was diagnosed by fasting blood glucose ≥126 mg/dl or antidiabetic drug use (23% of the sample). RESULTS: All anthropometric indexes were associated with diabetes in a modified Poisson regression, adjusting for age, smoking, and physical activity, in women, but not in men. In men, only the area under the receiver-operating characteristic curve (AUC) for WHR was statistically associated with diabetes (0.67, 95% confidence interval (CI) 0.57-0.77). A cutoff of ≥0.95 had sensitivity of 84.6% (73.3-95.9) and negative post-test probability of 12.8% (3.2-22.4). Among women, WC >88 cm, WHR ≥0.85, and WHtR > 0.54 had sensitivity >93% and negative post-test probability <7.5%. CONCLUSIONS: WHR ≥0.85, WC >88.0 cm, and WHtR >0.54 for women and WHR ≥0.95 for men are highly suggestive of diabetes among this population of hypertensive patients. Indexes below these cutoffs turn diabetes unlikely in this context. The investigation of reproducibility of this performance in other outpatient clinics is warranted.

Estratificação de risco e manejo inicial dos pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST / Risk stratification and initial management of patients with acute coronary syndrome without ST-segment elevation

: A doença arterial coronariana é a principal causa de morte no mundo e a síndrome coronariana aguda sem supradesnivelamento do seguimento ST (SCASSST). É a sua manifestação aguda mais frequente. Esta revisão tem como objetivo definir a estratificação de risco dos pacientes com SCASSST e o manejo terapêutico otimizado do grupo de alto risco, visando reduzir a ocorrência dos desfechos adversos potencias a este grupo de grande importância epidemiológica.

Associations among metabolic syndrome, ischemia, inflammatory, oxidatives, and lipids biomarkers.

CONTEXT: Metabolic syndrome (MS) is described as a cluster of cardiometabolic risk factors. Studies suggest that ischemia-modified albumin (IMA) is a biomarker of cardiovascular diseases. IMA levels could be associated with cardiometabolic risks and represent a possible indication of microvascular dysfunction in MS patients. OBJECTIVE: To confirm this possible association, we evaluated the association between IMA levels and MS. DESIGN: We performed a case-control study (32 healthy individuals and 74 subjects with MS) to evaluate the association between MS, IMA, and other biomarkers [high-sensitivity C-reactive protein (hs-CRP), oxidized low-density lipoprotein (OxLDL), oxidized low-density lipoprotein autoantibodies (anti-OxLDL), IL-6, lipid profile, and glucose]. RESULTS: The MS group showed higher levels of IMA (0.618 +/- 0.1355) as well as higher levels of hs-CRP, OxLDL, anti-OxLDL, and IL-6 than did control subjects (IMA = 0.338 +/- 0.0486) (P < 0.01). Multivariate analysis showed that IMA and MS association was independent of sex, age, diabetes mellitus 2, and hypercholesterolemia. CONCLUSION: We found an association between IMA and MS. Additional studies including prospective genetic variation approaches need to be performed to help elucidate this association between IMA and MS and its potential clinical role.

Cardiovascular risk attributable to diabetes in southern Brazil: a population-based cohort study.

OBJECTIVE: To analyze the effect of diabetes on general and cardiovascular disease (CVD) mortality and morbidity in southern Brazil. RESEARCH DESIGN AND METHODS: A population-based cohort study of 1,091 individuals was conducted. Diabetes was ascertained by medical history. The vital status of 982 individuals and the incidence of events were ascertained during another visit and through hospital records, death certificates, and verbal necropsy with relatives. RESULTS: The mean +/- SD age of participants was 43.1 +/- 17 years, and 55.7% were women. The prevalence of diabetes was 4.2%, and the mean follow-up time was 5.3 +/- 0.07 years. Mortality was 36.3% and 6.6% in participants with or without diabetes, respectively; the incidence of CVD was 20.8% and 3.0%, with an adjusted hazard ratio of 4.4 (95% CI 2.4-7.9). Diabetic population-attributable risk (PAR) for CVD mortality was 10.1% and 13.1% for total CVD. CONCLUSIONS: Diabetes is responsible for a large PAR for overall mortality and cardiovascular events in Brazil.

Síndrome metabólica: um fator de risco muscular / Metabolic syndrome: a cardiovascular risk factor

A doença cardiovascular está entre as principais causas de mortalidade em todo o mundo. Nas últimas décadas a associação de alguns fatores de risco, que antes eram avaliados de maneira isolada, como hipertensão arterial, obesidade e dislepidemia, passaram a ser avaliados como uma síndrome, denominada de Síndrome Metabólica. Este trabalho se propõe a revisar a literatura e abordar o que há de mais atual sobre este assunto.

Incidence of hypertension by alcohol consumption: is it modified by race?

OBJECTIVE: To investigate the influence of race, binge drinking and alcohol addiction on the association between consumption of alcoholic beverages and incidence of hypertension. METHODS: In a population-based cohort study, 1089 adults were interviewed and had blood pressure and anthropometric measurements carried out at home. Their alcohol consumption was ascertained by an amount-frequency questionnaire. Binge drinking was defined as consumption of five or more drinks on one occasion for men or four drinks for women, and abuse of alcohol as consumption of 30 g/day or more in men or 15 g/day or more in women. Incident cases of hypertension were characterized by blood pressure > or = 140/90 mmHg or use of hypertension medication. RESULTS: Among 589 normotensive individuals in the baseline visit, 127 incident cases of hypertension were identified, after a follow-up of 5.6 +/- 1.1 years. Binge drinking and alcohol dependency were not associated with the incidence of hypertension. Adjusted (age, education) risk ratios for the incidence of hypertension (95% confidence interval) were significant only for non-white abusers of ethanol: 11.8 (1.6-86.9). Systolic blood pressure of black abusers increased by 16.1 +/- 3.5 mmHg, in comparison with 4.9 +/- 1.5 mmHg among white abusers (P = 0.004). CONCLUSION: Individuals with an African ancestry, who consumed larger amounts of ethanol, are at higher risk of developing hypertension. This risk is not explained by a binge drinking pattern or addiction to alcohol.

Anthropometric indices and the incidence of hypertension: a comparative analysis.

OBJECTIVE: To investigate the association between several anthropometric measurements of obesity with the incidence of hypertension. RESEARCH METHODS AND PROCEDURES: Participants were 592 individuals free of hypertension, selected at random from the community. In the baseline evaluation, they were submitted to completed measures of demographics, anthropometrics, blood pressure, and other risk factors for hypertension. Incident hypertension was defined by blood pressure equal or higher than 140/90 mm Hg or use of blood pressure-lowering drugs. RESULTS: During a mean follow-up time of 5.6 +/- 1.1 years, 127 developed hypertension. The hazard ratios for the development of hypertension, adjusted for age, baseline blood pressure, gender, and alcohol consumption, were 1.042 (p = 0.091) for BMI, 1.023 (p = 0.028) for waist circumference, 1.042 (p = 0.013) for waist-to-height ratio, 1.061 (p = 0.014) for waist-to-height(2) index, 1.079 (p = 0.022) for waist-to-height(3) index, and 1.033 (p = 0.006) for the waist-to-hip ratio. DISCUSSION: The correction of the circumference of waist for stature or hip circumference improves its performance in the prediction of the incidence of hypertension.

Hipertensão arterial sistêmica: estudos diagnósticos / Hypertension: diagnostic studies

Confirmação diagnóstica e avaliação de repercussão sobre órgãos-alvo são passos críticos na avaliação de pacientes hipertensos. Demonstramos a importância da aferição repetida da pressão arterial, do tamanho do manguito e da temperatura ambiente para o diagnóstico de hipertensão arterial. Cefaléia tem associação fortuita com pressão arterial, assim como epistaxe. A tradicional classificação de Keith & Wagener (KW) não tem paralelismo com a gravidade da hipertensão arterial. A associação entre anormalidades fundoscópicas isoladas e pressão arterial é fortemente influenciada pela idade dos pacientes. O método microdensitométrico, desenvolvido em nosso serviço em conjunto com a engenharia biomédica, pode aumentar a eficiência da fundoscopia em predizer eventos cardiovasculares. Os achados descritos demonstram a importância de se empregar adequadas rotinas diagnósticas de hipertensão arterial e contribuem para o esclarecimento de muitas falsas associações com hipertensão arterial.

The confirmation of the diagnosis and the evaluation of end-organ damage are indispensable steps in the care of hypertensive patients. Repeated blood pressure measurements, cuff size and room temperature influence the diagnosis of hypertension. Headache and epistaxis have a casual association with blood pressure. The traditional Keith-Wagener (KW) classification does not vary in parallel with the severity of hypertension. The association between isolated funduscopic abnormalities and blood pressure is strongly influenced by age. The microdensitometric method, developed in our service with the collaboration of the bioengineering division, may improve the efficiency of funduscopy in predicting cardiovascular events. These findings confirm the importance of following the recommendations to measure blood pressure and contribute to the understanding of several false associations with hypertension.

Association between different measurements of obesity and the incidence of hypertension.

BACKGROUND: Obesity is a risk factor for the incidence of hypertension, but it is still unclear whether this risk can be better estimated by body mass index (BMI) or waist circumference (WC). METHODS: In the baseline evaluation of a population-based cohort, 1089 adults answered a pretested questionnaire and had their baseline blood pressure (BP) and anthropometric measurements assessed according to standardized recommendations. Excluding the individuals with hypertension at baseline, and those deceased or lost during the follow-up, 592 individuals (80.5% of those eligible) were visited again. Obesity was defined as BMI >/=30 kg/m(2) for both genders, and WC >/=102 cm for men and WC >/=88 cm for women. Incident cases of hypertension were characterized by BP >/=140/90 mm Hg or use of BP medication in the follow-up visit. RESULTS: After a mean follow-up of 5.6 +/- 1.1 years, 127 incident cases of hypertension were identified. The hazard ratios (Cox model), adjusted for age and baseline systolic BP (95% CI and P), for BMI higher than 30 kg/m(2) were 1.08 (0.52-2.24, P =.82) in men and 1.74 (0.93-3.26, P =.08) in women. The corresponding figures were 1.78 (0.76-4.09, P =.18) for men with WC >/=102, and 1.72 (1.09-2.73, P =.02) for women with WC >/=88 cm. CONCLUSIONS: We conclude that the risk for hypertension may be better identified by obesity defined by higher WC than higher BMI.