Qualidade de vida e índices de rigidez arterial em pacientes com isquemia crônica ameaçadora ao membro / Quality of life and arterial stiffness indices in patients with chronic limb-threatening ischemia

Introdução: Os fatores associados ao comprometimento da qualidade de vida em pacientes com isquemia crônica ameaçadora ao membro não estão bem estabelecidos. Objetivo: Verificar se existe associação entre a qualidade de vida e os índices de rigidez arterial, velocidade de onda de pulso (VOP) e o índice de aumentação normalizado para a frequência cardíaca de 75 bpm (AIx@75). Métodos: Trata-se de um estudo transversal, observacional, com a participação de 17 pacientes (65,65 ±11,79 anos) com isquemia crônica ameaçadora ao membro definida pela classificação de Rutherford 4, 5 e 6, e com o índice tornozelo-braço (ITB) < 0,80. A avaliação dos parâmetros vasculares e os índices de rigidez arterial foram realizadas com o aparelho Mobil-O-Graph ® que gera a onda de pulso aórtica a partir da oscilometria da artéria braquial. A qualidade de vida foi avaliada pelo questionário Vascular quality of life questionaire (VascuQoL-6), versão curta, desenvolvido especificamente para avaliar pacientes com comprometimento circulatório, arterial ou venoso. Resultados: Os valores do ITB e do escore de qualidade de vida foram 0,48 ± 0,14 e 15,88 ± 1,03; respectivamente. Dos 17 pacientes, 12 apresentavam hipertensão arterial sistólica e dezesseis apresentaram a VOP maior que 10 m/s. Não foram observadas correlações entre o escore de qualidade de vida com o AIx@75 (p=0,54 e r=0,16), a VOP (p=0,332 e r=0,248) e o ITB (p=0,707 e r=0,098). Conclusão: O presente estudo demonstrou que pacientes com isquemia crônica ameaçadora ao membro apresentam comprometimento importante da qualidade de vida sem associação com os índices de rigidez arterial e ITB.

Introduction: The factors associated with impaired quality of life in patients with chronic limb-threatening ischemia are not well established. Objective: Check whether there is an association between quality of life and arterial stiffness indexes, pulse wave velocity (PWV) and the augmentation index corrected to 75 beats per minute heart rate (AIx@75). Methods: This is a cross-sectional, observational study, with the participation of 17 patients (65.65 ± 11.79 years) with chronic limb-threatening ischemia defined by the Rutherford classification 4, 5 and 6, and with the ankle-arm index (ABI) < 0.80. The evaluation of vascular parameters and arterial stiffness indeces was performed with the MobilO-Graph ® device that generates the aortic pulse wave from the brachial artery oscillometry. Quality of life was assessed using the questionnaire Vascular quality of life questionaire (VascuQoL-6), short version, developed specifically to evaluate patients with circulatory, arterial or venous involvement. Results: The values of the ITB and the quality of life score were 0.48 ± 0.14 and 15.88 ± 1.03; respectively. Of the 17 patients, 12 had systolic arterial hypertension and sixteen had PWV greater than 10 m / s. No correlations were observed between the quality of life score with AIx @ 75 (p = 0.54 and r = 0.16), PWV (p = 0.332 and r = 0.248) and ABI (p = 0.707 and r = 0.098). Conclusion: The present study demonstrated that patients with chronic limb-threatening ischemia present significant impairment of quality of life without association with arterial stiffness and ABI.

Prevalência de síndrome metabólica e rigidez arterial em uma amostra populacional de Salvador, Bahia / Prevalence of metabolic syndrome and arterial stiffness in a population sample from Salvador, Bahia

As Doenças Cardiovasculares (DCV) são alterações nos vasos sanguíneos decorrentes, principalmente, da aterosclerose, e representam 28% dos óbitos anuais no Brasil. Em 2013, a prevalência de DCV era de 4,2% na população adulta e 11,4% nos idosos. A Síndrome Metabólica (SM), cuja prevalência é estimada entre 25 e 30%, é um dos principais fatores de risco para a instalação das DCV, assim como a Rigidez Arterial (RA), determinada pela Velocidade de Onda de Pulso (VOP) alterada. O Sistema Sphygmocor é utilizado para mensuração da VOP através da razão entre enrijecimento arterial, elasticidade e complacência vascular, considerando valores normais aqueles abaixo de 10m/s. A VOP foi o método de escolha, junto a medidas antropométricas e exames laboratoriais, para avaliar a prevalência de SM e RA numa amostra populacional de Salvador, Bahia. O teste T de Student foi utilizado para comparar as variáveis e o teste Qui Quadrado, para comparar as proporções das variáveis qualitativas. O cálculo das prevalências foi realizado com o número de indivíduos com RA ou SM no numerador e o número total da amostra no denominador, com resultado multiplicado por 102 . O estudo foi aprovado pelo Comitê de Ética em Pesquisa através do parecer número 1.827.621 de 21 de novembro de 2016. A amostra de 162 participantes demonstrou prevalência de 25,93% de Síndrome Metabólica e 26,57% de Rigidez Arterial, expondo a importância de maior atenção à prevenção das DCV na atenção primária à Saúde.

Cardiovascular Diseases (CVD) are modifications in blood vessels resulting mainly from atherosclerosis and represent 28% of annual deaths in Brazil. In 2013, the prevalence of CVD was 4.2% in the adult population and 11.4% in the elderly. Metabolic Syndrome (MS), whose prevalence is estimated between 25 and 30%, is one of the main risk factors for the settlement of CVD, as well as Arterial Stiffness (AS), determined by altered Pulse Wave Velocity (PWV). The Sphygmocor System is used to measure PWV through the ratio between arterial stiffening, elasticity, and vascular complacency, considering normal valor those below 10m/s. PWV was the method of choice, with anthropometric measurements and laboratory tests, to evaluate the prevalence of MS and AS in a population sample from Salvador, Bahia. The Student's T test was used to compare the variables and the Chi Square test to compare the proportions of the qualitative variables. The calculation of prevalence was made with the number of individuals with AS or MS in the numerator and the total number of sample in the denominator, with the result multiplied by 102. The study was approved by the Research Ethics Committee through opinion number 1,827,621 of November 21, 2016. The sample of 162 participants showed a prevalence of 25.93% of Metabolic Syndrome and 26.57% of Arterial Stiffness, exposing the importance of greater attention to the prevention of CVD in primary health care.

Impact of hypertension on arterial stiffness and cardiac autonomic modulation in patients with peripheral artery disease: a cross-sectional study / Impacto da hipertensão na rigidez arterial e modulação autonômica cardíaca em pacientes com doença arterial periférica: um estudo transversal

ABSTRACT Objective: To examine the impact of hypertension on cardiovascular health in patients with symptomatic peripheral artery disease and to identify factors associated with uncontrolled hypertension. Methods: A cross-sectional study including 251 patients with symptomatic peripheral artery disease (63.9% males, mean age 67±10 years). Following hypertension diagnosis, blood pressure was measured to determine control of hypertension. Arterial stiffness (carotid-femoral pulse wave velocity) and cardiac autonomic modulation (sympathovagal balance) were assessed. Results: Hypertension was associated with higher carotid-femoral pulse wave velocity, regardless of sex, age, ankle-brachial index, body mass index, walking capacity, heart rate, or comorbidities (ß=2.59±0.76m/s, b=0.318, p=0.003). Patients with systolic blood pressure ≥120mmHg had higher carotid-femoral pulse wave velocity values than normotensive individuals, and hypertensive patients with systolic blood pressure of ≤119mmHg (normotensive: 7.6±2.4m/s=≤119mmHg: 8.1±2.2m/s 120-129mmHg:9.8±2.6m/s=≥130mmHg: 9.9±2.9m/s, p<0.005). Sympathovagal balance was not associated with hypertension (p>0.05). Conclusion: Hypertensive patients with symptomatic peripheral artery disease have increased arterial stiffness. Arterial stiffness is even greater in patients with uncontrolled high blood pressure.

RESUMO Objetivo: Analisar a influência da hipertensão na saúde cardiovascular em pacientes com doença arterial periférica sintomática, e identificar fatores associados à hipertensão arterial não controlada. Métodos: Neste estudo transversal foram incluídos 251 pacientes com doença arterial periférica (63,9% homens e média de idade 67±10 anos). Hipertensão foi diagnosticada e pressão arterial foi avaliada para determinar o controle da hipertensão. Foram avaliadas rigidez arterial (velocidade da onda de pulso carótida-femoral) e modulação autonômica cardíaca (balanço simpatovagal). Resultados: Hipertensão foi associada com maior velocidade da onda de pulso carótida-femoral, independentemente do sexo, idade, índice tornozelo-braço, índice de massa corpórea, capacidade de deambulação, frequência cardíaca, ou comorbidades (ß=2,59±0,76m/s, b=0,318, p=0,003). Pacientes com pressão arterial sistólica ≥120mmHg tiveram maior velocidadeda onda de pulso carótida-femoral do que normotensos, e pacientes hipertensos com pressão arterial sistólica ≤119mmHg (normotensos: 7,6±2,4m/s=≤119mmHg: 8,1±2,2m/s 120-129mmHg: 9,8±2,6m/s=≥130mmHg: 9,9±2,9m/s, p<0,005). Balanço simpatovagal não foi associado à hipertensão. Conclusão: Pacientes hipertensos com doença arterial periférica sintomática apresentam maior rigidez arterial. Em pacientes com pressão arterial não controlada, a rigidez arterial é ainda mais elevada.

The association between Hba1c and arterial stiffness among non-diabetic patients with chronic kidney disease / Associação entre Hba1c e rigidez arterial entre pacientes sem diabetes com doença renal crônica

Abstract Background Cardiovascular events are seen more frequently after the age of 60 and they are a significant cause of morbidity and mortality. Arterial stiffness is a property that can be expressed by pulse wave velocity and this value is assumed to be a predictor of cardiovascular events. Patients with chronic kidney disease and dysregulated blood sugar have increased atherosclerosis and arterial stiffness, but the relationship between physiological levels of Hba1c and arterial stiffness is less clear in chronic kidney disease patients without diabetes mellitus. Objectives Here, we aimed to investigate the degree of arterial stiffness among non-diabetic, non-dialysis dependent chronic kidney disease patients with physiological HbA1c levels. Methods We enrolled 51 patients who were followed up at Ege University Hospital Nephrology Department between February and June 2015. Non-diabetic, non-dialysis dependent chronic kidney disease patients were included in the study. Blood pressure and pulse wave velocity were measured with an applanation tonometry device (Sphygmocor Vx Software Atcor Medical, Australia). Correlations between pulse wave velocity and the aforementioned parameters were investigated (see below). Results We detected a significant correlation between pulse wave velocity and systolic blood pressure (p=0.0001) and Hba1c (p=0.044) separately. There was an inverse correlation with creatinine clearance (p=0.04). We also detected a significant correlation with serum phosphorus level (p=0.0077) and furosemide use (p=0.014). No correlations were found among the other parameters. Conclusions Arterial stiffness is an important predictor of cardiovascular events and measuring it is an inexpensive method for estimating morbidity and mortality. Our study supports the importance of measuring arterial stiffness and of controlling blood glucose levels, even at physiological Hba1c values, especially for chronic kidney disease patients.

Resumo Contexto Os eventos cardiovasculares são mais frequentes em pessoas com mais de 60 anos, e sugere-se que sejam causas significativas de morbidade e mortalidade. A rigidez arterial é expressa pela velocidade da onda de pulso, e presume-se que esse valor seja um preditor de eventos cardiovasculares. Os pacientes com doença renal crônica e desregulação do açúcar no sangue têm aterosclerose e rigidez arterial aumentadas. No entanto, a relação entre os níveis fisiológicos de Hba1c e a rigidez arterial entre pacientes com doença renal crônica sem diabetes melito é menos clara. Objetivos Buscamos investigar o grau de rigidez entre os pacientes sem diabetes e portadores de doença renal crônica sem dependência de diálise com níveis fisiológicos de HbA1c. Métodos Incluímos 51 pacientes, sem diabetes e com doença renal crônica sem dependência de diálise, que estavam em acompanhamento no Departamento de Nefrologia do Ege University Hospital entre fevereiro e junho de 2015. A pressão sanguínea e a velocidade da onda do pulso foram medidas com um dispositivo de tonometria de aplanação (Sphygmocor Vx Software Atcor Medical, Austrália). A correlação entre a velocidade da onda de pulso e os parâmetros mencionados anteriormente foi investigada. Resultados Detectamos correlação significativa entre a velocidade da onda de pulso e a pressão arterial sistólica (p = 0,0001) e Hba1c (p = 0,044) separadamente. Foi constatada correlação inversa com a depuração de creatinina (p = 0,04). Também detectamos correlação significativa com o nível de fósforo sérico (p = 0,0077) e o uso de furosemida (p = 0,014). Não foi encontrada correlação entre outros parâmetros. Conclusões A rigidez arterial é um preditor importante de eventos cardiovasculares, e a sua medição é um método de baixo custo para estimar a morbidade e mortalidade. Nosso estudo corrobora a importância da medição da rigidez arterial e do controle dos níveis de glicemia sanguínea mesmo em valores de Hba1c fisiológicos, principalmente para pacientes portadores de doença renal crônica.

Cognitive impairment related to arterial stiffness in cardiovascular disease patients with severe periodontitis / Deterioro cognitivo relacionado a la rigidez arterial en pacientes con enfermedad cardiovascular y periodontitis grave

ABSTRACT Severe periodontal disease (SPD) associated with systemic peripheral inflammation, cognitive impairment (CI) and arterial stiffness (AS) has been recognized. The aim of this study was to investigate whether CI and arterial stiffness (AS) occur in cardiovascular disease (CVD) patients with SPD. A crosssectional case-control study included hospitalized patients with CVD. Demographic characteristics, CVD and atherogenic risk factors were recorded. SPD was diagnosed by clinical and radiographic dental examinations. Dental clinical attachment level (CAL) and CAL % were recorded. A Mini-Mental State Examination test (MMSE) assessed cognition, a MMSE score of < 27 was set as the cut-off point of CI; a score > 27 was considered as no CI. Patients were categorized into: MMSE<27 (cases) and MMSE>27 (controls). AS was evaluated by pulse wave velocity (PWV). Serum VCAM-1 levels were determined in a random sample. Results: This study comprised 91 patients (cases, n=26; 29.6%; controls, n=65, 71.4%); aged 73±8 vs. 73±7 years, respectively (p=0.73), of whom 53.8% and 36.9% respectively, were women; SPD was found to be a risk factor for CI; the presence of SPD increased the risk for MMSE <27 by an average 5.39 times (model 1). PWV was associated with MMSE < 27 in the three models. The risk of having MMSE < 27 increased an average of2.404-fold for each 1-unit increase in PWV SPD and AS had significant and independent associations on the risk for development CI. MMSE negatively correlated with CAL% (r=0.69) and PWV (r=0.70). PWV positively correlated with CAL% (r=0.67). Serum VCAM-1 levels were higher in SPD with lower MMSE scores. In conclusion, SPD increases the risk of development of cognitive decline in CVD patients. PWV was directly associated with the risk of cognitive decline. These findings denote a significant opportunity to improve periodontal health in order to avert CI in CVD patients.

RESUMEN La enfermedad periodontal severa (EPS) podría estar asociada a la rigidez arterial (RA) y al deterioro cognitivo (DC). Se realizó un estudio transversal de casos y controles y se investigó la presencia de RA y DC en pacientes con enfermedad cardiovascular (ECV) y EPS. En pacientes hospitalizados con ECVse registraron las características demográficas y factores de riesgo aterogénicos. El DC se diagnosticó a través del Mini-Mental State Examination (MMSE). Punto de corte: MMSE<27 (casos); puntaje >27 ausencia de DC (controles). La EPS fue diagnosticada clínica y radiográficamente. Se registraron el nivel inserción clínica (NIC) y NIC %. La RA fue evaluada a través de la velocidad de onda de pulso (VOP). VCAM-1 sérico se determinó en una muestra aleatoria. Se incluyeron 91 pacientes (casos,n=26; 29.6%; controles,n=65, 71.4%); edad promedio: 73±8 vs. 73±7 años, respectivamente (p=0.73); % de mujeres: 53.8 vs. 36.9, respectivamente y EPS (n=54) y ausencia de EP (noEP) en 37. MMSE< 27 en 26 pacientes; 23 de ellos, con EPS. La presencia de EPS aumentó el riesgo de MMSE< 27 en 5.39 veces (modelo 1). La VOP se asoció a MMSE< 27 (Modelo 1, 2 y 3). El riesgo de MMSE< 27 incrementó en promedio en 2.40 veces por cada aumento de unidad de VOP. EPS y RA mostraron asociaciones significativas e independientes sobre el riesgo de DC. MMSE se correlacionó negativamente con NIC % (r=0.69) y POV (r=0.70); y POV, positivamente con NIC % (r=0.67). Los niveles séricos de VCAM-1 fueron más elevados en presencia de EPS y puntajes bajos de MMSE. Puede concluirse que en pacientes con ECV y EPS, el aumento en RA incrementaría el riesgo de DC. Estos hallazgos enfatizan la necesidad de promover y mantener la salud bucal para evitar el DC en pacientes con ECV.

Efficacy of a behavior change program on cardiovascular parameters in patients with hypertension: a randomized controlled trial / Eficácia de um programa de mudança de comportamento sobre parâmetros cardiovasculares em pacientes com hipertensão arterial sistêmica: ensaio clínico controlado randomizado

ABSTRACT Objective To investigate the efficacy of a behavior change program named Vida Ativa Melhorando a Saúde on cardiovascular parameters in hypertensive patients. Methods Ninety hypertensive patients aged over 40 years were randomly allocated to one of two groups: Vida Ativa Melhorando a Saúde or Control (n=45 respectively). Patients in the Vida Ativa Melhorando a Saúde group took part in a behavior change program aimed to encourage changes in physical activity levels and eating habits, according to the Social Cognitive Theory. The program consisted of 90-minute weekly group meetings conducted by a physical therapist and a dietitian. One chapter of the educational material (workbook) provided was discussed per meeting. Participants in the Control Group attended a single educative lecture on lifestyle changes. Brachial and central blood pressure, arterial stiffness and endothelial function parameters were measured pre- and post-intervention. Results Vida Ativa Melhorando a Saúde led to reduction of brachial (131.3±15.8mmHg to 125.1±17.3mmHg; p<0.01) and central (123.6±16.3mmHg to 119.0±20.6mmHg; p=0.02) systolic and brachial diastolic (123.6±16.3mmHg to 119.0±20.6mmHg; p<0.01) blood pressure values, and improvement of post-occlusive reactive hyperemia (from 5.7±2.5mL·100mL−1 to 6.5±2.1mL·100mL−1 tissue·min−1; p=0.04). No changes in body composition, heart rate and arterial stiffness parameters were detected in both groups (p>0.05). Conclusion Vida Ativa Melhorando a Saúde program improved blood pressure and microvascular reactivity in hypertensive patients. Trial registration: ClinicalTrials.gov: NCT02257268

RESUMO Objetivo Analisar a eficácia do programa de mudança de comportamento Vida Ativa Melhorando a Saúde sobre parâmetros cardiovasculares em pacientes hipertensos. Métodos Noventa pacientes hipertensos ≥40 anos foram aleatoriamente randomizados em dois grupos: Vida Ativa Melhorando a Saúde (n=45) e Controle (n=45). O Grupo Vida Ativa Melhorando a Saúde participou de um programa de mudança de comportamento que objetiva motivar mudanças na atividade física e nos hábitos alimentares, de acordo com a teoria sociocognitiva. O programa foi conduzido em grupos, durante 12 semanas consecutivas, em encontros semanais (~90 minutos), conduzidos por um profissional de edução física e um nutricionista. Um capítulo do material didático era discutido em cada um desses encontros. O Grupo Controle participou de uma única palestra educativa sobre mudanças de estilo de vida. Medidas de pressão arterial braquial e central, rigidez arterial, e de função endotelial foram realizadas nos momentos pré e pós-intervenção. Resultados O Grupo Vida Ativa Melhorando a Saúde reduziu a pressão arterial sistólica braquial (de 131,3±15,8mmHg a 125,1±17,3mmHg; p<0,01) e central (de 123,6±16,3mmHg a 119,0±20,6mmHg; p=0,02) e a pressão arterial diastólica braquial (123,6±16,3mmHg a 119,0±20,6mmHg; p<0,01) e apresentou melhora na hiperemia reativa pós-oclusão (de 5,7±2,5mL·100mL−1a 6,5±2,1mL·100mL−1tecido·min−1; p=0,04). Não houve modificação na composição corporal, na frequência cardíaca e nem nos parâmetros de rigidez arterial em ambos os grupos (p>0,05). Conclusão O Programa Vida Ativa Melhorando a Saúde melhorou a pressão arterial e a reatividade microvascular em pacientes hipertensos. Registro do estudo: ClinicalTrials.gov: NCT02257268

Efeitos da doença e adequação da hemodiálise em pacientes com rigidez arterial / Efectos de la enfermedad y adecuación de la hemodiálisis en pacientes con rigidez arterial / Effects of disease and hemodialysis adequacy in patients with arterial stiffness

RESUMO Objetivos Analisar a adequação do tratamento hemodialítico em pacientes com rigidez arterial e associar os efeitos da doença renal com os fatores sociodemográficos e clínicos. Método Estudo epidemiológico, transversal realizado com 149 renais crônicos em tratamento de hemodiálise em hospital escola do interior do Estado de São Paulo. Utilizou-se para medida da rigidez arterial o aparelho de Dyna-MAPA®. Foram aplicados os testes de regressão linear multivariada, t Student e o qui-quadrado para os biomarcadores e a ocorrência de rigidez arterial. Resultados A maioria dos pacientes encontrava em idade produtiva, inativa profissionalmente, do sexo masculino, união estável, fazendo restrição hídrica e alimentar, com menos de 48 meses de tratamento dialítico; 36,9% dos pacientes apresentavam rigidez arterial. Os biomarcadores creatinina, ureia e fósforo estavam aumentados; hematócrito e hemoglobina estavam diminuídos, média de peso interdialítico de 2,34 ± 1,4 kg, e a maioria do Kt/V inadequado. Quanto aos efeitos da doença renal observou-se significância estatística com os inscritos na lista de transplantes, maior tempo de tratamento e aumento da creatinina. Conclusão Estes resultados podem proporcionar a diminuição da morbimortalidade cardiovascular nestes pacientes.

RESUMEN Objetivos Analizar la adecuación del tratamiento hemodialítico en pacientes con rigidez arterial y asociar los efectos de la enfermedad renal con los factores sociodemográficos y clínicos. Método Estudio epidemiológico, transversal realizado con 149 renales crónicos en tratamiento de hemodiálisis, en el interior del Estado de São Paulo. Utilizaron el instrumento para medir la rigidez arterial el aparato de Dyna-MAPA®. Se aplicaron los pruebas de Regresión Lineal Multivaria, t Student y el Chi-Cuadrado para los biomarcadores y la ocurrencia de rigidez arterial. Resultados La mayoría estaba en edad productiva, inactiva profesionalmente, del sexo masculino, en unión estable, haciendo restricción hídrica y alimentar y con menos de 48 meses de tratamiento dialítico y 36,9% de los pacientes presentaban rigidez arterial. Los biomarcadores creatinina, urea y fósforo estaban aumentados, hematocrito y hemoglobina estaban disminuidos, media de peso interdialítico de 2,34 ± 1,4 kg, y la mayoría del Kt / V inadecuado. En cuanto a los efectos de la enfermedad renal se observó significancia estadística con los inscritos en la lista de trasplantes, mayor tiempo de tratamiento y aumento de la creatinina. Conclusión: Se espera que estos resultados proporcionen la disminución de la morbimortalidad cardiovascular de estos pacientes.

ABSTRACT Objectives To analyze the adequacy of hemodialysis treatment in patients with arterial stiffness and to associate the effects of renal disease with sociodemographic and clinical factors. Method A cross-sectional epidemiological study with 149 chronic renal patients undergoing hemodialysis treatment, in the interior of the State of São Paulo. They used to measure arterial stiffness with the Dyna-MAPA® device. The tests statistical were multivariate linear regression, t Student and chi-square were applied to the biomarkers and the occurrence of arterial stiffness. Results Most were of productive age, professionally inactive, male, in a stable union, water, and food restriction, and with less than 48 months of dialysis treatment and 36.9% of patients had arterial stiffness. The biomarkers creatinine, urea, and phosphorus were increased, hematocrit and hemoglobin were decreased, mean interdialytic weight was 2.34 ± 1.4kg, and most of the Kt / V inadequate. The effects of renal disease were statistically significant with those enrolled in the transplant list, longer treatment time, and increased creatinine. Conclusion These results are expected to reduce cardiovascular morbidity and mortality in these patients.

Cardiovascular Risk in Psoriasis Patients: Clinical, Functional and Morphological Parameters / Risco Cardiovascular em Pacientes Psoriásicos: Avaliação de Parâmetros Clínicos, Funcionais e Morfológicos

Abstract Background: Psoriasis correlates with metabolic disorders, early atheromatosis and increased cardiovascular risk. Objectives: To assess markers of cardiovascular disease in psoriatic patients. Methods: Cross-sectional, observational study involving 11 psoriatic participants and 33 controls. Anthropometric, biochemical, hemodynamic and imaging parameters were evaluated. Arterial stiffness was assessed by oscillometric measurement of the brachial artery. Intima-media thickness (IMT) and left ventricular diastolic function were assessed by Doppler echography and echocardiography. Between-group comparisons of numerical variables were performed by the Student's t-test or Wilcoxon Mann-Whitney test for independent samples. Significance level was set at 5%. Results: Psoriatic patients showed increased pulse wave velocity (PWV) (9.1 ± 1.8 vs 8.0 ± 2 m/s, p = 0.033), IMT of the left common carotid artery (p = 0.018) and a higher percentage of patients above the 75th percentile according to the ELSA table when compared with controls (54.5 vs 18.2%, p = 0.045). Psoriatic patients also showed an increase in peripheral/central systolic blood pressure (137.1 ± 13.2 vs 122.3 ± 11.6 mmHg, p = 0.004)/(127 ± 13 vs 112.5 ± 10.4 mmHg, p = 0.005), peripheral/central diastolic blood pressure (89.9 ± 8.9 vs 82.2 ± 8, p = 0.022)/(91 ± 9.3 vs 82.2 ± 8.3, p = 0.014), total cholesterol (252 ± 43.5 vs 198 ± 39.8 mg/dL, p < 0.001), LDL cholesterol (167 ± 24 vs 118 ± 40.8 mg/dL, p < 0.001) and C-reactive protein (7.6 ± 35.4 vs 1 ± 1.2 mg/L p < 0.001) compared with controls. Conclusion: Psoriasis patients show increased PWV, IMT, peripheral and central blood pressures, and serum cholesterol and C-reactive protein levels, denoting a higher cardiovascular risk.

Resumo Fundamento: A psoríase correlaciona-se a distúrbios metabólicos, ateromatose precoce e aumento do risco cardiovascular. Objetivos: Avaliar marcadores de doença cardiovascular na população psoriásica. Métodos: Estudo observacional transversal, envolvendo 11 participantes psoriásicos e 33 controles. Foram avaliados parâmetros antropométricos, laboratoriais, hemodinâmicos e de imagem. A rigidez arterial foi avaliada por oscilometria da artéria braquial. A espessura médio-intimal (EMI) e a função diastólica do ventrículo esquerdo foram avaliadas por meio da ecografia e ecocardiografia Doppler. As comparações de variáveis numéricas entre grupos foram realizadas por teste t-Student e Wilcoxon Mann-Whitney para amostras independentes, adotando-se o nível de significância de 5%. Resultados: Os pacientes psoriásicos apresentaram aumento de VOP (9,1 ± 1,8 e 8 ± 2 m/s, p = 0,033), EMI da artéria carótida comum esquerda (p = 0,018) e maior proporção de percentil > 75 pela tabela ELSA (54,5 e 18,2%, p = 0,045) e) quando comparados aos controles. Pacientes psoriásicos também mostraram aumento nos seguintes parâmetros em relação ao grupo controle, respectivamente: pressão arterial sistólica periférica/central (137,1 ± 13,2 e 122,3 ± 11,6 mmHg, p = 0,004)/(127 ± 13 e 112,5 ± 10,4 mmHg, p = 0,005), pressão arterial diastólica periférica/central (89,9 ± 8,9 e 82,2 ± 8 mmHg, p = 0,022) / (91 ± 9,3 e 82,2 ± 8,3 mmHg, p = 0,014), colesterol total (252 ± 43,5 e 198 ± 39,8 mg/dL, p < 0,001), colesterol LDL (167 ± 24 e 118 ± 40,8 mg/dL, p < 0,001) e proteína C reativa (7,6 ± 35,4 e 1 ± 1,2 mg/L, p<0,001). Conclusão: Pacientes psoriásicos apresentam elevações de VOP e EMI, além de maiores pressões arteriais periféricas e centrais, níveis séricos de colesterol e de proteína C reativa, denotando maior risco cardiovascular.

Arterial stiffness in hyperthyroid patients is deteriorated due to thyroid hormones

ABSTRACT Objective The aim of this study is to evaluate and compare arterial stiffness, which is an independent risk indicator for cardiovascular diseases (CVDs), between patients with overt hyperthyroidism, subclinical hyperthyroidism, euthyroidism by antithyroid therapy and healthy volunteers with pulse wave analysis (PWA). Subjects and methods A total of 102 volunteers were included in the study (30 in the overt hyperthyroid group, 28 in the subclinical hyperthyroid group and 14 with euthyroidism by antithyroid therapy and 30 healthy). The arterial stiffness measurements of the participants in the study were performed with the Mobil-O-Graph PWA device (I.E.M. GmBH, Stolberg, Germany), which makes cuff based oscillometric measurement from the brachial artery. Results Systolic blood pressure, pulse rate, central systolic blood pressure, cardiac output, heart rate-corrected augmentation index (Aix@75) and pulse wave velocity (PWV) measurements were significantly higher in the hyperthyroid group than in the control group. The heart rate and PWV in the subclinical hyperthyroid group were significantly higher than the control group. In the euthyroid group, systolic blood pressure, central systolic blood pressure, cardiac output, cardiac index and PWV were found significantly higher than the control group. There was also a negative correlation between Aix@75 and thyroid-stimulating hormone (TSH), and a positive correlation between Aix@75 and free thyroid hormones. Conclusion In our study, we observed that the arterial stiffness was adversely affected by an overt or subclinical increase in thyroid hormones and this correlated with thyroid hormone levels. We recommend that PWV measurement, which is a simple method for detecting CVD risk, can be used in these patients.

The effect of hemodialysis on the body composition and cardiovascular disease markers in recently diagnosed end stage renal disease patients

SUMMARY AIM: Uremic toxins and excess fluid contributes to increased cardiovascular (CV) risk. We aimed to determine the body fluid status in patients who are just starting hemodialysis (HD) and to determine the effects of excess fluid removed by HD on the CV system. METHODS: A total of 52 patients with chronic kidney disease (CKD) who had just started HD were included. Before the HD, the left atrial diameter was measured, the volumes were calculated, the pulse wave velocity (PWV) and the augmentation index (AIx) were measured, the bioimpedance analysis (BIA) was performed, the blood was taken for brain natriuretic peptide (BNP). When patients reached their dry weight with HD, the same measurements were repeated. RESULTS: Measurements were made to determine the volume status, and all parameters except the fat tissue index decreased significantly after HD. With the removal of fluid by HD, there was an average weight reduction of 4.38 kilograms. Positive correlations between PWV and age and cardiothoracic ratio (CTR) before HD were determined. Negative correlations were found between PWV and lean tissue mass (LTM) and intracellular water (ICW) before HD. At the end of the last HD, PWV was positively correlated with age, CTR, central pulse pressure Correlation between pulse wave velocity and LTI was negative CONCLUSIONS: HD significantly improves PWV in patients reaching dry weight. Reduction of fluid excess by ultrafiltration in HD patients may reduce CV mortality by reducing arterial stiffness.

RESUMO INTRODUÇÃO: Em pacientes com doença renal crônica (DRC), toxinas urêmicas e hipervolemia contribuem para aumentar o risco cardiovascular. Nosso objetivo foi determinar o estado de hidratação em pacientes com DRC iniciando hemodiálise (HD) e avaliar os efeitos da correção da hipervolemia sobre o sistema cardiovascular. MÉTODOS: Foram incluídos 52 pacientes que haviam acabado de iniciar HD. Antes do início da sessão, foram determinados o diâmetro e o volume atrial esquerdo, a velocidade de onda de pulso (VOP) e o índice de amplificação sistólica ("augmentation index", AI). Além disso, realizamos análise da composição corporal por bioimpedância elétrica (BIA) e mensuramos os níveis plasmáticos de peptídeo natriurético tipo B. Os mesmos procedimentos foram repetidos após os pacientes alcançarem o "peso seco". RESULTADOS: O peso corporal dos pacientes foi reduzido, em média, em 4,38 kg. Na BIA, todos os parâmetros, exceto o índice de gordura corporal, foram significativamente reduzidos após a hemodiálise. Antes da HD, a VOP se correlacionou positivamente com idade e razão cardiotorácica (RCT), e negativamente com a massa magra e a água intracelular. Ao final da hemodiálise, a VOP se correlacionou positivamente com idade, RCTe pressão de pulso central, correlacionando-se negativamente com a Lean Tissue Index (LTI). CONCLUSÃO: A hemodiálise melhora a VOP por meio da redução da volemia. O controle da hipervolemia via ultrafiltração pode reduzir a mortalidade cardiovascular por meio da redução da rigidez arterial.

Arterial stiffness and 25-hydroxyvitamin D levels in chronic kidney disease patients

Summary Objective: Arterial stiffness refers to arterial wall rigidity, particularly developing in central vessels. Arterial stiffness increases in early stage chronic kidney disease (CKD), and it is a strong predictor of cardiovascular and all cause mortality. Vitamin D has beneficial effects on blood pressure, vascular endothelial function and arterial stiffness. 25-hydroxyvitamin D (25(OH)D) deficiency is quite common worldwide and in the CKD population. We aimed to evaluate the prevalence of 25(OH)D deficiency and its relation with arterial stiffness in CKD. Method: Our study included 101 patients (51 male, 50 female), with stages 3B-5 CKD not on dialysis. A single-cuff arteriograph device (Mobil-O-Graph) was used to evaluate arterial stiffness parameters of pulse wave velocity (PWV) and augmentation index (Alx@75). The patients were divided into two groups: group I vitamin D non-deficient [25(OH)D > 15 ng/mL] and group II vitamin D deficient [25(OH)D ≤ 15 ng/mL]. Results: Overall, the mean 25(OH)D level was 14.1±7.9 ng/mL and 70 patients (69.4%) were vitamin D deficient. The mean Alx@75 value was significantly higher in group II (28.6±10.8% vs. 23.3±13.5%, p=0.038). PWV was higher in group II, but the difference was not significant. Group II exhibited significantly lower serum albumin (p<0.001), hemoglobin (p=0.005), calcium (p=0.041) and estimated glomerular filtration rate (eGFR) (p=0.041), but significantly higher 24-hour proteinuria (p=0.011) and more females (p=0.006). Vitamin D was negatively correlated with Alx@75 augmentation pressure, parathyroid hormone, proteinuria and body mass index, and positively correlated with albumin, hemoglobin, eGFR, calcium and transferrin. 25(OH)D was independently associated with Alx@75 (beta=-0.469, p=0.001) and albumin (beta=0.447, p=0.002). Conclusion: In CKD patients 25(OH)D deficiency was common, particularly in females. Level of 25(OH)D was independently associated with Alx@75.

Hypertension and arterial stiffness in heart transplantation patients

OBJECTIVES: Post-transplantation hypertension is prevalent and is associated with increased cardiovascular morbidity and subsequent graft dysfunction. The present study aimed to identify the factors associated with arterial stiffness as measured by the ambulatory arterial stiffness index. METHODS: The current study used a prospective, observational, analytical design to evaluate a group of adult heart transplantation patients. Arterial stiffness was obtained by monitoring ambulatory blood pressure and using the ambulatory arterial stiffness index as the surrogate outcome. Multivariate logistic regression analyses were performed to control confounding. RESULTS: In a group of 85 adult heart transplantation patients, hypertension was independently associated with arterial stiffness (OR 4.98, CI 95% 1.06-23.4) as well as systolic and diastolic blood pressure averages and nighttime descent. CONCLUSIONS: Measurement of ambulatory arterial stiffness index is a new, non-invasive method that is easy to perform, may contribute to better defining arterial stiffness prognosis and is associated with hypertension.

Arterial stiffness and endothelial inflammation in prediabetes and newly diagnosed diabetes patients

ObjectiveThere is a growing body of data supporting the association between diabetes and microcirculatory disfunction. We aimed to study e-selectin levels, and their associations with serum markers of inflammation and arterial stiffness in prediabetes and newly diagnosed diabetes patients in this study.Subjects and methodsSixty patients (25 females) with a newly established elevated fasting serum glucose [20 impaired fasting glucose (IFG), 20 impaired glucose tolerance (IGT), 20 newly diagnosed diabetes (T2DM)] and 17 healthy controls (13 females) were included in the study. Serum e-selectin and hs-CRP levels, and arterial stiffness parameters of the patients were studied.ResultsFasting serum glucose was the most important predictor of serum e-selectin levels. Pulse wave velocity and central aortic pressures were significantly higher in IFG, IGT and T2DM groups, compared to controls (p = 0.001, < 0.001, 0.013 and 0.015, 0.002, 0.009, respectively). The mean arterial pressure did not show any significant association with serum e-selectin and hs-CRP levels (β coefficient: 0.092, p = 0.358; and β coefficient: 0.189, p = 0.362, respectively).ConclusionPrediabetes patients have increasing e-selectin levels through the diagnosis of T2DM. E-selectin is associated with serum glucose levels. Prediabetic and newly diagnosed diabetics have higher arterial stiffness measurements. Serum e-selectin may be a good marker of endothelial inflammation and dysfunction increasing in parallel with serum glucose levels, predicting future cardiovascular events.

A distensibilidade da aorta prediz o acidente vascular cerebral em pacientes hipertensos / Aortic stiffness is an independent predictor of stroke in hypertensive patients

FUNDAMENTO: A doença cardiovascular continua a ser principal causa de morte nos países desenvolvidos e não é inteiramente prevista por fatores de risco clássicos. O aumento da rigidez arterial constitui um importante determinante de morbidade e mortalidade cardiovascular. OBJETIVO: Avaliar se a velocidade da onda de pulso prediz a ocorrência de acidente vascular cerebral (AVC) em pacientes hipertensos. MÉTODOS: Estudo de coorte, observacional, prospetivo, multicêntrico, incluindo 1.133 pacientes hipertensos (586 homens), com uma média de idade de 51,05 ± 12,64 anos. Todos os pacientes foram submetidos à avaliação da VOP pelo método Complior, a uma avaliação clínica pormenorizada e à medição da pressão arterial. RESULTADOS: A incidência cumulativa de risco de AVC nos hipertensos com VOP aumentada foi de 3,25% (IC: 1,97%-5,25%), em comparação com 0,78% (IC: 0,28% - 1,87%) nos hipertensos com VOP normal (risco relativo (RR) = 4,15; IC: 1,53 - 11,26). Numa análise multivariável, ajustando o modelo aos fatores de risco cardiovasculares clássicos, a VOP foi um preditor independente de AVC, com um hazard ratio (HR) = 1,40 (IC: 1,13 - 1,73, p < 0,002), indicando um incremento de 40% no risco de AVC por cada incremento de 1 m/seg na VOP. A adição da VOP a um modelo composto pelos fatores de risco cardiovascular convencionais melhorou significativamente a sua capacidade discriminativa para o risco de AVC (C de Harrel aumentou de 0,68 para 0,71 após inclusão da VOP; p <0,01). CONCLUSÃO: A distensibilidade arterial aferida pela VOP aórtica é um fator de risco independente de AVC em pacientes hipertensos, sendo recomendável a sua integração em programas de follow-up de situações em que o risco cardiovascular é manifesto.

BACKGROUND: Cardiovascular disease remains the leading cause of death in developed countries and is not entirely predicted by classic risk factors. Increased arterial stiffness is an important determinant of cardiovascular morbidity and mortality. OBJECTIVE: To assess whether Aortic Pulse Wave Velocity (PWV) predicts the occurrence of stroke in hypertensive patients METHODS: A cohort, observational and prospective study, including 1133 hypertensive patients (586 men), with a mean age 51.05 ± 12.64 years, was designed. PWV with the Complior method was performed in all patients, as well as a detailed clinical evaluation and blood pressure measurement. RESULTS: The cumulative incidence of stroke in hypertensive patients with increased PWV was 3.25% (CI: 1.97% -5.25%), compared with 0.78% (CI: 0.28% -1.87%) in hypertensive patients with normal PWV (Risk Ratio (RR) =4.15; CI:1.53-11.26). In a multivariate analysis, adjusting the model to classical cardiovascular risk factors, PWV was an independent predictor of stroke, with a Hazard Ratio (HR) = 1.40 (CI:1.13-1.73, p<0.001), indicating a 40% increase in the risk of stroke per 1m/s increment in PWV. The addition of PWV to a model consisting of conventional cardiovascular risk factors significantly improved the discriminative capacity for stroke (Harrell's C increased from 0.68 to 0.71 after the inclusion of the PWV; p<0.01). CONCLUSION: Aortic PWV is a risk factor for stroke in hypertensive patients, and its integration into clinical follow-up programs in patients whose cardiovascular risk is manifest is strongly recommended.

Is arterial stiffness in HIV-infected individuals associated with HIV-related factors?

We investigated the association between pulse wave velocity (PWV) and HIV infection, antiretroviral treatment-related characteristics, viral load, immune status, and metabolic changes in a cross-sectional study nested in a cohort of HIV/AIDS patients who have been followed for metabolic and cardiovascular changes since 2007. The study included patients recruited from the cohort (N = 261) and a comparison group (N = 82) of uninfected individuals, all enrolled from April to November 2009. Aortic stiffness was estimated using the carotid-femoral PWV (Complior-Artech, Paris, France). The groups were similar with respect to age, metabolic syndrome, diabetes mellitus, Framingham score, and use of antihypertensive and hypolipidemic medications. Hypertension was more frequent among the controls. Individuals with HIV had higher triglyceride, glucose and HDL cholesterol levels. Among individuals with HIV/AIDS, those with a nadir CD4+ T-cell count <200 cells/mm³ had a higher PWV (P = 0.01). There was no statistically significant difference when subjects were stratified by gender. Heart rate, age, male gender, and blood pressure were independently correlated with PWV. Nadir CD4+ T-cell count did not remain in the final model. There was no significance difference in PWV between HIV-infected individuals and uninfected controls. PWV was correlated with age, gender, and blood pressure across the entire population and among those infected with HIV. We recommend cohort studies to further explore the association between inflammation related to HIV infection and/or immune reconstitution and antiretroviral use and PWV.

Mecanismos fisiopatológicos da hipertensão no idoso / Physiopathological mechanisms of arterial hypertension in the elderly

A hipertensão arterial é a doença crônica mais prevalente em pacientes idosos e é responsável pelas principais complicações cardiovasculares neles. É importante o reconhecimento da fisiopatologia da doença, sobretudo dos mecanismos envolvidos na elevação da pressão arterial sistólica, predominante entre os idosos. Os principais mecanismos incluem aumento de rigidez arterial por fadiga das fibras de elastina e acúmulo de colágeno na parede de grandes artérias, e disfunção endotelial por diferentes mecanismos. Novos mecanismos moleculares têm sido descritos, como alterações de telômeros, micropartículas e células endoteliais progenitoras. Os idosos também apresentam maior sensibilidade ao sal, o que pode contribuir para um componente de hipervolemia na fisiopatologia da hipertensão arterial. O entendimento desses mecanismos pode auxiliar na melhor abordagem terapêutica dos pacientes idosos com hipertensão arterial

High blood pressure is the most prevalent chronic disease in elderly patients and is responsible for major cardiovascular complications in them. It is important to recognize the pathophysiology of disease, particularly of the mechanisms involved in elevation in systolic blood pressure, prevalent among the elderly. The main mechanisms include increased arterial stiffness by fatigue of elastin fibers and collagen accumulation in the wall of large arteries, and endothelial dysfunction by different mechanisms. New molecular mechanisms have been described, such as changes of telomeres, progenitor endothelial cells and microparticles. The elderly also have a higher salt sensitivity, which can contribute to a role for hypervolemia in the pathophysiology of hypertension. The understanding of these mechanisms can provide a better treatment of elderly patients with hypertension.

Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados / Assesment of arterial damage by noninvasive peripheral arterial tonometry in non-diabetic hemodialysis patients

Background: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. Aim: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. Material and Methods: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. Results: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7± 0.4 and2.7 ± 0.4 respectively p < 0.01). Conclusions: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.