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    Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT)
    (Circulation, 2011) ACT Investigators; Tura, Bernardo R; Santos Junior, Bráulio dos; Cramer, Helena
    Background: It remains uncertain whether acetylcysteine prevents contrast-induced acute kidney injury. Methods and results: We randomly assigned 2308 patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced acute kidney injury (age >70 years, renal failure, diabetes mellitus, heart failure, or hypotension) to acetylcysteine 1200 mg or placebo. The study drugs were administered orally twice daily for 2 doses before and 2 doses after the procedure. The allocation was concealed (central Web-based randomization). All analysis followed the intention-to-treat principle. The incidence of contrast-induced acute kidney injury (primary end point) was 12.7% in the acetylcysteine group and 12.7% in the control group (relative risk, 1.00; 95% confidence interval, 0.81 to 1.25; P=0.97). A combined end point of mortality or need for dialysis at 30 days was also similar in both groups (2.2% and 2.3%, respectively; hazard ratio, 0.97; 95% confidence interval, 0.56 to 1.69; P=0.92). Consistent effects were observed in all subgroups analyzed, including those with renal impairment. Conclusions: In this large randomized trial, we found that acetylcysteine does not reduce the risk of contrast-induced acute kidney injury or other clinically relevant outcomes in at-risk patients undergoing coronary and peripheral vascular angiography. Clinical trial registration: http://www.clinicaltrials.gov. Unique identifier: NCT00736866.
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    Outcomes of patients with left main coronary artery disease undergoing medical or surgical treatment: a propensity- matched analysis
    (Coronary Artery Disease, 2011) De Lorenzo, Andrea; Tura, Bernardo; Bassan, Fernando; Pittella, Felipe; Rocha, Antonio Sergio C
    Objective: To evaluate the outcomes of patients with significant (≥ 50%) left main coronary artery disease (LMCAD) undergoing medical treatment (MT) or coronary artery bypass grafting surgery (CABG). Methods: A total of 181 patients with significant LMCAD were followed for 4 ± 2 years. MT was done when patients refused CABG or because of either thin native vessels or high clinical risk. Events were defined as all-cause death, myocardial infarction, percutaneous coronary intervention, or subsequent CABG. Logistic regression analysis was used to identify independent predictors of death. A propensity score was created to compare outcomes of patients from the two treatment groups. Results: CABG was performed in 78.5% of the patients. Overall, there were no significant differences in the incidences of death or other events between treatment groups. In patients with normal left ventricular (LV) function (ejection fraction, ≥ 45%), there were no significant differences in event rates with MT or CABG (death, 7.7 vs. 12.1%; myocardial infarction, 0 vs. 1.9%; percutaneous coronary intervention, 3.8 vs. 5.6%). For patients with LV dysfunction, death was more frequent with MT than with CABG (53.8 vs. 22.9%, P<0.001), whereas the incidence of other events was not statistically different. Age and LV dysfunction, but not treatment type, were independent predictors of death. When comparing propensity-matched patients from both treatment groups, there was also no difference in survival. Conclusion: Patients with 50% or more LMCAD and LV dysfunction had increased survival with CABG. However, outcomes of patients with 50% or more LMCAD and normal LV function were not significantly different with either MT or CABG.
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    Increased Preoperative C-Reactive Protein Levels Are Associated with Inhospital Death After Coronary Artery Bypass Surgery
    (Inflammation, 2012) De Lorenzo, Andrea; Pittella, Felipe; Rocha, Antonio
    Increased C-reactive protein (CRP) is a predictor of cardiovascular risk, but its influence on outcomes after coronary artery bypass grafting surgery (CABG) is still incompletely studied. We studied the association between preoperative CRP and inhospital death after CABG. Patients with acute or chronic infectious or inflammatory disorders, autoimmune diseases, cancer, and prior cardiac surgery were excluded. Seventy-six patients were studied [27.6% with elevated CRP (>3 mg/l)]. Elevated CRP was more frequently found in patients who died than in those who survived (83.3% vs 17.1%, p=0.003); mean CRP levels were, respectively, 6.5±3.4 vs 2.4±3.5 mg/l (p=0.03). The hazard ratio of death was 11.7 for elevated CRP, and the ROC curve for the discrimination of death with CRP had an area under the curve of 0.82. An improvement to mortality risk prediction following CABG may be offered by the preoperative analysis of CRP.
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    Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery
    (Revista Brasileira de Cirurgia Cardiovascular, 2012) Rocha, Antônio Sergio C. da; Pittella, Felipe; De Lorenzo, Andrea; Barzan, Valmir; Colafranceschi, Alexandre Siciliano; Brito, José Oscar R.; Mattos, Marco Antonio de; Silva, Paulo Roberto Dutra da
    Objetivo: Analisar os resultados da cirurgia de revascularização miocárdica (CRVM) isolada com circulação extracorpórea em pacientes com idade ³ 70 anos em comparação àqueles com < 70 anos. Métodos: Pacientes submetidos consecutivamente à CRVM isolada. Os pacientes foram agrupados em G1 (idade³ 70 anos) e G2 (idade < 70 anos). Os desfechos analisados foram letalidade hospitalar, infarto agudo miocárdio (IAM), acidente vascular encefálico (AVE), reoperação para revisão de hemostasia (RRH), necessidade de balão intra-aórtico (BIA), complicações respiratórias, insuficiência renal aguda (IRA), mediastinite, sepse, fibrilação atrial (FA) e bloqueio atrioventricular total (BAVT). Resultados: Foram estudados 1033 pacientes, 257 (24,8%) do G1 e 776 (75,2%) do G2. A letalidade hospitalar foi significantemente maior no G1 quando comparado ao G2 (8,9% vs. 3,6%, P=0,001), enquanto a incidência de IAM foi semelhante (5,8% vs. 5,5%; P=0,87). Maior número de pacientes do G1 necessitou de RRH (12,1% vs. 6,1%; P=0,003). Da mesma forma, no G1 houve maior incidência de complicações respiratórias (21,4% vs. 9,1%; P<0,001), mediastinite (5,1% vs. 1,9%; P=0,013), AVE (3,9% vs. 1,3%; P=0,016), IRA (7,8% vs. 1,3%, P<0,001), sepse (3,9% vs. 1,9%; P=0,003), fibrilação atrial (15,6% vs. 9,8%; P=0,016) e BAVT (3,5% vs. 1,2%; P=0,023) do que o G2. Não houve diferença significante na necessidade de BIA. Na análise regressão logística multivariada “forward stepwise”, a idade ³ 70 anos foi fator preditivo independente para maior.
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    Caries experience in young children with congenital heart disease in a developing country
    (Epidemiology, 2013) Pimentel, Elizangela Lins Cavalcanti; Azevedo, Vitor Manuel Pereira; Azevedo, Vitor Manuel Pereira; Azevedo, Vitor Manuel Pereira
    Oral care is frequently suboptimal in children from developing countries, especially those suffering from severe systemic diseases. The aim of the present study was to analyze the oral epidemiological profile of 3-to-5-year-old children with congenital heart disease. Dental and medical records of children evaluated at the Dental Service of the National Institute of Cardiology, Rio de Janeiro, Brazil, were reviewed. Caries experience was reported using the dmft index. Negative behavior towards dental management was recorded. The sample consisted of 144 children aged 4.41 ± 0.95 years. The mean dmft value was 5.4 ± 4.9, and 80.5% had at least one caries lesion. Dmft index was greater in the presence of cyanotic cardiac disease and in children with negative behavior. An increase in the “missing” component of the dmft index was also found in children using medicine on a daily basis. A higher caries experience was associated with children whose fathers had only an elementary education. In conclusion, children with congenital heart disease had high levels of caries experience at a young age. Cyanosis, negative behavior, daily use of medicine, one-parent family and the educational level of fathers seem to influence caries experience in children with congenital cardiac disease.
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    Feasibility analysis of changing the decision-making in health management with scarce resources
    (Business and Management Review, 2014) Baumworcel, Leonardo; Scavarda, Annibal; Guimarães, Tereza Felippe; Colafranceschi, Alexandre Siciliano
    Heart failure is the final pathway of most diseases that involve the heart, as a challenge in health management. Heart transplantation is a viable strategy for patients in end-stage disease. The donor shortage requires a process to ensure the appropriate selection of the recipient. In Brazil there is a single list of candidates in chronological order of arrival, the existence of a risk score could dynamically allocate these patients. The purpose of this analysis is to assess the feasibility of changing the allocation process of candidates for heart transplantation according to the IMPACT score. This research is prospective observational retrospective analysis of transplanted cohort at the National Institute of Cardiology. The study included 42 patients and IMPACT score of six or more is associated with the highest mortality after transplantation. Allocation of patients according to their IMPACT score can facilitate decision making about which candidate must be transplanted.
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    Impairment of systemic microvascular endothelial and smooth muscle function in individuals with early-onset coronary artery disease: studies with laser speckle contrast imaging
    (Coronary Artery Disease, 2014) Souza, Elaine G.; De Lorenzo, Andrea; Huguenin, Grazielle; Oliveira, Glaucia M.M; Tibiriça, Eduardo
    Objectives: The assessment of systemic microvascular reactivity is currently considered to be critical in the stratification of cardiovascular risk. In the present study, we compared skin microvascular function in individuals with early-onset (premature) coronary artery disease (EOCAD, n= 30) with that of age-matched and sex-matched healthy individuals (n =30). Materials and methods Using laser speckle contrast imaging, cutaneous blood flow was assessed in the forearm at rest and during reactivity tests, including postocclusive reactive hyperemia and the iontophoresis of acetylcholine or sodium nitroprusside with increasing currents of 30, 60, 90, 120, 150, and 180 lA for 10-s intervals spaced 1 min apart. Carotid intima–media thickness was evaluated using an ultrasound system and a 7.5MHz ultrasound transducer. Results: The endothelium-dependent skin microvascular vasodilator responses that were induced by both acetylcholine and postocclusive reactive hyperemia were significantly reduced in patients with EOCAD compared with healthy individuals. The vasodilator responses that were induced by sodium nitroprusside were also significantly reduced in individuals with EOCAD. These systemic microvascular alterations were concurrent with increased carotid intima–media thickness in these patients. Conclusion: Laser speckle contrast imaging identifies endothelial-dependent and endothelial-independent microvascular dysfunction in individuals presenting with EOCAD, and thus could be valuable as an early peripheral marker of atherothrombotic disease.
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    Características antropométricas e metabólicas em obesos com transtorno alimentar
    (HUPE - Hospital Universitário Pedro Ernesto, 2015) Silva, Henyse G. V. da; Magalhães, Vera Cristina; Oliveira, Beatriz A.; Rosa, Juliana S.; Santos, Thaíza T; Moreira, Annie B
    O transtorno de compulsão alimentar periódica (TCAP) é um distúrbio psiquiátrico com alta morbidade, associado à obesidade e ao alto risco cardiovascular. O objetivo deste trabalho foi identificar alterações antropométricas e/ou metabólicas em obesos com TCAP e compará-las àqueles sem TCAP. Estudo transversal realizado no ambulatório do Napta/ UERJ, envolvendo 39 adultos obesos, sem doenças malignas ou consumptivas e medicamentos que interferissem nos re- sultados, sendo 22 com e 17 sem TCAP. As variáveis coletadas foram peso, estatura, perímetro da cintura, pressão arterial; e foram analisadas glicemia, perfil lipídico, dosagem de leptina, adiponectina e insulina, sendo calculado o Índice HOMA IR. Os dados foram expressos como média (desvio-padrão), sendo utilizados os testes: Qui-quadrado e t-Student. O valor de signi- ficância foi 5%. Amostra composta por 82% de mulheres, com elevada prevalência de hipertensão arterial, resistência insu- línica e sedentarismo, sem diferenças entre os grupos com ou sem TCAP. Todos apresentaram o perímetro da cintura acima da recomendação, mais de 60% apresentaram HDL-colesterol baixo e um terço, triglicerídeos elevados. Não houve diferença dos níveis de adiponectina nem de leptina entre obesos com ou sem TCAP, apesar de os valores estarem fora dos limites normais. Obesos, independentemente do diagnóstico de TCAP, têm elevado risco cardiovascular com alta prevalência de hipertensão arterial, dislipidemia, circunferência de cintura alterada e sedentarismo. Além disso, apresentam inflamação crônica de baixo grau com baixos níveis de adiponectina e altos de leptina. Entretanto, apesar de estas afirmativas terem sido confirmadas, não foram identificadas diferenças signifi- cativas entre obesos com o transtorno alimentar.
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    Avaliação do Prognóstico na Cardiomiopatia Chagásica através do Teste Cardiopulmonar de Exercício
    (International Journal of Cardiovascular Sciences, 2015) Souza, Fernando Cesar de Castro e; De Lorenzo, Andrea; Serra, Salvador Manoel; Colafranceschi, Alexandre Siciliano
    Fundamentos: A insuficiência cardíaca de etiologia chagásica (ICCh) parece ter maior mortalidade que a de outras com disfunção sistólica. O teste cardiopulmonar de exercício (TCPE) é uma ferramenta de avaliação prognóstica ainda pouco estudada na cardiopatia chagásica. Objetivo: Avaliar se o TCPE pode discriminar as diferenças prognósticas da ICCh em comparação às de etiologia não chagásica (ICNCh) e verificar quais das suas variáveis são preditoras independentes de mau prognóstico. Métodos: Análise retrospectiva de 21 pacientes com ICCh e 76 pacientes com ICNCh encaminhados ao TCPE, e seguidos quanto à sua mortalidade em dois anos. Resultados: No seguimento, houve óbito de 5 pacientes no grupo chagásico (GC) e 25 no grupo não chagásico (GNC). A curva de Kaplan-Meier não mostrou diferença na curva de sobrevida entre os grupos (p=0,43). A regressão logística encontrou a potência circulatória como uma variável preditora independente para óbito para ambos os grupos, com uma razão de risco para o GC de 17,3 (IC95% 1,39-217,0; p=0,027) e no GNC de 4,8 (IC95% 1,59-14,6; p=0,005). A curva ROC para esta variável encontrou uma área de 0,91 (IC95% 0,78-1,00; p=0,006) com um valor de corte ≤1280mmHg.mL.kg-1.min-1 no GC e uma área de 0,75 (IC95% 0,64-0,86; p<0,0001) com um valor de corte de ≤1245mmHg.mL.kg-1.min-1 no GNC. Conclusão: A potência circulatória foi a variável associada à morte em ambos os grupos, e deve ser mais amplamente utilizada como indicador de prognóstico na insuficiência cardíaca.
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    Reduced systemic microvascular density and reactivity in individuals with early onset coronary artery disease
    (Microvascular Research, 2015) Tibiriça, Eduardo; Souza, Elaine G; De Lorenzo, Andrea; Oliveira, Glaucia M.M.
    Objective: This study sought to test whether patients with early-onset coronary artery disease (EOCAD, n=30) showed systemic microvascular rarefaction and endothelial dysfunction in comparison to age- and sex-matched healthy controls (CTL, n = 30), as evaluated by skin video-capillaroscopy. Methods: Functional capillary density (FCD)was defined as the number of spontaneously perfused capillaries per square millimeter of skin area and assessed by high-resolution intra-vital color microscopy in the dorsum of the middle phalanx. Capillary recruitment (capillary reserve)was evaluated using post-occlusive reactive hyperemia (PORH) after arm ischemia for 3 min. Results: The mean capillary density at restwas significantly reduced in patientswith EOCADcompared to controls (CTL 95±20 and EOCAD 80±18 capillaries/mm2, P= 0.0040). During PORH, capillary density was also markedly reduced in EOCAD patients (CTL 96 ± 18 and EOCAD 71 ± 20 capillaries/mm2, P b 0.0001). Moreover, the capillary density in EOCAD patients was significantly reduced during PORH (EOCAD at rest 80± 19 and EOCAD during PORH 71 ± 20 capillaries/mm2, P = 0.0073). Conclusions: Patientswith EOCAD presented systemic capillary rarefaction and impaired microvascular endothelial function. Thus, the early detection of these microvascular alterations in young adults at an increased risk of coronary artery disease could be useful as a surrogate marker of subclinical atherosclerosis.
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    The association of selenium status with thyroid hormones and anthropometric values in dyslipidemic patients
    (Nutrición Hospitalaria, 2015) Carvalho, Roberta F; Rosa, Glorimar; Huguenin, Grazielle VB; Luiz, Ronir R; Moreira, Annie SB; Oliveira, Glaucia MM
    Background: Selenium (Se) is an essential micronu- trient that performs physiological functions in the meta- bolism of thyroid hormone and may have an association with anthropometric variables relevant to cardiovascu- lar disease. Aim: To study the associations between Se status, thyroid hormones and anthropometric variables in dyslipidemic patients.Methods: Eighty-three patients were assessed in a cross-sectional study. Blood samples were analyzed for Se and thyroid hormones. Anthropo- metric measurements were taken, and dietary Se intake was investigated. Results: Mean plasma Se concentrations were low in the patients, at 88.7 ± 16.7 μg/L. Patients with plasma Se ≥ 95 μg/L were found to have a higher body mass index (BMI) (30.74 ± 4.31 vs 27.68 ± 5.63 kg/m2 , P = 0.02) and waist-to-height ratio (0.65 ± 0.05 vs 0.59 ± 0.07, P = 0.003) when compared to those with concentrations between 80 and 94 μg/L. Se intake associated positively with T3 L/T4 L ratio (r = 0.273; P= 0.03), BMI (r= 0.257, P= 0.04) and WC (r= 0.299, P= 0.02). Conclusion: The patients with the highest normal plasma Se concentrations were found to have increases in the anthropometric variables we in- vestigated. There is a need for further study in order to elucidate these findings. Furthermore, we found a positi- ve association between Se intake and the most metaboli- cally active form of the thyroid hormones.
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    Effect of physical exercise training in patients with Chagas heart disease: study protocol for a randomized controlled trial (PEACH study)
    (Trails, 2016) Mendes, Fernanda de Souza Nogueira Sardinha; Sousa, Andréa Silvestre; Souza, Fernando Cesar de Castro Cesar; Pinto, Vivian Liane Mattos; Silva, Paula Simplicio; Saraiva, Roberto Magalhães; Xavier, Sergio Salles; Veloso, Henrique Horta; Holanda, Marcelo Teixeira; Costa, Andréa Rodrigues; Carneiro, Fernanda Martins; Silva, Gilberto Marcelo Sperandio; Borges, Juliana Pereira; Tibiriçá, Eduardo; Pinheiro, Roberta Olmo; Lara, Flávio Alves; Hasslocher-Moreno, Alejandro Marcel; Brasil, Pedro Emmanuel Alvarenga Americano; Mediano, Mauro Felippe Felix
    Background: The effects of exercise training on Chagas heart disease are still unclear. This study aimed to evaluate the effect of exercise training over functional capacity, cardiac function, quality of life, and biomarkers in Chagas heart disease. Methods: The PEACH study is a superiority randomized clinical trial which will include subjects who meet the following criteria: Chagas heart disease with a left ventricular ejection fraction below 45 % with or without heart failure symptoms; clinical stability in the last 3 months; adherence to clinical treatment; and age above 18 years. The exclusion criteria are: pregnancy; neuromuscular limitations; smoking; evidence of non-chagasic heart disease; systemic conditions that limit exercise practice or cardiopulmonary exercise test; unavailability to attend the center three times a week during the intervention period; and practitioners of regular exercise. The intervention group will perform an exercise training intervention three times per week during 6 months and will be compared to the control group without exercise. Both groups will undergo the same monthly pharmaceutical and nutritional counseling as well as standard medical treatment according to the Brazilian consensus on Chagas disease. The primary outcome is functional capacity based on peak exercise oxygen consumption during cardiopulmonary exercise testing. Secondary outcomes are: cardiac function; body composition; muscle respiratory strength; microvascular reactivity; cardiac rhythm abnormalities; autonomic function; biochemical; oxidative stress and inflammatory biomarkers; and quality of life. Subjects will be evaluated at baseline, and at 3 and 6 months after randomization. Thirty patients will be randomly assigned into exercise or control groups at a ratio of 1:1. Discussion: Findings of the present study will be useful to determine if physical exercise programs should be included as an important additional therapy in the treatment of patients with Chagas heart disease. Trial registration: ClinicalTrials.gov ID: NCT02517632 (registered on 6 August 2015).
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    Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country
    (Journal of Nuclear Cardiology, 2016) Santos, Mauro Augusto dos; Santos, Marisa Silva; Tura, Bernardo Rangel; Felix, Renata; Brito, Adriana Soares X; De Lorenzo, Andrea
    Myocardial perfusion imaging is widely used for the risk stratification of coronary artery disease. In view of its cost, besides radiation issues, judicious evaluation of the appropriateness of its indications is essential to prevent an unnecessary economic burden on the health system. We evaluated, at a tertiary-care, public Brazilian hospital, the appropriateness of myocardial perfusion scintigraphy indications, and estimated the budget impact of applying appropriateness criteria. An observational, cross-sectional study of 190 patients with suspected or known coronary artery disease referred for myocardial perfusion imaging was conducted. The appropriateness of myocardial perfusion imaging indications was evaluated with the Appropriate Use Criteria for Cardiac Radionuclide Imaging published in 2009. Budget impact analysis was performed with a deterministic model. The prevalence of appropriate requests was 78%; of inappropriate indications, 12%; and of uncertain indications, 10%. Budget impact analysis showed that the use of appropriateness criteria, applied to the population referred to myocardial perfusion scintigraphy within 1 year, could generate savings of $ 64,252.04 dollars. The 12% inappropriate requests for myocardial perfusion scintigraphy at a tertiary-care hospital suggest that a reappraisal of MPI indications is needed. Budget impact analysis estimated resource savings of 18.6% with the establishment of appropriateness criteria for MPI.
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    Acute cellular rejection and HLA mismatch in heart transplantation: insights from a developing country
    (Clinical Transplantation, 2016) Schtruk, Lígia Beatriz Chaves Espinoso; Guimarães, Tereza Cristina Fellipe; Pôrto, Luis Cristóvão; Kuschnir, Maria Cristina Caetano; Colafranceschi, Alexandre Siciliano; Silva Filho, Paulo Moreira da; Lorenzo, Andrea De
    The notable evolution of heart transplant (HTX) has paralleled the capacity of diagnosing rejection and, consequently, initiating timely treatment. Acute cellular rejection, diagnosed by endomyocardial biopsy, is the most frequent in the first 6 months after HTX. HLA matching is not routinely performed in HTX due to the absence of consensus regarding its usefulness. However, the use of HLA typing might be underscored if it could predict an increased risk of rejection. Therefore, the aim of this study was to evaluate, at a public cardiology center in Brazil, the association between HLA mismatches and the incidence of acute cellular rejection in the first 6 months after HTX. Data were obtained from hospital records and from the National Transplant System. Overall, there was no association between the number of HLA mismatches and the frequency of acute cellular rejection, but there was a tendency toward a higher incidence of rejection with HLA-DR incompatibility.
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    Microvascular Function and Endothelial Progenitor Cells in Patients with Severe Hypercholesterolemia and the Familial Hypercholesterolemia Phenotype
    (Cardiology, 2017) De Lorenzo, Andrea; Moreira, Annie S B; Muccillo, Fabiana B; Assad, Marcelo; Tibiriçá, Eduardo V
    Objective: To evaluate endothelial progenitor cells (EPCs) and systemic microvascular function in patients with severe hypercholesterolemia, comparing patients with the definite familial hypercholesterolemia (FH) phenotype (DFH) or probable/possible FH phenotype (PFH). There is a large spectrum of atherosclerotic disease between these two clinical phenotypes of FH, and to acquire further knowledge of the pathophysiology of vascular disease in both is desirable. Methods: Subjects with severe hypercholesterolemia, defined as low-density lipoprotein cholesterol (LDL-C) >190 mg/dL, were classified as DFH or PFH and underwent measurement of the number of EPCs by flow cytometry and evaluation of cutaneous microvascular reactivity using a laser speckle contrast-imaging system with iontophoresis of acethylcholine (ACh) or sodium nitroprusside. EPCs were defined as CD45- or CD45low, CD34+CD133+CD309+ cells. Categorical variables were compared using Fisher test and continuous variables with Student t test or Mann-Whitney test, and a value of p < 0.05 was considered statistically significant. Results: Patients with DFH had higher LDL-C than those with PFH. There was no difference in the median number of EPCs between patients with DFH or PFH, but there was a significant reduction of endothelial-dependent, ACh-induced vasodilatation in the former. Conclusion: Patients with DFH have impaired microvascular endothelial-dependent vasodilatation compared to those with PFH, indicating more severe vascular disease in the former.
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    Características Clínicas, Antropométricas e Bioquímicas de Pacientes com ou sem Diagnóstico Confirmado de Hipercolesterolemia Familiar
    (Arquivos Brasileiros de Cardiologia, 2018) De Lorenzo, Andrea; Silva, Juliana Duarte Lopes da; James, Cinthia E.; Pereira, Alexandre C.; Moreira, Annie Seixas Bello
    Fundamentos: A hipercolesterolemia familiar (HF) é uma doença autossômica dominante, caracterizada por altos níveis plasmáticos do colesterol da lipoproteína de baixa densidade (LDL-C) e pelo alto risco de desenvolvimento prematuro de doenças cardiovasculares. Objetivo: Avaliar características clínicas e antropométricas de pacientes com fenótipo para hipercolesterolemia familiar (HF), com ou sem diagnóstico genético de HF. Métodos: Quarenta e cinco pacientes com LDL-C > 190 mg/dL foram genotipados para seis genes relacionados com a HF: LDLR, APOB, PCSK9, LDLRAP1, LIPA e APOE. Pacientes que apresentaram resultado positivo para qualquer uma das mutações foram diagnosticados com HF por confirmação genética. O fenótipo para HF foi classificado pelo critério da Dutch Lipid Clinic Network. Resultados: Comparando os pacientes com a HF geneticamente confirmada com aqueles sem a confirmação, os primeiros apresentaram maior pontuação do escore para HF, uma maior frequência de xantelasma e maiores níveis de LDL-C e apo B. Houve correlações significativas entre o LDL-C e a pontuação do escore para HF (R = 0,382, p = 0,037) e entre LDL-C e gordura corporal (R = 0,461, p = 0,01). Os pacientes com mutações, no entanto, não apresentaram qualquer correlação entre o LDL-C e outras variáveis, enquanto aqueles sem mutação apresentaram correlação entre o LDL-C e a pontuação do escore. Conclusão: O LDL-C correlacionou-se com a pontuação do escore e com a gordura corporal, tanto na população total de pacientes quanto nos pacientes sem a confirmação genética de HF. Naqueles com HF geneticamente confirmada, não houve correlação entre o LDL-C e outras variáveis clínicas ou bioquímicas dos pacientes.
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    High-intensity interval training or continuous training, combined or not with fasting, in obese or overweight women with cardiometabolic risk factors: study protocol for a randomised clinical trial
    (BMJ Open, 2018) De Lorenzo, Andrea; Moraes, Roger de; Van Bavel, Diogo; Tibirica, Eduardo
    Introduction Physical inactivity and increased caloric intake play important roles in the pathophysiology of obesity. Increasing physical activity and modifying eating behaviours are first-line interventions, frequently hampered by lack of time to exercise and difficulties in coping with different diets. High-intensity interval training (HIIT) may be a time-efficient method compared with moderate-intensity continuous training (CT). Conversely, diets with a fasting component may be more effective than other complex and restrictive diets, as it essentially limits caloric intake to a specified period without major diet composition changes. Therefore, the combination of HIIT and fasting may provide incremental benefits in terms of effectiveness and time efficiency in obese and sedentary populations. The aim of this study is to determine the effect of HIIT versus CT, combined or not with fasting, on microcirculatory function, cardiometabolic parameters, anthropometric indices, cardiorespiratory fitness and quality of life in a population of sedentary overweight or obese women with cardiometabolic risk factors. Methods and analysis Sedentary women aged 30–50 years, with a body mass index ≥25 kg/m2 and cardiometabolic risk factors, will be randomised to HIIT performed in the fasting state, HIIT performed in the fed state, CT in the fasting state or CT in the fed state. Cardiometabolic parameters, anthropometric indices, cardiorespiratory fitness, quality of life and microvascular function (cutaneous capillary density and microvascular reactivity evaluated by laser speckle contrast imaging) will be evaluated before initiation of the interventions and 16 weeks thereafter. Ethics and dissemination The trial complies with the Declaration of Helsinki and has been approved by the local ethics committee (Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil). All patients provide written informed consent before enrolment and randomisation. The study’s results will be disseminated to the healthcare community by publications and presentations at scientific meetings.
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    Design of the GutHeart—targeting gut microbiota to treat heart failure trial: a Phase II, randomized clinical trial
    (ESC Heart Failure, 2018) Mayerhofer, Cristiane C.K.; Awoyemi, Ayodeji O; Moscavitch, Samuel D.; Lappegård, Knut Tore; Hov, Johannes R.; Aukrust, Pål; Hovland, Anders; Lorenzo, Andrea; Halvorsen, Sigrun; Seljeflot, Ingebjørg; Gullestad, Lars; Trøseid, Marius; Broch, Kaspar
    Aims Heart failure (HF) is a multifactorial disease. Current treatments target only a fraction of the putative pathophysiological pathways. In patients with HF, reduced cardiac output and congestion cause increased gut wall permeability. It has been suggested that leakage of microbial products is detrimental to the heart, at least partly through activation of systemic inflammatory pathways, which again could promote gut leakage. Whether manipulating the gut microbiota can improve cardiac function in patients with HF remains unknown. We aim to evaluate the effect of drugs targeting the gut microbiota on left ventricular function, quality of life, and functional capacity, as well as on markers of gut leakage and inflammation, in stable patients with HF with reduced ejection fraction. Methods and results GutHeart is a randomized, open-label, controlled trial. Four centres will randomize 150 patients with stable HF and a left ventricular ejection fraction <40% to receive the antibiotic rifaximin, the probiotic yeast Saccharomyces boulardii (ATCC 74012), or no treatment (control) in a 1:1:1 fashion. Treatment will last for 3 months. The primary endpoint is baseline-adjusted left ventricular ejection fraction as measured by echocardiography after 3 months. A further follow-up 6 months after randomization will be undertaken. Conclusions This trial is likely to give new insights into important disease processes involving the gut microbiota in HF patients, hereby leading to new potential therapeutic strategies to prevent and down-regulate the inflammation seen in these patients.
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    Budget Impact of Cryoablation Versus Radiofrequency Ablation of Atrial Fibrillation in the Brazilian Public Healthcare System
    (Value in Health Regional Issues, 2019) Paço, Patricia; Tura, Bernardo; Santos, Marisa; Amparo, Pedro; De Lorenzo, Andrea
    Background: Cryoablation is a new technology for ablation of atrial fibrillation (AF), effective and safe when compared with standard radiofrequency (RF) ablation. Nevertheless, the economic impact of its incorporation is unknown, especially considering the public health system of a developing country. This study analyzed the budget impact of cryoablation incorporation for treatment of paroxysmal AF in the Brazilian public health system. Methods: The budget impact was calculated as the cost difference between the current scenario (RF ablation guided by electroanatomic mapping) and the new scenario (cryoablation). The cost of each intervention was obtained by multiplying the price of a single procedure by the number of candidates for it. Other technologies (RF ablation guided by intracardiac echocardiography or with a nonirrigated catheter) were considered in a sensitivity analysis. Results: The budget impact showed savings of $43 097 096.84 with cryoablation. In the sensitivity analysis, cryoablation resulted in cost savings compared with RF ablation guided by intracardiac echocardiography, whereas in comparison to RF ablation with the nonirrigated catheter, cryoablation was more expensive. A market share assessment, performed using an incorporation rate of 3% per year, indicated savings of approximately $800 000 per 5 years. Conclusions: Cryoablation of AF resulted in cost savings compared with the current scenario (RF ablation guided by electroanatomic mapping). When alternative technologies were considered, cryoablation was more expensive than RF ablation with a nonirrigated catheter, but it also resulted in savings compared with RF ablation guided by intracardiac echocardiography. Overall, cryoablation of AF may reduce expenditures in the Brazilian public health system.
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    Oral Contraceptives and Cardiovascular Risk: Adding Clinical Evidence to the Pathophysiology
    (International Journal of Cardiovascular Sciences, 2020) Kasal, Daniel Barata; Lorenzo, Andrea De
    Women cardiovascular health is an important and often neglected issue. Cardiovascular diseases (CVDs) are the main cause of death in women, in Brazil and worldwide.1 Oral contraceptives are the main method used for contraception in Brazil.2 The issue of oral contraceptives and cardiovascular risk has been raised since the first descriptions of this class of pharmaceuticals, in the 1960s. The development of low-dose combined oral contraceptives (COCs) containing ethinyl estradiol and different progestins has reduced, albeit not eliminated, cardiovascular morbidity in women taking these medications.3 The main side effects associated with COCs are procoagulant effects. Therefore, the use of COCs is associated with increased risk of developing acute myocardial infarction, venous thromboembolism and stroke.4 In addition, adverse changes in the lipid profile and glucose tolerance have been described.5 Clearly, ageing and exposure to other risk factors, mainly smoking and obesity, play an important role in the development of adverse outcomes related to COCs. In addition, formulations with different progestins may produce distinct effects on circulation.