Mecânica Atrial na Cardiomiopatia Hipertrófica: Discriminando Hipertrofia de Fibrose Ventricular / Atrial Mechanics in Hypertrophic Cardiomyopathy: Discriminating between Ventricular Hypertrophy and Fibrosis

Resumo Fundamento A cardiomiopatia hipertrófica (CMH) e a hipertrofia ventricular esquerda (HVE) secundária à hipertensão arterial sistêmica (HAS) podem estar associadas a anormalidades funcionais do átrio esquerdo (AE). Objetivos Caracterizar a mecânica do AE na CMH e na HAS e avaliar qualquer correlação com a extensão da fibrose ventricular esquerda medida por ressonância magnética cardíaca (RMC) em pacientes com CMH. Métodos A função longitudinal do AE derivada do ecocardiograma bidimensional com speckle tracking foi adquirida a partir de cortes apicais de 60 pacientes com CMH e 34 indivíduos controles, pareados por idade. Pacientes com CMH também foram submetidos à RMC, com medida da extensão do realce tardio por gadolínio. A associação com parâmetros de strain do AE foi analisada. Valores p < 0,05 foram definidos como estatisticamente significativos. Resultados A média da fração de ejeção do ventrículo esquerdo não foi diferente entre os grupos. A razão E/e' estava comprometida no grupo CMH e preservada no grupo controle. A mecânica do AE estava significativamente reduzida na CMH em comparação aos pacientes com HAS. O strain rate do AE nas fases de reservatório (SRrAE) e na fase contrátil (SRctAE) foram os melhores parâmetros de discriminação de CMH com uma área sob a curva (AUC) de 0,8, seguido do strain do AE na fase de reservatório (SrAE) (AUC 0,76). O SRrAE e o SRctAE apresentaram elevada especificidade (89% e 91%, respectivamente), e o SrAE apresentou sensibilidade de 80%. Um decréscimo de 2,79% no strain rate do AE na fase de condução (SRcdAE) foi preditor de um aumento de 1 cm na extensão do RT pelo gadolínio (r2=0,42, β 2,79, p=0,027). Conclusões O SRrAE e o SRctAE foram os melhores fatores de discriminação de HVE secundária à CMH. O SRcdAE foi preditor do grau de fibrose ventricular esquerda avaliada por RMC. Esses achados sugerem que a mecânica do AE pode ser um potencial preditor de gravidade de doença na CMH.

Abstract Background Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. Objectives We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. Methods Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. Results Mean LV ejection fraction was not different between the groups. The E/e' ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, β 2.79, p=0.027). Conclusions LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

Prevalence of echocardiographic left ventricular hypertrophy among hypertensives in a tertiary health institution in Nigeria

OBJECTIVE: Systemic hypertension remains an important risk factors for cardiovascular diseases and a major global public health problem. Left ventricular hypertrophy (LVH) is a recognized complication of hypertension and strongly predicts cardiovascular morbidity and mortality. In Nigeria, few studies evaluated the role of echocardiography in the diagnosis of LVHs among hypertensives. This study sets out to determine the prevalence of LVH among hypertensives as determined by echocardiography.MATERIAL AND METHODS: One hundred and seventy-eight hypertensives and eighty-nine age and sex-matched controls were recruited consecutively into the study. They all had echocardiography done to determine which among had LVH. The partition value for LVH for hypertensives was determined using the 97th percentile of the left ventricular mass for controls as a cutoff point. RESULTS:Echocardiographic determined the prevalence of LVH among hypertensives was 32.4%.CONCLUSION:The echocardiographic prevalence of LVH was 32.4% in the study population. This is a significant proportion among the study population considering the clinical impact of LVH among patients with hypertension.

Cardiomiopatia Hipertrófica: uma revisão pelo olhar da ressonância magnética / Hypertrophic Cardiomyopathy: a review using magnetic resonance imaging

A cardiomiopatia hipertrófica é a cardiopatia genética mais frequente na população geral e é caracterizada por uma hipertrofia ventricular esquerda assimétrica. Entretanto, as alterações fenotípicas desta cardiomiopatia vão muito além da hipertrofia ventricular, e incluem alterações do aparato valvar mitral, dos músculos papilares e do ventrículo direito. Devido à dificuldade no diagnóstico diferencial entre as múltiplas causas de hipertrofia, a ressonância magnética cardíaca vem cumprindo um papel fundamental na avaliação diagnóstica e prognóstica desta cardiomiopatia. A cineressonância magnética na definição da localização e extensão da hipertrofia, o realce tardio, na detecção das áreas de fibrose miocárdica e técnicas mais recentes como o Mapa de T1 que avalia a fibrose intersticial e o volume extracelular; e finalmente o Tissue Tracking na análise da deformação miocárdica.(AU)

Hypertrophic cardiomyopathy, the most common genetic cardiopathy in the general population, is characterized by asymmetric left ventricular hypertrophy. However, the phenotypic changes in this cardiomyopathy extend beyond ventricular hypertrophy and include changes in the mitral valve apparatus, papillary muscles, and right ventricle. Due to the difficult differential diagnosis among multiple causes of hypertrophy, cardiac magnetic resonance has played a fundamental role in its diagnostic and prognostic evaluation; magnetic cine-resonance in defining the location and extent of hypertrophy; late enhancement, in the detection of areas of myocardial fibrosis; more recent techniques such as T1 mapping that assesses interstitial fibrosis and extracellular volume; and finally tissue tracking in the analysis of myocardial deformation. (AU)

Network Meta-analysis of oral blood-activating and stasis-removing Chinese patent medicines in treatment of hypertensive left ventricular hypertrophy / 中国中药杂志

This study was designed to assess the clinical efficacy of oral blood-activating and stasis-removing Chinese patent medicines in treating hypertensive left ventricular hypertrophy(LVH) based on network Meta-analysis. The clinical randomized controlled trials(RCTs) concerning the treatment of hypertensive LVH with oral blood-activating and stasis-removing Chinese patent medicines were retrieved from CNKI, Wanfang, VIP, SinoMed, PubMed, Web of Science, and Cochrane Library from their inception to September 2021. Two researchers independently completed the literature screening, data extraction, and quality evaluation. The data were then analyzed by RevMan 5.3, Stata 15.1, and ADDIS 1.16.8. Finally, a total of 31 RCTs were included, involving 3 001 patients and four oral blood-activating and stasis-removing Chinese patent medicines. In terms of the alleviation of heart damage, the Chinese patent medicines combined with conventional western medicine groups were superior to the conventional western medicine groups in lo-wering the left ventricular mass index(LVMI). There was no significant difference in LVMI, left ventricular ejection fraction(LVEF), or the ratio of early diastolic peak flow velocity to late diastolic peak flow velocity(E/A) between different Chinese patent medicines combined with conventional western medicine groups. Xinnao Shutong Capsules/Tablets combined with conventional western medicine had the best efficacy in reducing LVMI and elevating LVEF, while Xinkeshu Capsules/Tablets combined with conventional western medicine had the best effect in improving E/A. In the control of blood pressure, when all Chinese patent medicines except for Xinnao Shutong Capsules/Tablets were combined with conventional western medicine, the resulting systolic blood pressure(SBP) and diastolic blood pressure(DBP) were significantly lower than those in the conventional western medicine group. Xinkeshu Capsules/Tablets combined with conventional western medicine produced the best effect in reducing SBP and DBP, followed by Xinnao Shutong Capsules/Tablets. In terms of safety, no serious adverse reactions occurred in all trials. The four oral blood-activating and stasis-removing Chinese patent medicines included in this study exhibited obvious advantages in the treatment of hypertensive LVH when they were combined with conventional western medicine, with the best effects observed in the Xinnao Shutong Capsules/Tablets combined with conventional western medicine group. However, due to the limitation of the quantity and quality of the included articles, the conclusion of this study still needs to be verified by more high-quality, multi-center, and large-sample RCTs.

Effect and mechanism of leonurine on pressure overload-induced cardiac hypertrophy in rats / 中国中药杂志

To investigate the effects of leonurine(Leo) on abdominal aortic constriction(AAC)-induced cardiac hypertrophy in rats and its mechanism. A rat model of pressure overload-induced cardiac hypertrophy was established by AAC method. After 27-d intervention with high-dose(30 mg·kg~(-1)) and low-dose(15 mg·kg~(-1)) Leo or positive control drug losartan(5 mg·kg~(-1)), the cardiac function was evaluated by hemodynamic method, followed by the recording of left ventricular systolic pressure(LVSP), left ventricular end-diastolic pressure(LVESP), as well as the maximum rate of increase and decrease in left ventricular pressure(±dp/dt_(max)). The degree of left ventricular hypertrophy was assessed based on heart weight index(HWI) and left ventricular mass index(LVWI). Myocardial tissue changes and the myocardial cell diameter(MD) were measured after hematoxylin-eosin(HE) staining. The contents of angiotensin Ⅱ(AngⅡ) and angiotensin Ⅱ type 1 receptor(AT1 R) in myocardial tissue were detected by ELISA. The level of Ca~(2+) in myocardial tissue was determined by colorimetry. The protein expression levels of phospholipase C(PLC), inositol triphosphate(IP3), AngⅡ, and AT1 R were assayed by Western blot. Real-time quantitative PCR(qRT-PCR) was employed to determine the mRNA expression levels of β-myosin heavy chain(β-MHC), atrial natriuretic factor(ANF), AngⅡ, and AT1 R. Compared with the model group, Leo decreased the LVSP, LVEDP, HWI, LVWI and MD values, but increased ±dp/dt_(max) of the left ventricle. Meanwhile, it improved the pathological morphology of myocardial tissue, reduced cardiac hypertrophy, edema, and inflammatory cell infiltration, decreased the protein expression levels of PLC, IP3, AngⅡ, AT1 R, as well as the mRNA expression levels of β-MHC, ANF, AngⅡ, AT1 R, c-fos, and c-Myc in myocardial tissue. Leo inhibited AAC-induced cardiac hypertrophy possibly by influencing the RAS system.

Importância dos métodos de imagem no diagnóstico diferencial de cardiopatia hipertensiva e cardiomiopatia hipertrófica: relato de caso / The importance of imaging methods in the differential diagnosis of hypertensive cardiopathy and hypertrophic cardiomyopathy: a case report

Caso clínico de homem de 31 anos, branco, casado, cozinheiro, natural do Nepal, procedente de São Paulo há 4 anos, em acompanhamento ambulatorial após encaminhamento do pronto-socorro (PS) por angina atípica e pressão alta sic. Pela análise do prontuário verificou-se que o paciente permaneceu no PS por 48 horas e ao exame físico a ausculta cardíaca era normal e a pressão arterial (PA) 140X85 mm Hg. O eletrocardiograma (ECG) mostrava critérios eletrocardiográficos para hipertrofia ventricular esquerda (HVE) e alterações da repolarização ventricular e os marcadores de necrose miocárdica apresentavam aumentos discretos. Na consulta ambulatorial o paciente não referia queixas, a PA estava normal e foram realizados: monitorização ambulatorial da pressão arterial (MAPA) de 24 horas, ecocardiograma (ECO) e angiotomografia de coronárias. A MAPA mostrou níveis pressóricos normais (vigília e sono respectivamente 112x65 e 106x51 mmHg), o ECO não detectou HVE e a angiotomografia de coronárias não identificou obstruções coronarianas e o escore de cálcio era zero. A ressonância magnética de coração (RMC) mostrou aumento da espessura miocárdica de ventrículo direito (VD), hipertrofia miocárdica assimétrica de predomínio septal acometendo paredes anterior e lateral do ventrículo esquerdo (VE) com maior espessura no segmento inferoseptal medial (25 mm). Detectou-se presença de realce tardio mesocárdico nas inserções superior e inferior do VD na região do septo interventricular, além de realce tardio heterogêneo em segmentos antero-septal e ínfero-septal mediobasal. A massa de fibrose miocárdica foi estimada em 6,4g (2,2% da massa total do VE). Todos esses achados são típicos de cardiomiopatia hipertrófica (CMH) com predomínio septal e envolvimento do VD. Este caso chamou a atenção por se tratar de paciente com apresentação clínica de angina, hipertensão e critérios de HVE pelo ECG não confirmada pelo ECO em que a RMC fez o diagnóstico de CMH. Portanto, a avaliação multimodal com diversas técnicas diagnósticas muitas vezes se faz necessária para a confirmação diagnóstica da CMH.

Clinical case of 31-year-old male patient, white, married, born in Nepal living in São Paulo for 4 years, refered to the emergency room (ER) for atypical angina and high blood pressure sic. He remained under observation for 48 hours, and during this period the physical examination showed normal cardiac auscultation and blood pressure (BP) 140X85 mm Hg. The electrocardiogram (ECG) had criteria for left ventricular hypertrophy (LVH) and ventricular repolarization abnormality. He also had a slight increase of myocardial necrosis markers. As his symptoms improved, he was sent to the cardiac ambulatory. When the patient returned to the ambulatory he had no cardiac complaints, his BP was normal. It was then requested 24-hour ambulatory blood pressure monitoring (ABPM), echocardiography (ECHO), and coronary angiotomography. The ABPM presented normal blood pressure levels (awake and asleep respectively 112x65 and 106x51 mmHg), the ECHO did not show LVH, coronary angiotomography did not detect coronary obstructions and the calcium score was zero. A cardiac magnetic resonance (CMR) of the heart was performed which showed increased myocardial thickness of the right ventricle (RV), asymmetric myocardial hypertrophy of septal interventricular that also affecting anterior and lateral walls of the left ventricle (LV) with greater thickness in the medial inferoseptal segment (25 mm). It also presented signal of late mesocardial enhancement in the superior and inferior RV insertions of the interventricular septum and heterogeneous late enhancement in anteroseptal and inferoseptal mediobasal segments. The myocardial fibrosis mass was estimated in 6.4g (2.2% of the total LV mass). All these findings are typical of septal hypertrophic cardiomyopathy (HCM) with involvement of the RV. This case drew attention because it was a patient with a clinical presentation of angina, hypertension, and criteria for LVH by the ECG not confirmed by ECHO, but the CMR characterized as HCM. Therefore, multimodal evaluation diagnostic techniques in patient with electrocardiographic criteria of LVH without correlation with ECHO imagens were essential to the diagnosis of HCM.

Análise de Custo-Efetividade da Terapia com Evolocumabe em Pacientes com Alto Risco de Eventos Cardiovasculares no Contexto do SUS - Brasil / Cost-Effectiveness Analysis of Evolocumab Therapy in Patients at High Risk of Cardiovascular Events in the Context of the Brazilian Unified Health System

Resumo Fundamento: Em associação às estatinas, os inibidores da pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9) demonstraram ser eficazes na redução de eventos cardiovasculares em pacientes de alto risco. Objetivo: Analisar a custo-efetividade da implementação de evolocumabe para pacientes com alto risco de eventos cardiovasculares no contexto do Sistema Único de Saúde (SUS) no Brasil. Métodos: Um modelo de Markov foi utilizado, baseando-se em uma amostra ambulatorial de pacientes com doença arterial coronariana. Os desfechos primários analisados foram infarto agudo do miocárdio, acidente vascular cerebral isquêmico (AVCi), revascularização do miocárdio e morte cardiovascular. O resultado foi expresso por meio da razão de custo-efetividade incremental (RCEI), considerando-se uma taxa de desconto de 5% ao ano, e uma análise de sensibilidade foi realizada, tendo em vista a imprecisão de valores. Resultados: Selecionaram-se 61 pacientes com risco cardiovascular estimado em 35% em 10 anos, se em uso de atorvastatina 80mg/dia, e em 22,75%, se adicionado o evolocumabe. O custo global por paciente no período de 10 anos foi de R$ 46.522,44 no grupo em monoterapia com atorvastatina versus R$ 236.141,85 na terapia combinada, com uma efetividade global de 0,54 e 0,73, respectivamente. Isso resultou em uma RCEI R$ 1.011.188,07 (R$ 864.498,95 a R$ 1.296.748,43) por desfecho cardiovascular evitado. Conclusões: Apesar de não existirem padrões nacionais para custo-efetividade, os dados encontrados sugerem que a estratégia de associação do evolocumabe à terapia com estatina não é, no momento, custo-efetiva.

Abstract Background: Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. Objectives: We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. Methods: Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. Results: Mean LV ejection fraction was not different between the groups. The E/e' ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, β 2.79, p=0.027). Conclusions: LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

Desempenho do eletrocardiograma no diagnóstico da hipertrofia ventricular esquerda em hipertensos idosos e muito idosos / Performance of the electrocardiogram in the diagnosis of left ventricular hypertrophy in older and very older hypertensive patients

Resumo Fundamento: A hipertrofia ventricular esquerda (HVE) é um importante fator de risco cardiovascular, independente da hipertensão arterial. Apesar da evolução dos exames de imagem, o eletrocardiograma (ECG) ainda é o mais utilizado na avaliação inicial, porém, com baixa sensibilidade. Objetivo: Avaliar o desempenho dos principais critérios eletrocardiográficos para HVE em indivíduos hipertensos idosos e muito idosos. Métodos: Em coorte de hipertensos foram realizados ECGs e EcoDopplercardiogramas (ECO), e separados em três grupos etários: <60 anos, Grupo I; 60-79 anos Grupo II; e ≥80 anos, Grupo III. Os critérios eletrocardiográficos mais utilizados foram aplicados para o diagnóstico da HVE: Perúgia; Peguero-Lo Presti; Gubner-Ungerleider; Narita; (Rm+Sm) x duração; Cornell voltagem; Cornell voltagem duração; Sokolow-Lyon voltagem; R de aVL ≥11 mm; RaVL duração. Na avaliação do desempenho desses critérios, além da sensibilidade (Sen) e especificidade (Esp), foram analisadas as "Odds Ratios diagnóstico" (DOR). Consideramos p-valor <0,05 para as análises, com testes bi-caudais. Resultados: Em 2.458 pacientes, a HVE estava presente pelo ECO em 781 (31,7%). Nos Grupos I e II, os melhores desempenhos foram para os critérios de Narita, Perúgia, (Rm+Sm) x duração, sem diferenças estatísticas entre eles. No Grupo III (muito idosos) os critérios de Perúgia e (Rm+Sm) x duração tiveram os melhores desempenhos: Perúgia [44,7/89,3; (Sen/Esp)] e (Rm+Sm) duração [39,4%/91,3%; (Sen/Esp), p<0,05)], com os melhores resultados de DOR:6,8. Isto sugere que nessa população de muito idosos esses critérios têm maior poder discriminatório para separar pacientes com HVE. Conclusão: Nos hipertensos muito idosos os critérios eletrocardiográficos de Perúgia e (Rm+Sm) x duração apresentaram os melhores desempenhos diagnósticos para HVE.

Abstract Background: Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor, regardless of arterial hypertension. Despite the evolution of imaging tests, the electrocardiogram (ECG) is still the most used in the initial evaluation, however, with low sensitivity. Objective: To evaluate the performance of the main electrocardiographic criteria for LVH in elderly and very elderly hypertensive individuals. Methods: In a cohort of hypertensive patients, ECGs and doppler echocardiographies (ECHO) were performed and separated into three age groups: <60 years, Group I; 60-79 years Group II; and ≥80 years, Group III. The most used electrocardiographic criteria were applied for the diagnosis of LVH: Perugia; Pegaro-Lo Presti; Gubner-Ungerleider; Narita; (Rm+Sm) x duration; Cornell voltage; Cornell voltage duration; Sokolow-Lyon voltage; R of aVL ≥11 mm; RaVL duration. In evaluating the performance of these criteria, in addition to sensitivity (Sen) and specificity (Esp), the "Diagnostic Odds Ratios" (DOR) were analyzed. We considered p-value <0.05 for the analyses, with two-tailed tests. Results: In 2,458 patients, LVH was present by ECHO in 781 (31.7%). In Groups I and II, the best performances were for the criteria of Narita, Perugia, (Rm+Sm) x duration, with no statistical differences between them. In Group III (very elderly) the Perugia criteria and (Rm+Sm) x duration had the best performances: Perugia [44,7/89.3; (Sen/Esp)] and (Rm+Sm) duration [39.4%/91.3%; (Sen/Esp), p<0.05)], with the best PAIN results:6.8. This suggests that in this very elderly population, these criteria have greater discriminatory power to separate patients with LVH. Conclusion: In very elderly hypertensive patients, the Perugia electrocardiographic criteria and (Rm+Sm) x duration showed the best diagnostic performance for LVH.

Blood pressure control of hypertensive patients followed in a high complexity clinic and associated variables / Controle da pressão arterial de hipertensos acompanhados em um ambulatório de alta complexidade e variáveis associadas

Abstract Introduction: Arterial hypertension is a disease that has a high impact on cardiovascular mortality and morbidity; however, it is still insufficiently controlled. Objectives: To assess hypertension control in patients seen at a specialized clinic and to identify associated variables. Method: Cross-sectional study involving the analysis of medical records from 782 patients treated in a highly complex outpatient clinic. Inclusion criteria: age ≥18 years, diagnosed with hypertension, in treatment ≥6 months. Patients with secondary hypertension (104) and incomplete data (64) were excluded. The main outcome was blood pressure control (systolic <140 and diastolic <90 mmHg). The independent variables studied were: sociodemographic and clinical characteristics (use of drugs, comorbidities and laboratory tests). Pearson's χ2 tests, Fisher's test, Student's t and Wilcoxon-Mann-Whitney tests were performed in the bivariate analysis and logistic regression in the multiple analyses, adopting p≤0.05. Results: The prevalence of hypertensive control was 51.1%. It was associated with a lack of control: body mass index (OR = 1.038; 95% CI = 1.008 - 1.071), history of stroke (OR = 0.453; 95% CI = 0.245 - 0.821), left ventricular hypertrophy (OR = 1.765; 95% CI = 1.052 - 3.011), and number of medications (OR = 1.082; 95% CI = 1.033 - 1.136). Conclusion: About half of the hypertensive patients had their blood pressure controlled; clinical variables and target organ damage were associated with the control.

Resumo Introdução: A hipertensão arterial é uma doença com alto impacto na mortalidade e morbidade cardiovascular, contudo ainda demonstra insuficientes taxas de controle. Objetivos: Avaliar o controle da hipertensão em pacientes atendidos em um ambulatório especializado e identificar variáveis associadas. Método: Estudo transversal com análise do prontuário de 782 pacientes atendidos em um ambulatório de alta complexidade. Critérios de inclusão: idade ≥ 18 anos e diagnóstico de hipertensão em tratamento ≥ 6 meses. Foram excluídos hipertensão secundária (104) e dados incompletos (64). O desfecho principal foi o controle da pressão arterial (Sistólica < 140 e diastólica < 90 mmHg). As variáveis independentes estudadas foram: características sociodemográficas e clínicas (uso de medicamentos, comorbidades e exames laboratoriais). Realizou-se testes χ2 de Pearson, teste Fisher, t de Student e Wilcoxon-Mann-Whitney na análise bivariada e Regressão Logística na análise múltipla, adotando p ≤ 0,05. Resultados: A prevalência de controle dos hipertensos foi 51,1%. Associou-se à falta de controle: índice de massa corporal (OR = 1,038; IC95% = 1,008 - 1,071), histórico de acidente vascular encefálico (OR = 0,453; IC95% = 0,245 - 0,821) e hipertrofia ventricular esquerda (OR = 1,765; IC95% = 1,052 - 3,011), e número de medicamentos (OR = 1,082; IC95% = 1,033 - 1,136). Conclusão: Cerca da metade dos hipertensos estava com pressão arterial controlada e variáveis clínicas e lesão em órgão alvo associaram-se ao controle.

Análise Comparativa do Padrão de Fluxo de Artérias Coronárias das Hipertrofias Miocárdicas Secundárias e por Mutação Sarcomérica / Comparative Analysis of the Coronary Arteries Flow Pattern in Secondary Myocardial Hypertrophies and by Sarcomeric Mutation

Fundamento: O fluxo coronariano com predomínio diastólico aumenta duas a cinco vezes na hiperemia, mediada por vasodilatação (reserva de fluxo coronariano), podendo, na hipertrofia, ocorrer isquemia relativa. Na hipertrofia secundária, o fluxo em repouso torna-se isquêmico pelo aumento da demanda. Na cardiomiopatia hipertrófica com fibrose perivascular, há funcionalização de vasos colaterais, para aumentar a irrigação dos segmentos hipertrofiados. Objetivo: Determinar o padrão do fluxo coronariano em pacientes com hipertrofia secundária e cardiomiopatia hipertrófica, avaliando a reserva de fluxo coronariano. Métodos: Avaliamos o fluxo coronariano em 34 pacientes com hipertrofia secundária, em 24 com cardiomiopatia hipertrófica e em 16 controles. A artéria descendente anterior foi detectada com Doppler transtorácico com calibração adequada do equipamento. Nos grupos controle e com hipertrofia secundária, foi calculada a reserva de fluxo coronariano com dipiridamol (0,84 mg/kg) endovenoso. O mesmo procedimento foi realizado em seis pacientes do grupo com cardiomiopatia hipertrófica, nos quais também foi avaliado o fluxo das colaterais da região hipertrófica. Os dados foram comparados por variância com significância de 5%. Resultados: Na hipertrofia secundária, houve aumento do índice de massa e, na cardiomiopatia hipertrófica, predominou o aumento da espessura relativa. A fração de ejeção e a disfunção diastólica foram maiores no grupo com cardiomiopatia hipertrófica. A reserva de fluxo coronariano foi menor no grupo com cardiomiopatia hipertrófica, sendo detectado, também, fluxo de colaterais com redução da reserva de fluxo coronariano. Conclusão: A análise da circulação coronariana com Doppler transtorácico é possível em indivíduos normais e hipertróficos. Pacientes com hipertrofia secundária e cardiomiopatia hipertrófica apresentam diminuição da reserva de fluxo coronariano, e aqueles com cardiomiopatia hipertrófica mostram fluxo de vasos colaterais dilatados observados na região hipertrófica, com diminuição da reserva de fluxo coronariano.(AU)

Background: Coronary flow with a diastolic predominance increases two to five times in hyperemia, mediated by vasodilation (coronary flow reserve, CFR) and, in hypertrophy, relative ischemia may occur. In secondary hypertrophy (LVH), the flow, normal at rest, becomes ischemic due to increased demand. In hypertrophic cardiomyopathy (HCM) with perivascular fibrosis, collateral vessels appear to increase the irrigation of hypertrophied segments. Objective: To determine the coronary flow pattern in patients with secondary hypertrophy and hypertrophic cardiomyopathy, evaluating the coronary flow reserve. Methods: Coronary flow was evaluated in 34 patients with secondary hypertrophy, 24 with hypertrophic cardiomyopathy and in 16 controls. The anterior descending artery was detected with transthoracic Doppler with adequate equipment calibration. In the hypertrophic cardiomyopathy group, the flow of collaterals from the hypertrophic region was evaluated. In the control and secondary hypertrophy groups and in six patients in the hypertrophic cardiomyopathy group, the intravenous dipyridamole (0.84 mg) coronary flow reserve was calculated. The data were compared by variance with a significance of 5%Results: In secondary hypertrophy there was an increase in mass index and blood pressure, and in hypertrophic cardiomyopathy an increase in relative thickness predominated. Ejection fraction and diastolic dysfunction were higher in the hypertrophic cardiomyopathy group. The coronary flow reserve was lower in the hypertrophic cardiomyopathy group, and flow of collaterals was also detected, with a reduction in the coronary flow reserve. Conclusion: the analysis of coronary circulation with transthoracic Doppler is possible in normal and hypertrophic individuals. Patients with secondary hypertrophy and hypertrophic cardiomyopathy have a decrease in the coronary flow reserve, and patients with hypertrophic cardiomyopathy show a hyper flow of dilated collateral vessels observed in the hypertrophic region, with a decrease in the coronary flow reserve.(AU)

Ecoestresse físico na cardiomiopatia hipertrófica: como, quando e por quê? / Exercise stress echocardiography in hypertrophic cardiomyopathy: how, when and why?

Resumo Historicamente, o papel do ecocardiograma de estresse físico no manejo da cardiomiopatia hipertrófica tem sido negligenciado na prática clínica, de acordo com a análise das diretrizes do American College of Cardiology/ American Heart Association de 2002, que recomendavam cautela no uso dessa metodologia, em portadores de cardiomiopatia hipertrófica, devido ao risco de possível ocorrência tanto de arritmia cardíaca, como de colapso hemodinâmico no esforço. Atualmente, o estresse físico na cardiomiopatia hipertrófica integra a avaliação rotineira de pacientes sintomáticos com ou sem gradiente da via de saída do ventrículo esquerdo < 50 mmHg, em repouso. Para este grupo, é um método seguro e confiável para medir o gradiente da via de saída do ventrículo esquerdo durante o esforço e sólido diferenciador de pacientes com cardiomiopatia hipertrófica não obstrutivos (gradiente ausente, tanto em repouso quanto no esforço) daqueles com gradientes lábeis (gradiente ausente no repouso e presente no esforço). Portanto, na avaliação da cardiomiopatia hipertrófica, o estresse físico é igualmente útil na quantificação do grau de regurgitação mitral, nas alterações da contratilidade segmentar do ventrículo esquerdo e na avaliação da função diastólica do ventrículo esquerdo, diante do esforço, sendo capaz de predizer o futuro desenvolvimento de sintomas de insuficiência cardíaca. O método é também importante na determinação das diferentes estratégias de tratamento para cada paciente, desde a miomectomia cirúrgica ou a ablação septal alcoólica, para aqueles com gradiente lábil, com sintomas limitantes e refratários ao tratamento medicamentoso versus transplante cardíaco para aqueles sem gradiente.(AU)

Amiloidose cardíaca: cardiomiopatia infiltrativa com comportamento hemodinâmico restritivo ­ relato de caso / Cardiac amyloidosis: infiltrative cardiomyopathy with restrictive hemodynamic behavior ­ case report

A amiloidose é uma condição rara que descreve um grupo heterogêneo de distúrbios que cursam com a deposição extracelular de agregados proteicos fibrilares em tecidos e órgãos. Relata-se aqui o caso de paciente do sexo masculino, com 76 anos de idade, que, há 2 meses, iniciou quadro progressivo de dispneia aos mínimos esforços. Na investigação, observou-se aumento cardíaco global, e o ecocardiograma evidenciou cardiopatia restritiva infiltrativa e derrame pericárdico. Pela elevada suspeição clínica, foi solicitada ressonância magnética cardíaca, que foi altamente sugestiva de amiloidose cardíaca. Dessa forma, assim como no caso relatado, o acometimento cardíaco possui como principal forma de manifestação o tipo miocardiopatia restritivo, sendo um quadro de insuficiência cardíaca crônica com etiologia de difícil diagnóstico em pacientes acima de 50 anos, com prognóstico bastante reservado. Assim, apesar de permanecer como um desafio diagnóstico para o clínico, sua hipótese deve sempre ser aventada na ausência de outra causa que justifique tais achados (AU)

Prognostic power of conventional echocardiography in individuals without history of cardiovascular diseases: A systematic review and meta-analysis

Echocardiographic abnormalities are associated with a higher incidence of adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to evaluate whether echocardiographic abnormalities are predictors of cardiovascular events in individuals without previous cardiovascular diseases. The PubMed, Scopus, and SciELO databases were searched for longitudinal studies investigating the association between echocardiographic abnormalities and cardiovascular events among individuals without known cardiovascular diseases. Two independent reviewers analyzed data on the number of participants, age and sex, echocardiographic alterations, follow-up time, and cardiovascular outcomes. The meta-analysis estimated the risk ratio (RR) and 95% confidence interval (CI). Heterogeneity was assessed using I2 test. Twenty-two longitudinal studies met the eligibility criteria, comprising a total of 55,603 patients. Left ventricular hypertrophy (LVH) was associated with non-fatal cardiovascular events (RR 2.16; 95% CI 1.22-3.84), death from cardiovascular disease (RR 2.58; 95% CI 1.83- 3.64), and all-cause mortality (RR 2.02; 95% CI 1.34-3.04). Left ventricular diastolic dysfunction (LVDD) and left atrial dilation (LA) were associated with fatal and non-fatal cardiovascular events (RR 2.01; 95% CI 1.32-3.07) and (RR 1.78; 95% CI 1.16-2.73), respectively. Aortic root dilation was associated with non-fatal cardiovascular events (RR 1.25; 95% CI 1.09-1.43). In conclusion, LVH, LVDD, dilations of the LA, and of the aortic root were associated with an increased risk of adverse events in individuals without previous cardiovascular diseases. This study suggests that simple data obtained on conventional echocardiography can be an important predictor of cardiovascular outcomes in a low-risk population.

Achados ao ecocardiograma transtorácico em pacientes hospitalizados com COVID- 19: resultados do registro brasileiro de ecocardiografia durante a pandemia de COVID-19 (ECOVID) / Transthoracic echocardiography findings of hospitalized patients with COVID-19: results from the brazilian echocardiography registry during the COVID-19 Pandemic (ECOVID)

Fundamento: A ecocardiografia transtorácica (ETT) pode desempenhar um papel crucial na avaliação das manifestações cardíacas da COVID-19. Objetivo: Nosso objetivo foi relatar a prevalência das principais anormalidades ecocardiográficas em pacientes hospitalizados com COVID-19. Métodos: Realizou-se estudo observacional multicêntrico prospectivo com pacientes com COVID-19 submetidos a ETT durante a internação. Pacientes com insuficiência cardíaca prévia, doença arterial coronariana ou fibrilação atrial foram classificados como portadores de doença cardiovascular (DCV) prévia. Foram coletados dados clínicos e ecocardiográficos da estrutura e da função cardíaca. Resultados: Avaliamos 310 pacientes com COVID-19, com 62±16 anos de idade, 61% homens, 53% com hipertensão arterial, 33% com diabetes e 23% com DCV prévia. No total, 65% dos pacientes necessitaram de suporte em unidade de terapia intensiva. As alterações ecocardiográficas mais prevalentes foram hipertrofia do ventrículo esquerdo (VE) (29%), hipertensão pulmonar (25%), disfunção sistólida do VE (16,5%), disfunção sistólica do ventrículo direito (VD) (15,9%), disfunção diastólica do VE grau II/III (11%) e alteração da contratilidade regional do VE (11%). Derrame pericárdico foi incomum (7%). Hipertrofia do VE (25 vs. 45%, p=0,001), disfunção sistólica do VE (11 vs. 36%, p<0,001), alterações da contratilidade regional (6 vs. 29%, p<0,001), disfunção diastólica do VE grau II/III (9 vs. 19%, p=0,03) e hipertensão pulmonar (22 vs. 36%, p=0,019) foram menos comuns nos pacientes sem do que com DCV prévia. A disfunção sistólica do VD mostrou-se semelhante em pacientes sem e com DCV prévia (13 vs. 25%, p=0,07). Conclusões: Entre os pacientes hospitalizados com COVID-19, os achados ecocardiográficos anormais foram comuns, porém menos encontrados naqueles sem DCV. A disfunção sistólica do VD pareceu afetar de forma semelhante pacientes com e sem DCV prévia. (AU)

Background: Transthoracic echocardiography (TTE) may play a crucial role in the evaluation of cardiac manifestations of coronavirus disease 2019 (COVID-19). Objective: We aimed to report the prevalence of the main echocardiographic abnormalities of hospitalized COVID-19 patients. Methods: We performed a prospective multicenter observational study in patients with COVID-19 who underwent TTE during hospitalization. Patients with pre-existing heart failure, coronary artery disease, or atrial fibrillation were categorized as having previous cardiovascular disease (CVD). Clinical and echocardiographic data about cardiac structure and function were collected. Results: We evaluated 310 patients with COVID-19 (mean age, 62±16 years; 61% men; 53% with arterial hypertension; 33% with diabetes; and 23% with previous CVD). Overall, 65% of the patients required intensive care unit support. The most prevalent echocardiographic abnormalities were LV hypertrophy (29%), pulmonary hypertension (25%), left ventricular (LV) systolic dysfunction (16.5%), right ventricular (RV) systolic dysfunction (15.9%), grade II/III LV diastolic dysfunction (11%), and LV regional wall motion abnormality (11%). Pericardial effusion was uncommon (7% of cases). LV hypertrophy (25% vs. 45%, p=0.001), LV systolic dysfunction (11% vs. 36%, p<0.001), regional wall motion abnormalities (6% vs. 29%, p<0.001), grade II/III LV diastolic dysfunction (9% vs. 19%, p=0.03), and pulmonary hypertension (22% vs. 36%, p=0.019) were less common in patients without previous CVD. RV systolic dysfunction occurred at similar frequencies in patients with versus without previous CVD (13% vs. 25%, p=0.07). Conclusions: Among patients hospitalized with COVID-19, abnormal echocardiographic findings were common, but less so among those without previous CVD. RV systolic dysfunction appeared to affect similar proportions of patients with versus without previous CVD. (AU)

Association between serum uric acid and subclinical cardiac damage in children with primary hypertension / 中国当代儿科杂志

OBJECTIVE@#To evaluate the condition of subclinical cardiac damage in children with primary hypertension and the association between serum uric acid and subclinical cardiac damage.@*METHODS@#A retrospective analysis was performed on the medical data of 55 children who were hospitalized and diagnosed with primary hypertension in the Department of Cardiology, Children's Hospital of Soochow University from January 2015 to June 2020. Forty-five healthy children, matched for age and sex, were enrolled as the control group. The two groups were compared in terms of clinical features, laboratory examination, and parameters for left ventricular structure, systolic function, and diastolic function. The correlation of serum uric acid with the parameters for left ventricular structure, systolic function, and diastolic function in children with primary hypertension was analyzed.@*RESULTS@#Compared with the control group, the hypertension group had significantly higher left ventricular mass (LVM), left ventricular mass index (LVMI), and relative wall thickness (RWT) (@*CONCLUSIONS@#Children with primary hypertension may have subclinical cardiac damage such as left ventricular hypertrophy, left ventricular diastolic dysfunction, left atrial enlargement, and proximal aortic dilation. Elevated serum uric acid is significantly associated with cardiac damage in children with primary hypertension.

Meta-analysis of clinical efficacy and safety of Compound Danshen Dripping Pills combined with conventional antihypertensive drugs in treatment of hypertensive left ventricular hypertrophy / 中国中药杂志

To systematically evaluate the clinical efficacy and safety of Compound Danshen Dripping Pills combined with conventional antihypertensive drugs in the treatment of hypertensive left ventricular hypertrophy. China National Knowledge Infrastructure(CNKI), Wanfang, VIP, PubMed, EMbase, Cochrane Library, Ovid and Web of Science databases were searched by computer to retrieve the randomized controlled trials(RCTs) of Compound Danshen Dripping Pills combined with conventional antihypertensive drugs in the treatment of hypertensive left ventricular hypertrophy from the establishment of databases to July 2020. After two researchers performed data retrieval, data extraction, and risk assessment of bias, they used RevMan 5.3 software for Meta-analysis. A total of 10 RCTs were included, with a total of 979 patients. Meta-analysis results showed that in terms of interventricular septal thickness(MD=-0.70, 95%CI[-1.15,-0.24], P=0.003), left ventricular posterior wall thickness(MD=-0.81, 95%CI[-1.41,-0.21], P=0.008), left ventricular mass index(MD=-8.75, 95%CI[-17.40,-0.10], P=0.05), systolic blood pressure(MD=-8.97, 95%CI[-13.46,-4.48], P<0.000 1), diastolic blood pressure(MD=-5.87, 95%CI[-8.39,-3.34], P<0.000 01) and left ventricular end-diastolic diameter(MD=-1.73, 95%CI[-2.38,-1.08], P<0.000 01), Compound Danshen Dripping Pills combined with conventional antihypertensive drugs was superior to conventional antihypertensive drugs. In terms of left ventricular ejection fraction(MD=0.41, 95%CI[-0.74, 1.55], P=0.49), there was no statistical difference in treatment between the two groups. Because of the small amount of literatures included in the safety aspect, it is impossible to give an accurate conclusion. The GRADE score showed that the level of evidence was low and extremely low. The results show that the Compound Danshen Dripping Pills combined with conventional antihypertensive drugs may effectively improve the clinical efficacy for hypertensive ventricular hypertrophy, and the safety needs to be further explored. Due to the low quality of the included literatures, more high-quality RCTs are needed for verification.