Functional capacity in children and adolescents with congenital heart disease / Capacidade funcional em crianças e adolescentes com cardiopatia congênita

ABSTRACT Objective: To evaluate the physical activity level and functional capacity of children and adolescents with congenital heart disease and to describe correlations between functionality, surgical and echocardiographic findings, metabolic and inflammatory profile and differences between acyanotic and cyanotic heart defects. Methods: A cross-sectional study including children and adolescents with congenital heart disease between six and 18 years old that were evaluated with the 6-minute walk test (6MWT) to assess functional capacity. The short version form of the International Physical Activity Questionnaire (IPAQ) was performed to evaluate physical activity levels. Also, echocardiography and blood collection, to evaluate the metabolic (blood glucose, lipids, insulin) and inflammatory markers (C-reactive protein), were assessed. Results: Twenty-five individuals were evaluated. Of them, 14 had acyanotic heart defects and 11 cyanotic heart defects. Mean age was 12.0±3.7 years, and 20 (80%) were male. IPAQ showed that six (24%) individuals were very active, eight (32%) were active, nine (36%) had irregular physical activity, and two (8%) were sedentary. The mean distance walked in the 6MWT, considering all studied individuals, was 464.7±100.4 m, which was 181.4±42.0 m less than the predicted (p=0.005). There was a positive correlation between Z score 6MWT and the number of surgical procedures (r=-0.455; p=0.022). Conclusions: Children and adolescents with congenital heart disease have low functional capacity, but they are not completely sedentary.

RESUMO Objetivo: Avaliar o nível de atividade física e a capacidade funcional de crianças e adolescentes com cardiopatia congênita, além de descrever correlações entre funcionalidade, achados cirúrgicos e ecocardiográficos, perfil metabólico e inflamatório e diferenças entre cardiopatias congênitas acianótica e cianótica. Métodos: Estudo transversal com crianças e adolescentes com cardiopatia congênita entre seis e 18 anos de idade. Foi realizado o teste de caminhada de 6 minutos para avaliar a capacidade funcional, e aplicou-se a versão curta do Questionário Internacional de Atividade Física (IPAQ) para avaliar os níveis de atividade física. Foram feitos também: exame ecocardiográfico, coleta de sangue para avaliação de perfil metabólico e inflamatório (glicemia, triglicerídeos, colesterol total, lipoproteína de alta densidade - HDL-colesterol, lipoproteína de baixa densidade - LDL-colesterol, hemograma completo, proteína C reativa, insulina). Resultados: Foram avaliados 25 indivíduos, dos quais 14 tinham cardiopatia congênita acianótica e 11 cianótica. A média de idade foi de 12,0±3,7 anos, e 20 (80%) eram do sexo masculino. O IPAQ mostrou que seis (24%) indivíduos eram muito ativos, oito (32%) eram ativos, nove (36%) tinham atividade física irregular e dois (8%) eram sedentários. A média de distância percorrida no teste de caminhada dos 6 minutos, considerando todos os indivíduos estudados, foi de 464,7±100,4 m, sendo 181,4±42,0 m menor do que o previsto (p=0,005). Encontrou-se correlação entre o escore Z do teste de caminhada de 6 minutos e o número de procedimentos cirúrgicos realizados (r=-0,455; p=0,022). Conclusões: Crianças e adolescentes com cardiopatia congênita têm baixa capacidade funcional, mas não são completamente sedentários.

Controle glicêmico em pacientes com diabetes mellitus e doença cardiovascular acompanhados em ambulatório de referência / Glycemic control in patients with diabetes mellitus and cardiovascular disease monitored at a reference outpatient clinic

INTRODUÇÃO: O controle da hiperglicemia característica do diabetes mellitus é parte importante do seu tratamento, e se associa, em longo prazo, à redução de complicações crônicas da doença. No entanto, atingir bom controle glicêmico não é tarefa fácil; múltiplas abordagens têm sido buscadas com este intuito. Nosso objetivo foi descrever o controle glicêmico de uma amostra de pacientes atendidos em nível terciário e analisar possíveis preditores de alcance de bom controle glicêmico no seguimento. MÉTODOS: Estudo observacional, coletados dados de pacientes com diabetes tipo 2 em acompanhamento ambulatorial, através de dados do prontuário eletrônico. Coletadas variáveis demográficas, clínicas e laboratoriais (glicemia, hemoglobina glicada (HbA1c), lipídios, creatinina e microalbuminúria). RESULTADOS: Foram incluídos 57 pacientes; 61,4% alcançaram HbA1c ≤8% (grupo Diabetes Mellitus controlado, DMC) e 22 (38,6%) não atingiram este valor (grupo Diabetes Mellitus não controlado, DMNC) em 1 ano. A maioria dos pacientes do grupo DMNC eram homens (p = 0,030); idade, associação com outras comorbidades, escolaridade, tempo de diabetes não foram diferentes entre os grupos. Número de consultas marcadas foi semelhante entre os grupos, mas o de consultas realizadas foi maior no grupo DMNC. O controle glicêmico inicial era pior no grupo DMNC (HbA1c 9,2 ±1,4 vs.11,0 ±1,5%, p < 0,001). Alta ambulatorial foi mais frequente no grupo DMC (p = 0,01). CONCLUSÃO: A intensificação do cuidado ao diabetes por equipe especializada em nível terciário é capaz de trazer melhor controle glicêmico para a maioria destes pacientes, especialmente quando encaminhados ainda com HbA1c não muito elevada

INTRODUCTION: Controlling hyperglycemia in diabetes mellitus is an important part of the treatment and is associated with long-term reduction of chronic complications. However, it is difficult to achieve, and different approaches to glycemic control are being investigated. We aimed to analyze glycemic control in a sample of patients treated at a tertiary hospital, as well as to analyze possible predictors of good glycemic control during follow-up. METHODS: In this observational study, we collected data from the electronic medical records of patients with type 2 diabetes treated at a reference outpatient clinic. We analyzed demographic, clinical and laboratory variables (blood glucose, glycosylated hemoglobin (HbA1c), lipids, creatinine and microalbuminuria). RESULTS: Out of 57 patients, 61.4% had HbA1c levels ≤8% (controlled diabetes mellitus group, CDM), and 38.6% (n = 22) did not reach this value (uncontrolled diabetes mellitus group, UDM) in 1 year. Most patients in the UDM group were men (p = 0.030). Age, association with other comorbidities, educational attainment, and duration of diabetes were not different between groups. The number of scheduled appointments was similar between groups, but the number of attended appointments was higher in the UDM group. Initial glycemic control was worse in the UDM group (HbA1c 9.2 ±1.4 vs. 11.0 ±1.5%, p < 0.001). Outpatient discharge was more frequent in the CDM group (p = 0.01). CONCLUSION: Intensifying diabetes care by a specialized team at tertiary centers can improve metabolic control for the majority of these patients, especially for those with a lower HbA1c at the time of referral

Micronutrientes antioxidantes e risco cardiovascular em pacientes com diabetes: uma revisão sistemática / Antioxidant micronutrients and cardiovascular risk in patients with diabetes: a systematic review

FUNDAMENTO: Associações inversas entre a ingestão de micronutrientes e desfechos cardiovasculares foram demonstradas previamente na população geral. OBJETIVO: Revisar sistematicamente o papel de micronutrientes no desenvolvimento/presença de desfechos cardiovasculares em pacientes com diabetes. MÉTODOS: Foi realizada uma busca nas bases de dados Medline, Embase e Scopus (Janeiro/1949-Março/2012) por estudos observacionais que avaliaram micronutrientes antioxidantes e desfechos cardiovasculares em pacientes com diabetes e, em seguida, os dados foram selecionados e extraídos (dois revisores independentes). RESULTADOS: Dos 15658 estudos identificados, cinco foram incluídos, sendo três de caso-controle e dois de coorte, com um acompanhamento de 7-15 anos. Uma metanálise não foi realizada devido aos diferentes micronutrientes antioxidantes (tipos e métodos de medição) e os desfechos avaliados. Os micronutrientes avaliados foram: vitamina C (dieta e/ou suplementação), cromo e selênio em amostras de unha, e α-tocoferol e zinco no soro. A ingestão de > 300 mg de vitamina C a partir de uplementos esteve associada a um risco aumentado de doença cardiovascular, doença arterial coronariana (DAC) e acidente vascular cerebral (RR 1,69-2,37). Altos níveis de α-tocoferol no soro foram associados a um risco 30% inferior de DAC em outro estudo (RR 0,71, IC 95% 0,53-0,94). Entre os minerais (zinco, selênio e cromo), foi observada uma associação inversa entre o zinco e a DAC: níveis inferiores a 14,1 μmol/L foram associados a um risco aumentado para DAC (RR 1,70, IC 95% 1,21-2,38). CONCLUSÃO: A informação disponível sobre essa questão é escassa. Estudos prospectivos adicionais são necessários para elucidar o papel desses nutrientes no risco cardiovascular de pacientes com diabetes.

BACKGROUND: Inverse associations between micronutrient intake and cardiovascular outcomes have been previously shown, but did not focus on diabetic patients. OBJECTIVE: To systematically review the role of micronutrients in the development/presence of cardiovascular outcomes in patients with diabetes. METHODS: We searched Medline, Embase, and Scopus (January/1949-March/2012) for observational studies that evaluated micronutrients and cardiovascular outcomes in patients with diabetes, and then selected and extracted the data (two independent reviewers). RESULTS: From the 15 658 studies identified, five were included, comprising three case-control and two cohorts, with a follow-up of 7-15 years. A meta-analysis was not performed due to the different antioxidant micronutrients (types and measurement methods) and outcomes evaluated. The micronutrients assessed were vitamin C intake in diet and/or supplementation, chromium and selenium in toenail samples, and α-tocopherol and zinc in serum levels. Intake of >300 mg of vitamin C through supplementation was associated with increased risk of cardiovascular disease, coronary artery disease (CAD), and stroke (RR 1.69-2.37). High levels of α-tocopherol in serum were associated with 30% lower CAD risk in another study (HR 0.71; 95%CI 0.53-0.94). Among minerals (zinc, selenium, and chromium), an inverse association between zinc and CAD was observed; levels lower than 14.1 µmol/L were associated with an increased risk for CAD (RR 1.70; 95%CI 1.21-2.38). CONCLUSION: The information available on this issue is scarce. Further prospective studies are needed to elucidate the role of these nutrients in the cardiovascular risk of patients with diabetes.

Aerobic exercise training induces metabolic benefits in rats with metabolic syndrome independent of dietary changes

OBJECTIVES: We evaluated the effects of aerobic exercise training without dietary changes on cardiovascular and metabolic variables and on the expression of glucose transporter Type 4 in rats with metabolic syndrome. METHODS: Twenty male spontaneously hypertensive rats received monosodium glutamate during the neonatal period. The animals were allocated to the following groups: MS (sedentary metabolic syndrome), MS-T (trained on a treadmill for 1 hour/day, 5 days/week for 10 weeks), H (sedentary spontaneously hypertensive rats) and H-T (trained spontaneously hypertensive rats). The Lee index, blood pressure (tail-cuff system), insulin sensitivity (insulin tolerance test) and functional capacity were evaluated before and after 10 weeks of training. Glucose transporter Type 4 expression was analyzed using Western blotting. The data were compared using analysis of variance (ANOVA) (p<0.05). RESULTS: At baseline, the MS rats exhibited lower insulin sensitivity and increased Lee index compared with the H rats. Training decreased the body weight and Lee index of the MS rats (MS-T vs. MS), but not of the H rats (H-T vs. H). There were no differences in food intake between the groups. At the end of the experiments, the systolic blood pressure was lower in the two trained groups than in their sedentary controls. Whole-body insulin sensitivity increased in the trained groups. Glucose transporter Type 4 content increased in the heart, white adipose tissue and gastrocnemius muscle of the trained groups relative to their respective untrained groups. CONCLUSION: In conclusion, the present study shows that an isolated aerobic exercise training intervention is an efficient means of improving several components of metabolic syndrome, that is, training reduces obesity and hypertension and increases insulin sensitivity. .

Monosodium glutamate neonatal treatment induces cardiovascular autonomic function changes in rodents

OBJECTIVES: The aim of this study was to evaluate cardiovascular autonomic function in a rodent obesity model induced by monosodium glutamate injections during the first seven days of life. METHOD: The animals were assigned to control (control, n = 10) and monosodium glutamate (monosodium glutamate, n = 13) groups. Thirty-three weeks after birth, arterial and venous catheters were implanted for arterial pressure measurements, drug administration, and blood sampling. Baroreflex sensitivity was evaluated according to the tachycardic and bradycardic responses induced by sodium nitroprusside and phenylephrine infusion, respectively. Sympathetic and vagal effects were determined by administering methylatropine and propranolol. RESULTS: Body weight, Lee index, and epididymal white adipose tissue values were higher in the monosodium glutamate group in comparison to the control group. The monosodium glutamate-treated rats displayed insulin resistance, as shown by a reduced glucose/insulin index (-62.5%), an increased area under the curve of total insulin secretion during glucose overload (39.3%), and basal hyperinsulinemia. The mean arterial pressure values were higher in the monosodium glutamate rats, whereas heart rate variability (>7 times), bradycardic responses (>4 times), and vagal (~38%) and sympathetic effects (~36%) were reduced as compared to the control group. CONCLUSION: Our results suggest that obesity induced by neonatal monosodium glutamate treatment impairs cardiac autonomic function and most likely contributes to increased arterial pressure and insulin resistance.

Exercise alleviates hypoalgesia and increases the level of calcitonin gene-related peptide in the dorsal horn of the spinal cord of diabetic rats

OBJECTIVE: The aim of this study was to evaluate the effects of treadmill training on nociceptive sensitivity and immunoreactivity to calcitonin gene-related peptide in the dorsal horn of the spinal cord of diabetic rats. METHODS: Male Wistar rats were divided into three groups: control, diabetic and trained diabetic. Treadmill training was performed for 8 weeks. The blood glucose concentrations and body weight were evaluated 48 h after diabetes induction and every 30 days thereafter. The nociceptive sensitivity was evaluated using the tail-flick apparatus. The animals were then transcardially perfused, and the spinal cords were post-fixed, cryoprotected and sectioned in a cryostat. Immunohistochemistry for calcitonin gene-related peptide analysis was performed on the dorsal horn of the spinal cord. RESULTS: The nociceptive sensitivity analysis revealed that, compared with the control and trained diabetic animals, the latency to tail deflection on the apparatus was longer for the diabetic animals. Optical densitometry demonstrated decreased calcitonin gene-related peptide immunoreactivity in the dorsal horn of the spinal cord in diabetic animals, which was reversed by treadmill training. CONCLUSION: We concluded that treadmill training can alleviate nociceptive hypoalgesia and reverse decreased calcitonin gene-related peptide immunoreactivity in the dorsal horn of the spinal cord of diabetic animals without pharmacological treatment.

Associação entre diabetes mellitus e gravidade da doença arterial coronariana em pacientes submetidos à intervenção coronária percutânea / Association between diabetes mellitus and severity of coronary artery disease in patients undergoing percutaneous coronary intervention

Objetivos: Avaliar a prevalência de diabetes mellitus buscando associação com a gravidade da doença arterial coronária em pacientes submetidos à intervenção coronária percutânea em centro de referência no sul do Brasil.Métodos: Estudo transversal. Foram avaliados todos os pacientes submetidos à intervenção coronária percutânea eletiva entre novembro/2006 e dezembro/2007 em hospital de referência. Aplicou-se questionário previamente ao procedimento e realizou-se glicemia capilar em jejum.Resultados: Foram realizadas 617 intervenções coronárias percutâneas e implantados 718 stents em 569 indivíduos (1,32 stents por intervenção).Destes, 177 pacientes (32,2%) foram considerados diabéticos. Característicasdemográficas, fatores de risco para doença arterial coronária, vaso alvo, diâmetro do vaso e extensão da lesão foram semelhantes entre os grupos. Doença arterial coronária grave, categorias III e IV, foi encontrada em 51,2% dos pacientes com diabetes, comparados com 37,6% dos sem diabetes (p<0,001). Houve correlação significativa entre os níveis de glicemia e a gravidade da doença arterial coronária(p<0,05).Conclusões: Existe associação entre a presença de diabetes e a gravidade angiográfica da doença arterial coronária em pacientes submetidos à intervenção coronária percutânea, o que sugere que essa maior gravidade possa contribuir para os desfechos adversos nesses pacientes.

Aim: To evaluate the prevalence of diabetes mellitus by searching for an association between severe coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI) in a reference center in southern Brazil. Methods: This was a cross-sectional study. Data were derived from patients undergoing PCI from November, 2006 to December, 2007 in a Brazilian reference center. A questionnaire was administered as well as a capillary blood glucose test before the procedure.Results: In all, 617 PCIs were performed with 718 stents implanted in 569 patients (1.32 stent/PCI).Diabetes was present in 177 patients (32%). Baseline demographics and angiographic characteristics(including CAD risk factors, target-vessels, vessel diameters, and lesion extensions) were similar between the two groups. Severe CAD (levels III and IV) was found in 51.2% of diabetic patients as compared to 37.6% of non-diabetic patients (p<0.001). Coronary artery disease was significantly less severe in non-diabetic subjects as compared to diabetic patients, with the presence of 1-vessel disease respectively in 38.5 vs. 27.9% (p<0.001). There was a significant correlation between bloodglucose levels and CAD severity (p<0.05).Conclusion: There is a significant correlation between the presence of diabetes and the severity of CAD in patients submitted for PCI, thereby suggesting that this more intense atherosclerotic process might contribute to the adverse cardiovascular events seen in diabetic patients.

Efeitos da angiotensina-I e isquemia na recuperação funcional em corações isolados / Effects of angiotensin-I and ischemia on functional recovery in isolated hearts

FUNDAMENTO: A ressuscitação de parada cardíaca pode apresentar disfunção miocárdica determinada pelo tempo da isquemia, e a inibição da enzima conversora de angiotensina (ECA) pode reduzir a disfunção cardíaca durante a reperfusão. OBJETIVO: Investigar os efeitos da angiotensina-I e diferentes períodos de isquemia na recuperação funcional em corações de ratos isolados. MÉTODOS: Os corações isolados de ratos Wistar (n = 45; 250-300 g) foram submetidos a diferentes períodos de isquemia global (20, 25 ou 30 min) e reperfundidos (30 min) com o tampão Krebs-Henseleit, ou com a adição de 400 nmol/L de angiotensina-I, ou com 400 nmol/L de angiotensina-I + 100 µmol/L de captopril durante o período de reperfusão. RESULTADOS: A derivada positiva máxima de pressão (+dP/dt max) e o produto frequência-pressão foram reduzidos nos corações expostos à isquemia de 25 min (~ 73 por cento) e à isquemia de 30 min (~ 80 por cento) vs. isquemia de 20 min. A pressão diastólica final do ventrículo esquerdo (PDFVE) e a pressão de perfusão (PP) foram aumentadas nos corações expostos à isquemia de 25 min (5,5 e 1,08 vezes, respectivamente) e à isquemia de 30 min (6 e 1,10 vezes, respectivamente) vs. isquemia de 20 min. A angiotensina-I ocasionou uma diminuição no +dP/dt max e no produto frequência-pressão (~ 85-94 por cento) em todos os períodos de isquemia e um aumento na PDFVE e na PP (6,9 e 1,25 vezes, respectivamente) apenas na isquemia de 20 min. O captopril foi capaz de reverter parcial ou completamente os efeitos da angiotensina-I na recuperação funcional nas isquemias de 20 e 25 min CONCLUSÃO: Os dados sugerem que a angiotensina-II participa direta ou indiretamente no dano pós-isquêmico e que a capacidade de um inibidor da ECA atenuar esse dano depende do tempo de isquemia.

BACKGROUND: Cardiac arrest resuscitation can present myocardial dysfunction determined by ischemic time, and inhibition of the angiotensin-converting enzyme (ACE) can reduce cardiac dysfunction during reperfusion. OBJECTIVE: To investigate the effects of angiotensin-I and different periods of ischemia on functional recovery in isolated rat hearts. METHODS: Isolated hearts from Wistar rats (n=45; 250-300 g) were submitted to different periods of global ischemia (20, 25 or 30 min) and reperfused (30 min) with Krebs-Henseleit buffer alone or with the addition of 400 nmol/L angiotensin-I, or 400 nmol/L angiotensin-I + 100 mmol/L captopril along the reperfusion period. RESULTS: The maximal positive derivative of pressure (+dP/dt max) and rate-pressure product were reduced in hearts exposed to 25 min ischemia (~73 percent) and 30 min ischemia (~80 percent) vs. 20 min ischemia. Left ventricular end-diastolic pressure (LVEDP) and perfusion pressure (PP) were increased in hearts exposed to 25 min ischemia (5.5 and 1.08 fold, respectively) and 30 min ischemia (6 and 1.10 fold, respectively) vs. 20 min ischemia. Angiotensin-I caused a decrease in +dP/dt max and rate-pressure product (~85-94 percent) in all ischemic periods and an increase in LVEDP and PP (6.9 and 1.25 fold, respectively) only at 20 min ischemia. Captopril was able to partially or completely reverse the effects of angiotensin-I on functional recovery in 20 min and 25 min ischemia. CONCLUSION: These data suggest that angiotensin-II directly or indirectly participates in the post-ischemic damage, and the ability of an ACE inhibitor to attenuate this damage depends on ischemic time.

Preditores de infecção no pós-operatório de cirurgia de revascularização miocárdica / Predictors of infection in post-coronary artery bypass graft surgery

INTRODUÇÃO: Embora a cirurgia de revascularização miocárdica (CRM) seja uma boa alternativa terapêutica na doença arterial grave, pode evoluir com complicações, especialmente infecções. OBJETIVOS: Determinar a incidência de infecção no pós-operatório de CRM e seus preditores clínicos em um centro de referência cardiológico brasileiro. MÉTODOS: Estudo de coorte. Foram coletados dados de todos os pacientes submetidos à CRM entre janeiro/2004 e fevereiro/2006, excluindo-se cirurgias de urgência, sem glicemia pré-operatória e com infecção prévia à cirurgia. Análise estatística: teste t-Student, qui quadrado e regressão logística. RESULTADOS: Foram avaliados 717 pacientes, 61,9 ± 11 anos, 67,1 por cento homens, 29,6 por cento com diabetes, dos quais 137 (19,1 por cento) desenvolveram infecção (62 por cento respiratória, 25 por cento superficial de ferida operatória, 9,5 por cento urinária, 3,6 por cento profunda de ferida operatória). Diabetes foi mais prevalente naqueles que desenvolveram infecção, assim como maior tempo de permanência do cateter venoso central (79,3 ± 40,5 vs. 61,0 ± 19,3 h, P<0,001). Após análise multivariada (modelo ajustado para dislipidemia, hipertensão, tabagismo e leucócitos), tanto diabetes (OR 4,18 [2,60-6,74]), quanto tempo de permanência do cateter venoso central (OR 1,019 [1,00-1,02]) e cateterismo cardíaco durante a internação (OR 2,03 [1,14-3,60] mantiveram-se preditores do desfecho infecção (P<0,001). Apesar do diabetes estar associado a maior percentual de infecções (P<0,001), glicemia do pré-operatório não se associou a maior risco de infecção. CONCLUSÕES: Diabetes e tempo de permanência do cateter venoso central se associaram ao desenvolvimento de infecção no pós-operatório de CRM. A glicemia pré-operatória não foi preditora de risco de infecção, provavelmente havendo necessidade de caracterização mais detalhada do controle glicêmico trans e pós-operatório imediato.

BACKGROUND: Although coronary artery bypass grafting (CABG) is a good alternative therapy in severe arterial disease, it may evolve with complications, especially infections. OBJECTIVES: To determine the incidence of infection in post-CABG and its clinical predictors in a cardiology reference center in Brazil. METHODS: Cohort study. Data were collected from all patients undergoing CABG between January/2004 and February/2006, excluding emergency surgery, absent record of glucose blood levels preoperatively and infection prior to surgery. Statistical analysis: Student's t test, chi square, logistic regression. RESULTS: We evaluated 717 patients, 61.9 ± 11 years old, 67.1 percent were men, 29.6 percent with diabetes, of whom 137 (19.1 percent) developed infection (62 percent respiratory, 25 percent superficial wound, 9.5 percent urinary, 3.6 percent deep wound). Diabetes was more prevalent in those who developed infection, as well as prolonged time of indwelling central venous catheter (79.3 ± 40.5 vs. 61.0 ± 19.3 hours, P<0.001). After multivariate analysis (model adjusted for dyslipidemia, hypertension, smoking and leukocytes), both diabetes (OR 4.18 [2.60-6.74]), prolonged central venous line (OR 1.019 [1.00-1.02] and cardiac catheterism (OR 2.03 [1.14-3.60] remained predictors of infection. While diabetes is associated with a higher percentage of infections (P <0.001), preoperative serum glucose was not associated with increased risk of infection. CONCLUSIONS: Diabetes and permanence of central venous catheters were associated with development of infection in post-CABG. The preoperative blood glucose was not a predictor of risk of infection. It is probably necessary to study with greater detail glycemic control trans- and post-operatively.

Perfil e evolução dos pacientes com diabetesmellitus submetidos à cirurgia de revascularização miocárdica em serviço de referência no sul do Brasil / Clinical features and outcomes in patients with diabetes mellitus undergoing coronary artery bypass graft in a reference center in southern Brazil

OBJETIVO: Descrever perfil/evolução de pacientes submetidos à cirurgia de revascularização miocárdica (CRM) em centro de referência cardiológico. MÉTODOS: Estudo de coorte; avaliados todos os pacientes submetidos à CRM (janeiro/2004 e fevereiro/2006, n = 717) quanto às características clínicas/laboratoriais antes, durante e após a cirurgia (infecções, tempo de internação, óbitos). RESULTADOS: Os pacientes tinham 61,9 ± 11 anos, 67,1 por cento homens, 29,6 por cento diabéticos. No transoperatório, aqueles com diabetes usaram cateter venoso central por mais tempo (p < 0,001), mas tempo de circulação extra- corpórea, de clampeamento da aorta e cirúrgico foi semelhante versus os sem diabetes. Infecção ocorreu em 19,1 por cento dos pacientes (40,1 por cento vs. 10,3 por cento nos com e sem diabetes, p < 0,001). Tempo de permanência no hospital foi maior nos pacientes com diabetes versus pacientes sem diabetes, mas não houve diferença no número de óbitos ocorridos entre os grupos (p = 0,797). CONCLUSÃO: Pacientes com diabetes submetidos a CRM desenvolvem mais infecções e permanecem mais tempo internados do que aqueles sem diabetes.

OBJECTIVE: To describe clinical/laboratory features of patients undergoing coronary artery bypass graft (CABG) in a cardiology reference center. METHODS: Cohort study; data from patients undergoing CABG (January 2004 to February 2006, n = 717) were evaluated for clinical/laboratory features before, during and after surgery (infections, duration of hospital stay, deaths). RESULTS: Patients were 61.9 ± 11 years old, 67.1 percent males, 29.6 percent diabetics. Intraoperatively, diabetics had a central venous catheter placed for a longer period (p < 0.001), but extracorporeal circulation, aortic clamping and total surgery times were similar to those for non-diabetics. Infection occurred in 19.1 percent of patients (40.1 percent diabetics vs. 10.3 percent non-diabetics, p < 0.001). The duration of hospital stay was longer for patients with diabetes vs. non-diabetic patients, but there was no difference in deaths between the two groups (p = 0.797). CONCLUSION: Patients with diabetes undergoing CABG develop more infectious diseases and stay longer in hospital than non-diabetics.

Cardiopatias congênitas em um serviço de referência: evolução clínica e doenças associadas / Congenital heart diseases in a reference service: clinical evolution and associated illnesses

FUNDAMENTO: Inúmeros fatores vêm contribuindo para a mudança do perfil do paciente com cardiopatia congênita (CC), incluindo o diagnóstico pré-natal e a disponibilidade de novos procedimentos terapêuticos. O conhecimento dessas mudanças é fundamental para um melhor atendimento. OBJETIVOS: Descrever o perfil dos pacientes com CC de um serviço de referência no Estado do Rio Grande do Sul, Brasil. MÉTODOS: Trata-se de um estudo transversal, com 684 pacientes portadores de CC, em um serviço de cardiologia pediátrica, de janeiro de 2007 a maio de 2008. Esses pacientes foram entrevistados (e/ou seus pais) e examinados (malformações congênitas, medidas antropométricas), além de terem seus prontuários revisados para mais detalhes sobre as cardiopatias, procedimentos e ecocardiografia. RESULTADOS: A idade dos pacientes variou de 16 dias a 66 anos, sendo 51,8 por cento do sexo feminino, com 93,7 por cento de brancos. A idade média determinada pelo diagnóstico foi de 15,8 ± 46,8 meses. As CC mais prevalentes foram a comunicação interventricular, a persistência do canal arterial e a Tetralogia de Fallot. Dos pacientes analisados, 59,1 por cento, com idade média de 44,3 ± 71,2 meses, realizaram algum procedimento terapêutico; 30,4 por cento tinham malformações congênitas extracardíacas; e 12 pacientes tinham síndrome genética comprovada. Quanto ao desenvolvimento, 46,6 por cento tiveram atraso ponderoestatural e 13,7 por cento atraso neuropsicomotor. Além disso, 18,4 por cento apresentaram história familiar de cardiopatia congênita. CONCLUSÕES: O atraso neuropsicomotor e o baixo ganho ponderoestatural podem estar associados às CC. Estabelecer um perfil dos pacientes com CC atendidos em uma instituição de referência pode servir como base para o planejamento adequado do atendimento desta população.

BACKGROUND: Several factors, which include prenatal diagnosis and availability of new therapeutic procedures, have contributed to change the profile of patients with congenital heart disease (CHD). Knowing these changes is important to a better health care. OBJECTIVES: Description of profile of patients with CHD in a reference service in the State of Rio Grande do Sul, Brazil. METHODS: It is a cross-sectional study including 684 patients with CHD in a service of pediatric cardiology from January 2007 to May 2008. We interviewed the patients (and/or their parents) and examined these patients (congenital malformations, anthropometric measures). Moreover, their charts were reviewed in order to detail heart diseases, procedures and echocardiography. RESULTS: Patients were from 16 days to 66 years old, 51.8 percent were female, and 93.7 percent were Caucasian. The mean age at diagnosis was 15.8 ± 46.8 months. Ventricular septal defect, patent ductus arteriosus and Tetralogy of Fallot were the most prevalent CHD. 59.1 percent of examined patients, whose average age was 44.3 ± 71.2 months, have been undergoing therapeutic procedures; 30.4 percent had congenital extracardiac malformations; and 12 patients had genetic syndrome. Regarding development, 46.6 percent had low weight and height gain, and 13.7 percent had neuropsychomotor delay. Furthermore, 18.4 percent had family history of congenital heart disease. CONCLUSIONS: Neuropsychomotor delay and low weight and height gain may be related to CHD. Establishing a profile of patients with CHD, who were treated at an institution of reference, may function as a basis in which health care of this population can be planed appropriately. (Arq Bras Cardiol 2010; 94(3):313-318)

Beneficial effects of treadmill training in experimental diabetic nerve regeneration

OBJECTIVES: We investigated the effects of treadmill training (10 weeks) on hindlimb motor function and nerve morphometric parameters in diabetic rats submitted to sciatic nerve crush. MATERIALS AND METHOD: Wistar rats (n = 64) were divided into the following groups: non-diabetic; trained non-diabetic; non-diabetic with sciatic nerve crush; trained non-diabetic with sciatic nerve crush; diabetic; trained diabetic; diabetic with sciatic nerve crush or trained diabetic with sciatic nerve crush. Diabetes was induced by streptozotocin injection (50 mg/kg, iv). Hindlimb motor function was evaluated weekly by assessing sciatic functional indices, and the proximal and distal portions of the sciatic nerve were used for morphometric analysis. RESULTS: At 13 weeks post-injury, the distal nerve portion of all injured groups and the proximal nerve portion of the diabetic with sciatic nerve crush group presented altered morphometric parameters such as decreased myelinated fiber diameter (~7.4 + 0.3μm vs ~4.8 + 0.2μm), axonal diameter (~5 + 0.2μm vs ~3.5 + 0.1μm) and myelin sheath thickness (~1.2 + 0.07μm vs ~0.65 + 0.07μm) and an increase in the percentage of area occupied by endoneurium (~28 + 3 percent vs ~60 + 3 percent). In addition, in the non-diabetic with sciatic nerve crush group the proximal nerve portion showed a decreased myelinated fiber diameter (7.4+0.3μm vs 5.8 + 0.3μm) and myelin sheath thickness (1.29 + 0.08μm vs 0.92 + 0.08μm). The non-diabetic with sciatic nerve crush, trained non-diabetic with sciatic nerve crush, diabetic with sciatic nerve crush and trained diabetic with sciatic nerve crush groups showed normal sciatic functional index from the 4th,4th,9th and 7th week post-injury, respectively. Morphometric alterations in the proximal nerve portion of the diabetic with sciatic nerve crush and non-diabetic with sciatic nerve crush groups were either prevented or reverted to values similar to the non-diabetic group by treadmill training. CONCLUSION: Diabetic condition promoted delay in sciatic nerve regeneration. Treadmill training is able to accelerate hindlimb motor function recovery in diabetic injured rats and prevent or revert morphometric alterations in proximal nerve portions in non-diabetic and diabetic injured rats.

Insulin therapy does not interfere with venous endothelial function evaluation in patients with type 2 diabetes mellitus

INTRODUCTION: Endothelium-dependent dilation is improved in insulin-treated diabetic patients, but this effect is probably due to improved glycemic control. The objective of the present study was to compare endothelium-dependent dilation in patients with well-controlled type 2 diabetes who are or are not using insulin as part of their therapy. METHODS: We studied 27 patients with type 2 diabetes (11 women, 60.3 years ± 6 years, with HbA1c < 7 percent and no nephropathy), including 16 patients treated with anti-diabetic agents (No-Ins, 8 women) and 11 patients treated with insulin alone or in combination with anti-diabetic agents (Ins, 3 women). Endothelial function was evaluated by the dorsal hand vein technique, which measures changes in vein diameter in response to phenylephrine, acetylcholine (endothelium-dependent vasodilation) and sodium nitroprusside (endothelium-independent vasodilation). RESULTS: Age, systolic blood pressure (No-Ins: 129.4 mmHg ± 11.8 mmHg, Ins: 134.8 mmHg ± 12.0 mmHg; P= 0.257), HbA1c, lipids and urinary albumin excretion rate [No-Ins: 9 mg/24 h (0-14.1 mg/24 h) vs. Ins: 10.6 mg/24 h (7.5-14.4 mg/24 h), P=0.398] were similar between groups. There was no difference between endothelium-dependent vasodilation of the No-Ins group (59.3 percent ± 26.5 percent) vs. the Ins group (54.0 percent ± 16.3 percent; P=0.526). Endothelium-independent vasodilation was also similar between the No-Ins (113.7 percent ± 35.3 percent) and Ins groups (111.9 percent ± 28.5 percent; P=0.888). CONCLUSIONS: Subcutaneous insulin therapy does not interfere with venous endothelial function in type 2 diabetes when glycemic and blood pressure control are stable.

Complicações macrovasculares do diabetes melito: peculiaridades clínicas, de diagnóstico e manejo / Macrovascular diabetic complications: clinical characteristics, diagnosis and management

O diabetes melito (DM) é um fator de risco independente para doença arterial coronariana, acidente vascular cerebral, doença vascular periférica e insuficiência cardíaca, que são as principais causas de morte nesses pacientes. Além disso, pacientes com DM e doença cardiovascular têm pior prognóstico, por apresentarem menor sobrevida, maior risco de recorrência da doença e pior resposta aos tratamentos propostos. Os avanços diagnósticos e terapêuticos das últimas décadas já mostram uma redução do risco de eventos cardiovasculares nesses pacientes, mas o risco absoluto desses é ainda duas vezes maior em relação ao dos pacientes não diabéticos. Portanto, é prioritária a adoção de um manejo intensivo, com controle rígido dos fatores de risco cardiovasculares. Esta revisão trata das principais características clínicas e apresenta uma abordagem prática do rastreamento, diagnóstico e tratamento da doença macrovascular nos pacientes com DM.

Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.

Tratamento associado (clínico-cirúrgico) da fibrose retroperitoneal idiopática / Associated treatment (medical and surgical) of idiopathic retroperitoneal fibrosis

Os autores descrevem caso de paciente com fibrose retroperitoneal idiopática e revisão da patologia. Esta rara doença de etiologia incerta caracteriza-se por inflamação crônica do retroperitôneo, ocasionalmente aprisionando e obstruindo estruturas, notavelmente os ureteres. Trata-se de um paciente do sexo masculino, 45 anos, com dor em flanco esquerdo irradiada para testículo, em cólica, com piora progressiva. Feito o diagnóstico de fibrose retroperitoneal com compressão ureteral à esquerda (tomografia computadorizada do abdome), o paciente foi submetido a desobstrução ureteral com colocação de cateter duplo “J” e, posteriormente, a tratamento clínico com prednisona. Não houve regressão da massa fibrótica, mas melhora clínica quanto à dor e à ausência de novo episódio de obstrução ureteral. Os autores ressaltam a necessidade de suspeição da patologia descrita, mesmo sendo rara, pela possibilidade de complicações graves, se seu diagnóstico não for realizado e o tratamento não for instituído no tempo ideal

A case report of a patient with idiopathic retroperitoneal fibrosis (RPF) is described and the condition is reviewed as well. RPF is a rare disease of unclear etiology characterized by chronic retroperitoneal inflammation, which can entrap and obstruct retroperitoneal structures, notably ureters. A 45-year-old male patient presented with colic-likeleft flank pain irradiating to the testicle and progressively worsening. Retroperitoneal fibrosis with left ureteral compression was diagnosed in a abdominal computed tomography scan and the patient was submitted to reteral unblocking with insertion of a double-J catheter and then to clinical treatment with prednisone. Although there was no regression of the fibrotic mass, pain clinically relieved and no new ureteral obstruction episodes were seen. This case illustrates the importance of suspecting the above described condition. Although rare, RPF can potentially cause severe complications if it is not diagnosed and treated timely

Disfunção autonômica cardiovascular no diabetes mellitus experimental / Cardiovascular autonomic dysfunction in experimental diabetes mellitus

Muitas informações novas têm sido publicadas nos últimos anos a respeito da fisiopatologia da disfunção autonômica cardiovascular em ratos e camundongos diabéticos. Nosso grupo tem estudado o curso temporal das alterações cardiovasculares associadas ao diabetes experimental há alguns anos, obtendo evidências consistentes de grave disautonomia em modelos animais de diabetes. O objetivo deste trabalho foi revisar a contribuição que estudos envolvendo diferentes modelos de deficiência e resistência à insulina têm fornecido para o entendimento, tratamento e prevenção da disfunção autonômica cardiovascular do diabetes.

Much new information has been published in the last few years regarding pathophysiology of cardiovascular autonomic dysfunction in diabetic rats and mice. Our group has been studying the time-course cardiovascular changes associated with experimental diabetes in the last years, and obtained consistent evidences of severe dysautonomia in diabetes animal models. The aim of this manuscript is to review the contribution that studies involving different animal models of insulin deficiency or resistance have given to understand, treat and prevent diabetic cardiovascular autonomic dysfunction.

O papel da lipemia pós-prandial na gênese da aterosclerose: particularidades do diabetes mellitus / The role of post-prandial lipids in atherogenesis: particularities of diabetes mellitus

A aterosclerose é uma doença multifatorial e complexa, que determina eventos clínicos causadores de morbi-mortalidade significativa, representada pela ocorrência de infarto agudo do miocárdio, angina e morte súbita. Está associada a anormalidades lipídicas, ativação plaquetária, trombose, inflamação, disfunção endotelial, estresse oxidativo e alterações metabólicas da matriz, entre outros distúrbios. Todas essas anormalidades são mais comuns e acentuadas no paciente com diabetes, assim como no estado pós-prandial. Dentre os fatores de risco para doença arterial coronariana que ainda não são efetivamente empregados nas estratégias de prevenção da doença em grandes populações destaca-se a hiperlipemia pós-prandial, possível marcador precoce de anormalidades metabólicas e disfunção vascular não observadas em jejum. Recentes resultados mostram que as alterações que ocorrem após uma única sobrecarga lipídica se relacionam negativamente à função endotelial, sendo que as alterações na reatividade vascular estão fortemente associadas à progressão da aterosclerose e aos eventos cardiovasculares. Essas alterações podem revelar um estado de intolerância às gorduras que já são detectadas em indivíduos saudáveis, antes mesmo que anormalidades em jejum sejam percebidas. Esta revisão aborda a fisiopatologia envolvida na lipemia pós-prandial e sua relação com a aterogênese, com ênfase no diabetes mellitus.

Atherosclerosis is a complex and multifactorial disease, which determines clinical events that cause significant morbi-mortality, represented by acute myocardial infarction, angina and sudden death. It is associated with lipid disturbances, platelet activation, thrombosis, endothelial dysfunction, inflammation, oxidative stress, altered matrix metabolism, among other disturbances. All these abnormalities are usual and more pronounced in diabetic patients, as well as in the post-prandial state. Among the coronary artery disease risk factors that are not usually employed in clinical practice in the whole population, postprandial hyperlipemia plays a major role, being a possible early marker of metabolic abnormalities and vascular dysfunction not yet seen in the fasting state. Recent results showed that post-oral lipid overload changes are negatively associated with endothelial dysfunction, and vascular reactivity abnormalities are strongly related to atherosclerosis progression and cardiovascular events. These abnormalities could disclose a lipid intolerance state that can be detected in apparently healthy subjects even before fasting abnormalities are seen. This review will deal with the pathophysiology changes involved in post-prandial hyperlipemia and its relationship with atherogenesis, with particular emphasis to diabetes mellitus.

Intervenção coronária percutânea no diabetes mellitus: análise da prática médica atual / Percutaneous coronary intervention in diabetes mellitus: an updated analysis of medical practice

Os pacientes com diabetes e cardiopatia isquêmica são freqüentemente considerados para a realização de revascularização miocárdica com o objetivo de diminuição do risco de eventos cardiovasculares ou melhora da qualidade de vida. Na prática clínica, as decisões quanto à realização de cirurgia ou intervenção coronariana percutânea são freqüentemente difíceis, devido à gravidade dos casos, extensão da doença e presença de co-morbidades. Além disso, a maioria dos dados disponíveis na literatura origina-se da análise de subgrupos de ensaios clínicos delineados para estudos da população em geral, não para diabéticos. O objetivo deste estudo foi revisar a literatura quanto à intervenção coronária percutânea em pacientes com diabetes, além de mostrar dados mais recentes dos resultados deste procedimento no Serviço de Hemodinâmica do Instituto de Cardiologia do RS.

Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.

Autonomic modulation of arterial pressure and heart rate variability in hypertensive diabetic rats

OBJECTIVE: The aim of the present study was to evaluate the autonomic modulation of the cardiovascular system in streptozotocin (STZ)-induced diabetic spontaneously hypertensive rats (SHR), evaluating baroreflex sensitivity and arterial pressure and heart rate variability. METHODS: Male SHR were divided in control (SHR) and diabetic (SHR+DM, 5 days after STZ) groups. Arterial pressure (AP) and baroreflex sensitivity (evaluated by tachycardic and bradycardic responses to changes in AP) were monitored. Autoregressive spectral estimation was performed for systolic AP (SAP) and pulse interval (PI) with oscillatory components quantified as low (LF:0.2-0.6Hz) and high (HF:0.6-3.0Hz) frequency ranges. RESULTS: Mean AP and heart rate in SHR+DM (131±3 mmHg and 276±6 bpm) were lower than in SHR (160±7 mmHg and 330±8 bpm). Baroreflex bradycardia was lower in SHR+DM as compared to SHR (0.55±0.1 vs. 0.97±0.1 bpm/mmHg). Overall SAP variability in the time domain (standard deviation of beat-by-beat time series of SAP) was lower in SHR+DM (3.1±0.2 mmHg) than in SHR (5.7±0.6 mmHg). The standard deviation of the PI was similar between groups. Diabetes reduced the LF of SAP (3.3±0.8 vs. 28.7±7.6 mmHg2 in SHR), while HF of SAP were unchanged. The power of oscillatory components of PI did not differ between groups. CONCLUSIONS: These results show that the association of hypertension and diabetes causes an impairment of the peripheral cardiovascular sympathetic modulation that could be, at least in part, responsible for the reduction in AP levels. Moreover, this study demonstrates that diabetes might actually impair the reduced buffer function of the baroreceptors while reducing blood pressure.

OBJETIVO: O objetivo do presente estudo foi investigar a modulação autonômica do sistema cardiovascular em ratos espontâneamente hipertensos (SHR) e diabéticos por estreptozotocina (STZ), avaliando a sensibilidade do reflexo barorreceptor e a variabilidade da pressão arterial e da freqüência cardíaca. MÉTODOS: Ratos SHR machos foram divididos em grupos controle (SHR) e diabéticos (SHR+DM, 5 dias após STZ). A pressão arterial (PA) e a sensibilidade dos barorreceptores (avaliada pelas respostas taquicárdicas e bradicárdicas a alterações da PA) foram monitoradas. Os sinais de pressão arterial sistólica (PAS) e o intervalo de pulso (IP) foram analisados no domínio do tempo e da freqüência pelo método autoregressivo sendo quantificados os componentes oscilatórios de baixa (BF: 0,2-0,6Hz) e alta (AF:0,6-3,0Hz) freqüência. RESULTADOS: A PA média e a freqüência cardíaca estavam reduzidas no grupo SHR+DM (131±3 mmHg e 276±6 bpm) em relação ao grupo SHR (160±7 mmHg e 330±8 bpm). A bradicardia reflexa a aumentos de PA estava atenuada no grupo SHR+DM quando comparada ao grupo SHR (0,55±0,1 vs 0,97±0,1 bpm/mmHg). A variabilidade da PAS no domínio do tempo (desvio padrão batimento-a-batimento da série temporal da PAS) foi menor no grupo SHR+DM (3,1±0,2 mmHg) quando comparada ao grupo SHR (5,7±0,6 mmHg). O desvio padrão do IP foi semelhante entre os grupos. O diabetes reduziu o componente BF da PAS (3,3±0,8 vs 28,7±7,6 mmHg² no SHR), mas não alterou o componente AF da PAS. Em relação aos componentes oscilatórios do IP não houve diferença entre os grupos. CONCLUSÕES: Estes resultados sugerem que a associação de hipertensão e diabetes causa uma importante diminuição da modulação simpática cardiovascular periférica que poderia, pelo menos em parte, ser responsável pela redução da PA. Além disso, este estudo demonstra que o diabetes pode, de fato, piorar a já reduzida função de tamponamento dos barorreceptores ao mesmo tempo em que reduz a pressão arterial.