Avaliação do perfil de metilação dos genes LDLR, PCSK9, LDLRAP1 em pacientes portadores de hipercolesterolemia familial / Evaluation of the methylation profile of LDLR, PCSK9, LDLRAP1 genes in patients with familial hypercholesterolemia

As variabilidades genotípicas que determinam algumas alterações fenotípicas e metabólicas podem ter seu diagnostico falho se baseado apenas nos dados genômicos. Na hipercolesterolemia familial (HF) pode-se observar que os dados de variantes nos genes da LDLR, PCSK9, APOB e LDLRAP1 sugeridos pelos consensos atuais para confirmar o diagnóstico, tem mostrado serem insuficientes, mostrando baixa porcentagem de confirmação, mesmo nos dos casos em que características fenotípicas apresentam dados sugestivos importantes. A complementação no auxílio diagnóstico com dados epigenéticos tem sido sugerida em muitas doenças, principalmente nas crônicos degenerativos. A metilação do DNA pode estar envolvida no mecanismo que regulam vários processos metabólicos, entre os quais os envolvidos na expressão de proteínas e neste estudo os que estão envolvidos no metabolismo do colesterol, que poderia explicar fenótipos hipercolesterolemicos sem demonstração clara de variantes nos genes de consenso. O objetivo do presente estudo foi comparar o perfil de metilação dos genes LDLR, PCSK9 e LDLRAP1 entre pacientes com diagnóstico de Hipercolesterolemia Familial confirmado através de variantes genéticas descritas na literatura e pacientes sem diagnóstico confirmado. Além da comparação com indíviduos normolipidêmicos. A seleção dos indivíduos foi realizada na Seção de Dislipidemia do Instituto Dante Pazzanese de Cardiologia (IDPC), do Departamento de Análises Clínicas e Toxicológicas da Universidade Federal do Rio Grande do Norte (UFRN), da Universidade Estadual de Campinas (UNICAMP) e da Faculdade de Medicina de São José do Rio Preto (FAMERP). Através dos critérios MEDPED foram selecionados 133 pacientes para a realização do sequenciamento de um painel de genes relacionados ao fenótipo de HF e a homeostasia do colesterol a fim de confirmar o diagnóstico. Todos os pacientes tiveram o DNA purificado, que foi submetido ao tratamento com bissulfito, amplificado, purificado, desnaturado e sequenciado no sistema PyroMark Q24. Avaliou-se o perfil de metilação, em sítio CpG dos genes da LDLR, PCSK9 e LDLR AP1. A análise estatística foi realizada utilizando o software SPSS v.19, GraphPad Prism, versão 1.03 e o e o software R. 4.1.0. Os pacientes foram classificados em Grupo I: Pacientes com diagnóstico molecular confirmado pelo estudo fenotípico e genotipico (n=40); Grupo II: Pacientes fenotipicamente determinados como hipercolesterolemico, mas sem diagnóstico molecular confirmado pelo estudo genomico (n=93); Grupo III: indivíduos fenotipicamente determinados normolipidêmicos de acordo com a V Diretriz Brasileira de Dislipidemia (n=23). A análise comparativa entre os grupos I x II e II x III, demonstrou diferença estatísta significativa em 13 sítios CpG do total de 28 sítios CpG analisados nos três genes. Além disso, foi possível concluir que alterações nos sítios CpG presentes no gene LDLR influenciaram na presença de xantomas e arco córneo. Houve correlação positiva entre a idade e perfil de metilação do gene PCSK9, assim como, alterações nos sítios CpG deste gene influenciaram na presença de arco córneo e IAM. Além disso, alterações no sítio CPG presente no gene LDLRAP1 influenciou no desenvolvimento de DAC, IAM e RM, além da presença de xantelasma

The genotypic variabilities that determine some phenotypic and metabolic alterations can be misdiagnosed if based only on genomic data. In familial hypercholesterolemia (FH) it can be observed that the data of variants in the genes of LDLR, PCSK9, APOB and LDLR AP1 suggested by the current consensus to confirm the diagnosis, has shown to be insufficient, showing a low percentage of confirmation, even in the cases in which phenotypic characteristics present important suggestive data. Complementing the diagnostic aid with epigenetic data has been suggested in many diseases, especially in chronic degenerative diseases. DNA methylation may be involved in the mechanisms that regulate several metabolic processes, including those involved in the expression of proteins that ,in this study, are involved in cholesterol metabolism, which could explain hypercholesterolemic phenotypes without a clear demonstration of variants in consensus genes. The aim of the present study was to compare the methylation profile of LDLR, PCSK9 and LDLRAP1 genes between patients with a diagnosis of Familial Hypercholesterolemia confirmed through genetic variants described in the literature and patients without a confirmed diagnosis. In addition to the comparison with normolipidemic individuals. The selection of individuals was carried out at the Dyslipidemia Section of the Instituto Dante Pazzanese de Cardiologia (IDPC), in the Department of Clinical and Toxicological Analyzes of the Federal University of Rio Grande do Norte (UFRN), in the State University of Campinas (UNICAMP) and in the Faculdade of Medicine of São José do Rio Preto (FAMERP). Through the MEDPED criteria, 133 patients were selected to perform the sequencing of a panel of genes related to the FH phenotype and cholesterol homeostasis in order to confirm the diagnosis. All patients had their DNA purified, which were subjected to bisulfite treatment, amplified, purified, denatured and sequenced on the PyroMark Q24 system. The methylation profile in the CpG site of the LDLR, PCSK9 and LDLRAP1 genes were evaluated. Statistical analysis were performed using SPSS v.19 software, GraphPad Prism, version 1.03 and R. 4.1.0 software. Patients were classified into Group I: Patients with a molecular diagnosis confirmed by phenotypic and genotypic studies (n=40); Group II: Patients phenotypically determined to be hypercholesterolemic, but without a molecular diagnosis confirmed by the genomic study (n=93); Group III: phenotypically determined normolipidemic individuals according to the V Brazilian Dyslipidemia Directive (n=23). The comparative analysis between groups I x II and II x III showed a statistically significant difference in 13 CpG sites of the total of 28 CpG sites analyzed in the three genes of the project. Furthermore, it was possible to conclude that alterations in the CpG sites present in the LDLR gene influenced the presence of xanthomas and arc corneum. There was a positive correlation between age and PCSK9 gene methylation profile, as well as changes in the CpG sites of this gene influenced the presence of arc corneum and AMI. In addition, alterations in the site present in the LDLRAP1 gene are influencing the development of CAD, AMI and MR, in addition to the presence of xanthelasma

Qualidade de vida de pacientes em hemodiálise com doença coronariana versus sem doença coronariana / Quality of life of hemodialysis patients with coronary disease versus no coronary disease

A doença renal crônica (DRC) é um problema da saúde pública mundial e preditora para progressão da doença arterial coronariana (DAC), causando limitações e alterações na vida cotidiana dos pacientes e familiares e, consequentemente, na qualidade de vida. Nesse cenário, o Assistente Social, como integrante da equipe multiprofissional, propõe alternativas de enfrentamento às situações que comprometem o processo da saú - de-doença dos pacientes. O estudo tem como objetivos avaliar o impacto da presença da DAC na qualidade de vida dos pacientes em hemodiálise e identificar as diferenças no perfil sociodemográfico desses pacientes, conforme a presença da doença. Método: Estudo trans - versal e descritivo realizado com 51 pacientes em hemodiálise (30 com DAC e 21 sem DAC), em um hospital universitário de cardiologia de São Paulo, através de questionário de qualidade de vida para pacientes em tratamento dialítico KDQOL-SF TM 1.3, questionário socioeconômico e dados clínicos descritos em prontuário eletrônico. Resultados: No to - tal dos pacientes, houve predomínio do sexo masculino, da cor/raça autodeclarada par - da e preta, ensino fundamental incompleto e em benefício previdenciário/assistencial. Os pacientes sem DAC encontram-se aproximadamente dois anos a mais em tratamento dia - lítico. Entre as dimensões do KDQOL-SF TM 1.3, os pacientes com DAC apresentaram melhores índices de qualidade de vida. Conclusão: A qualidade de vida dos pacientes com DRC em hemodiálise que apresentam diagnóstico de DAC, apresentou-se relativamente melhor do que a dos pacientes sem DAC. Não houve diferenças sociodemográficas relevantes entre os grupo

Chronic kidney disease (CKD) is a worldwide public health problem and a predictor of the progression of coronary artery disease (CAD), causing limitations and changes in the daily lives of patients and their families and, therefore, in their quality of life. In this scenario, the Social Worker, as a member of a multiprofessional team, proposes alternatives for coping with situations that compromise patients' health-disease process. The aims of this study were to assess the impact of the presence of CAD on the quality of life of patients on hemodialysis, and to identify the differences in sociodemographic profile of these patients, according to the presence of CAD. Methods: A cross-sectional, descriptive study was conducted with 51 patients on hemodialysis treatment, (30 with CAD and 21 without CAD), at a university cardiology hospital in the city of São Paulo, using a quality of life questionnaire for patients on dialysis treatment KDQOL-SF TM 1.3, a socioeconomic questionnaire, and clinical data described in the electronic medical records. Results: Of the total patients, there was a predominance of males, with self-declared color/race Brown and Black, incomplete primary education, and receiving social security benefits. The patients without CAD had been in dialysis treatment for approximately two years more. Among the dimensions of the KDQOL-SF TM 1.3, patients with CAD had better quality of life indices. Conclusion: The quality of life of patients with CKD on hemodialysis and diagnosed with CAD was relatively better than that of patients without ut CAD. There were no relevant sociodemographic differences between the group

Avaliação de aspectos funcionais da lipoproteína de alta densidade (HDL) e suas subfrações em pacientes com doença arterial coronária / Evalution of functional aspects from high density lipoproteins (HDL) and their subfractions from coronary heart disease patients

Estudos clínicos e epidemiológicos indicam que baixas concentrações plasmáticas da lipoproteína de alta densidade (HDL) estão forte e independentemente associadas a uma maior incidência de doença arterial coronária (DAC). Entretanto, o insucesso dos agentes que são capazes de aumentar a concentração de HDL-C sugere que a funcionalidade da HDL pode representar um alvo terapêutico mais apropriado. Para a avaliação de um dos aspectos funcionais da HDL, o presente trabalho descreve o desenvolvimento de um método de grande praticidade que permite uma visão integrada de uma etapa fundamental do metabolismo que é a transferência de lípides entre as diferentes classes de lipoproteínas. A avaliação deste fenômeno nas subfrações de HDL, aspecto ainda não explorado, poderá fornecer novas informações a respeito da fisiopatologia da DAC. O método descrito no presente trabalho permite a avaliação da transferência simultânea das quatro principais classes lipídicas doadas por uma nanoemulsão semelhante à LDL para a HDL3. Foi realizada análise dos possíveis interferentes neste método. Verificou-se que a elevação da temperatura de 0 a 40 °C resultou em aumento progressivo na transferência de todos os lipídeos para a HDL3. A variação de pH entre 6,5 e 8,5 e o aumento na concentração de albumina não alteraram os valores de transferência. O aumento no tempo de incubação acima de 60 minutos promoveu diminuição na transferência de colesterol esterificado para a HDL3 e aumento na transferência de fosfolipídeos. O método apresentou boa precisão intra e inter-ensaio, sendo o coeficiente de variação menor que 5% para todos os lipídeos. A porcentagem média de transferência de colesterol livre, fosfolipídeos, triacilglicerol e colesterol em 45 invíduos saudáveis foi de respectivamente de 1,1±0,06; 13,5±0,15; 2±0,05 e 0,84±0,04% e em 45 portadores de doença arterial coronária foi respectimente 1,0±0,04; 15,8±0,44; 1,77±0,04 e 1,0±0,06%. Não houve diferença nos valores de idade, IMC, colesterol total, HDL-C, LDL-C, triacilglicerol, apo A-1, apo B, CETP, PLTP e LCAT, mas os indivíduos portadores de doença arterial coronária apresentaram valores maiores de colesterol livre e colesterol total em relação aos indivíduos saudáveis. O método desenvolvido no presente estudo é prático, preciso e de potencial relevância como ferramenta no estudo dos distúrbios de função da HDL

Clinical and epidemiological studies show that low concentrations of high density lipoproteins (HDL) are strongly and independently associated to an increased incidence of coronary artery disease (CAD). However, the lack of success of some drugs developed to increase HDL cholesterol concentrations (HDL-C) suggests that the functional aspects of HDL may represent a more appropriate therapeutic target. To study one of the functional aspects of HDL, the present work describes the development of a practical method that provides an integrated view of a fundamental step of lipid metabolism, namely, the lipid transfer among different lipoprotein classes. This phenomenon in the HDL subfractions is yet unexplored, and could provide new insights on the pathophysiology of CAD. The method described here allows the measurement of the ability of HDL3 to receive the major lipid classes from a radioactively labeled nanoparticle that resemble LDL. The possible interfering factors at the lipid transfer to HDL3 were studied. The increase in the assay temperature from 0 to 40 °C results in a progressive increase in the net transfer of all lipids to HDL3. The increase in incubation time above 60 minutes resulted in a reduced transfer of cholesterol esters to HDL3 with a concomitant increase in the transfer of phospholipids to the latter. The method presented adequate intra and inter-assay precision, with a coefficient of variation smaller than 5% for all lipids. The average percentage of free cholesterol, phospholipids, triacilglycerol an cholesterol transfer to HDL3 was respectively of 1,1±0,06; 13,5±0,15; 2±0,05 e 0,84±0,04% in 45 healthy individuals and 1,0±0,04; 15,8±0,44; 1,77±0,04 e 1,0±0,06% in 45 CAD patients. There was no difference in the age, BMI, total cholesterol, HDL-C, LDL-C, triacilglycerol, apo A-1, apo B, CETP, PLTP and LCAT but the CAD patients had higher levels of total cholesterol and free cholesterol. The method described here is practical, precise and potentially relevant as a tool to study HDL function

El cirujano cardiovascular y la puntuación Syntax / The cardiovascular surgeon and the Syntax score

Se estableció la puntuación Syntax como herramienta para determinar la complejidad de la enfermedad coronaria y como guía para tomar decisiones entre la cirugía de revascularización coronaria y el intervencionismo coronario percutáneo. El propósito de esta revisión es examinar de manera sistemática qué es la puntuación Syntax, cómo el cirujano debe integrar la información en la selección y tratamiento del paciente. Revisamos los resultados del estudio SYNTAX, las guías de práctica clínica, así como los beneficios y las limitaciones de la puntuación. Finalmente, el rumbo hacia el futuro que tomará la puntuación Syntax.

The Syntax score has been established as a tool to determine the complexity of coronary artery disease and as a guide for decision-making among coronary artery bypass surgery and percutaneous coronary intervention. The purpose of this review is to systematically examine what the Syntax score is, and how the surgeon should integrate the information in the selection and treatment of patients. We reviewed the results of the SYNTAX Trial, the clinical practice guidelines, as well as the benefits and limitations of the score. Finally we discuss the future directions of the Syntax score.

Support vector machines classification for discriminating coronary heart disease patients from non-coronary heart disease / Clasificación con la máquina de vector de apoyo para diferenciar la cardiopatía coronaria de la cardiopatía no coronaria en los pacientes

OBJECTIVE: The present contribution concentrates on the application of support vector machines (SVM) for coronary heart disease and non-coronary heart disease classification. METHODS: We conducted many experiments with support vector machine and different variables of low-density lipoprotein cholesterol (LDLC), high-density lipoprotein cholesterol (HDLC), total cholesterol (TC), triglycerides (TG), glucose and age (dataset 346 patients with completed diagnostic procedures). Linear and non-linear classifiers were compared: linear discriminant analysis (LDA) and SVM with a radial basis function (RBF) kernel as a non-linear technique. RESULTS: The prediction accuracy of training and test sets of SVM were 96.86% and 78.18% respectively, while the prediction accuracy of training and test sets of LDA were 90.57% and 72.73% respectively. The cross-validated prediction accuracy of SVM and LDA were 92.67% and 85.4%. CONCLUSION: Support vector machine can be used as a valid way for assisting diagnosis of coronary heart disease.

OBJETIVO: El presente trabajo trata de la utilización de las máquinas de vector de apoyo a la hora de clasificar cardiopatías coronarias y cardiopatías no coronarias. MÉTODOS: Llevamos a cabo numerosos experimentos con máquinas de vector de apoyo y diferentes variables de colesterol de lipoproteínas de baja densidad (CLBD), colesterol de lipoproteínas de alta densidad (CLAD), colesterol total (TC), triglicéridos (TG), glucosa y edad de nuestro conjunto de datos (346 pacientes con procedimientos de diagnóstico completos). Se compararon los clasificadores lineales y no lineales: el análisis lineal discriminante (ALD) y las máquinas de vector de apoyo (SVM) con un kernel de función de base radial (FBR) como técnica no lineal. RESULTADO: La exactitud de predicción del conjunto de pruebas y de entrenamientos de SVM fue 96.86% y 78.18% respectivamente, mientras que la exactitud de prediccin de los conjuntos de prueba y entrenamientos de ALD fue 90.57% y 72.73% respectivamente. La exactitud de predicción de SVM y ALD tras la validación cruzada fue 92.67% y 85.4%. CONCLUSIÓN: La máquina de vector de apoyo puede usarse como una forma válida de ayuda a la hora de realizar el diagnóstico de la cardiopatía coronaria.

Morphological and morphometric analysis of coronary atherosclerosis--an autopsy study.

Coronary atherosclerosis is the most frequent cause of ischemic heart disease. The composition and vulnerability of the atherosclerotic plaque determines the development of acute coronary syndromes. In this study, 224 advanced atherosclerotic plaques were identified from the main coronary arterial branches of 10 autopsy heart specimens. The plaques were classified by American heart association (AHA) and modified American heart association classification. Vulnerability of the plaques and factors influencing vulnerability were assessed. Vulnerable plaques were mostly of Type IV category of AHA classification and of thin cap fibroatheroma type by modified American heart association classification. Inflammation was more frequent and was of a higher grade in vulnerable plaques. Calcification was predominantly of mild grade.

Selection of patients for myocardial perfusion scintigraphy based on fuzzy sets theory applied to clinical-epidemiological data and treadmill test results

Coronary artery disease (CAD) is a worldwide leading cause of death. The standard method for evaluating critical partial occlusions is coronary arteriography, a catheterization technique which is invasive, time consuming, and costly. There are noninvasive approaches for the early detection of CAD. The basis for the noninvasive diagnosis of CAD has been laid in a sequential analysis of the risk factors, and the results of the treadmill test and myocardial perfusion scintigraphy (MPS). Many investigators have demonstrated that the diagnostic applications of MPS are appropriate for patients who have an intermediate likelihood of disease. Although this information is useful, it is only partially utilized in clinical practice due to the difficulty to properly classify the patients. Since the seminal work of Lotfi Zadeh, fuzzy logic has been applied in numerous areas. In the present study, we proposed and tested a model to select patients for MPS based on fuzzy sets theory. A group of 1053 patients was used to develop the model and another group of 1045 patients was used to test it. Receiver operating characteristic curves were used to compare the performance of the fuzzy model against expert physician opinions, and showed that the performance of the fuzzy model was equal or superior to that of the physicians. Therefore, we conclude that the fuzzy model could be a useful tool to assist the general practitioner in the selection of patients for MPS.