Frequency of Subclinical Atherosclerosis in Brazilian HIV-Infected Patients / Frequência de Aterosclerose Subclínica em Brasileiros Infectados pelo HIV

Abstract Background: AIDS as well as atherosclerosis are important public health problems. The longer survival among HIV-infected is associated with increased number of cardiovascular events in this population, and this association is not fully understood. Objectives: To identify the frequency of subclinical atherosclerosis in HIV-infected patients compared to control subjects; to analyze associations between atherosclerosis and clinical and laboratory variables, cardiovascular risk factors, and the Framingham coronary heart disease risk score (FCRS). Methods: Prospective cross-sectional case-control study assessing the presence of subclinical atherosclerosis in 264 HIV-infected patients and 279 controls. Clinical evaluation included ultrasound examination of the carotid arteries, arterial stiffness by pulse wave velocity (PWV) and augmentation index (AIx), laboratory analysis of peripheral blood, and cardiovascular risk according to FCRS criteria. The significance level adopted in the statistical analysis was p < 0.05. Results: Plaques were found in 37% of the HIV group and 4% of controls (p < 0.001). Furthermore, carotid intima-media thickness was higher in the HIV group than in controls (p < 0.001). Patients with carotid plaque had higher fasting glucose, total cholesterol, low-density lipoprotein cholesterol, and triglycerides than those without plaques. The presence of HIV, adjusted for age, overweight/obesity, and smoking increased by almost fivefold the risk of atherosclerotic carotid plaque (OR: 4.9; 95%CI: 2.5-9.9; p < 0.001). Exposure to protease inhibitors did not influence carotid intima-media thickness, was not associated with carotid plaque frequency, and did not alter the mechanical characteristics of the arterial system (PWV and AIx). Conclusions: HIV-infected patients are at increased risk of atherosclerosis in association with classical cardiovascular risk factors. Treatment with protease inhibitors does not promote functional changes in the arteries, and shows no association with increased frequency of atherosclerotic plaques in carotid arteries. The FCRS may be inappropriate for this population.

Resumo Fundamento: Aterosclerose e AIDS são importantes problemas de saúde pública. A maior sobrevida de indivíduos infectados pelo HIV acha-se associada com maior número de eventos cardiovasculares nessa população, mas tal associação ainda não foi completamente esclarecida. Objetivos: Identificar a frequência de aterosclerose subclínica em pacientes infectados pelo HIV em comparação a controles; analisar as associações entre aterosclerose e variáveis clínicas e laboratoriais, fatores de risco cardiovascular e escore de risco de Framingham (ERF) para doença coronariana. Métodos: Estudo prospectivo transversal caso-controle avaliando a presença de aterosclerose subclínica em 264 pacientes infectados pelo HIV e 279 controles. A avaliação clínica incluiu ultrassonografia das artérias carótidas, análise da rigidez arterial através da velocidade de onda de pulso (VOP) e augmentation index (AIx), exames laboratoriais do sangue periférico e determinação do risco cardiovascular segundo os critérios do ERF. O nível de significância adotado na análise estatística foi p < 0,05. Resultados: Placas foram identificadas em 37% do grupo infectado pelo HIV e em 4% dos controles (p < 0,001). A espessura médio-intimal carotídea foi maior no grupo HIV do que nos controles (p < 0,001). Pacientes com placa carotídea apresentaram maiores níveis de glicemia de jejum, colesterol total, colesterol da lipoproteína de baixa densidade e triglicérides do que aqueles sem placas. A presença do HIV, ajustada por idade, sobrepeso/obesidade e tabagismo aumentou em quase cinco vezes o risco de placa aterosclerótica carotídea (OR: 4,9; IC95%: 2,5-9,9; p < 0,001). Exposição aos inibidores da protease não influenciou a espessura médio-intimal carotídea, não se associou com frequência de placa carotídea e não alterou as características mecânicas do sistema arterial (VOP e AIx). Conclusões: Pacientes infectados pelo HIV apresentam maior risco de aterosclerose na associação com os clássicos fatores de risco cardiovascular. Tratamento com os inibidores da protease não promove alterações funcionais nas artérias, nem se associa com maior frequência de placas ateroscleróticas carotídeas. O ERF pode ser inadequado para essa população.

Estimation of cardiovascular risk and detection of subclinical carotid atheromatosis in patients with diabetes without a history of cardiovascular disease

ABSTRACT Objectives Cardiovascular risk estimated by several scores in patients with diabetes mellitus without a cardiovascular disease history and the association with carotid atherosclerotic plaque (CAP) were the aims of this study. Materials and methods Cardiovascular risk was calculate using United Kingdom Prospective Diabetes Study (UKPDS) risk engine, Framingham risk score for cardiovascular (FSCV) and coronary disease (FSCD), and the new score (NS) proposed by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol. Ultrasound was used to assess CAP occurrence. A receiver operating characteristic (ROC) analysis was performed. Results One hundred seventy patients (mean age 61.4 ± 11 years, 58.8% men) were included. Average FSCV, FSCD and NS values were 33.6% ± 21%, 20.6% ± 12% and 24.8% ± 18%, respectively. According to the UKPDS score, average risk of coronary disease and stroke were 22.1% ± 16% and 14.3% ± 19% respectively. Comparing the risks estimated by the different scores a significant correlation was found. The prevalence of CAP was 51%, in patients with the higher scores this prevalence was increased. ROC analysis showed a good discrimination power between subjects with or without CAP. Conclusion The cardiovascular risk estimated was high but heterogenic. The prevalence of CAP increased according to the strata of risk. Understanding the relationship between CAP and scores could improve the risk estimation in subjects with diabetes.

Medición de la ingestión de sodio en la dieta de un grupo de niños entre uno y 18 meses de edad en una consulta pediátrica en Cali, Colombia / Measurement of dietary sodium intake in a group of children from one to 18 months of age in a pediatric service in Cali, Colombia

Resumen Introducción. Las estrías de grasa en la pared arterial pueden aparecer desde el tercer año Resumende vida y se relacionan con factores de riesgo aterogénico, como la hipertensión arterial sistémica y el contenido de sodio en la dieta. En pocos estudios se reporta el consumo de sodio en la dieta debido a la dificultad para la recolección de los datos. Objetivo. Determinar el consumo promedio de sodio en la dieta de niños de uno a 18 meses de edad, mediante una encuesta sobre la dieta a lo largo de tres días. Materiales y métodos. Se hizo un estudio de corte transversal con 48 niños sin enfermedad renal ni restricciones en la dieta, atendidos en consulta pediátrica entre enero y junio del 2011, el cual incluyó una encuesta sobre la dieta a los padres y la clasificación del estado nutricional por antropometría y medición de la presión arterial. Se analizaron el contenido de sodio y demás nutrientes de la dieta con el Programa Internacional de Consumo de Alimentos (CERES), las medidas antropométricas con el programa Anthro de la Organización Mundial de la Salud y las características sociodemográficas con el programa de Epi-info. Resultados. El 69 % de los niños tenía un consumo alto de sodio, el 6,2 % presentaba presión arterial elevada, y el 20,7 %, sobrepeso y obesidad. Conclusiones. La prevalencia de hipertensión arterial sistémica superó la informada para Colombia (1 a 3 %). Dos de los tres niños con presión arterial elevada tenían una dieta rica en sodio, así como sobrepeso y obesidad con valores superiores a lo informado para Colombia (16 %). Se sugiere medir la presión arterial tempranamente, recomendar la restricción de sal y azúcar en la alimentación de los menores de dos años, desarrollar estudios más grandes para obtener datos poblacionales sobre la ingestión de sodio, y diseñar estrategias de intervención, adecuadas y oportunas, para disminuir los riesgos en la edad adulta.

Abstract Introduction: The fatty streaks in an arterial wall can appear from the third year of age, and they show an association with atherogenic risk factors such as hypertension and sodium in the diet. Given the difficulty of data gathering, few studies report the intake of sodium in the diet. Objective: To determine average sodium intake in the diet of children between one and 18 months of age through a three-day dietary survey. Materials and methods: This was a cross-sectional study with 48 children without renal disease or diet restrictions seen in pediatric practice between January and June, 2011. It included a dietary survey for the parents, nutritional status classification by anthropometry, and blood pressure measurements. Sodium content and other nutrients in the diet program were analyzed with the International Food Consumption Program (CERES), anthropometry with the World Health Organization Anthro program, and Epi-info for socio-demographic characteristics. Results: In total, 69% of children had high sodium consumption, 6.2% had high blood pressure, and 20.7% were overweight and obese. Conclusions: The prevalence of hypertension exceeds that reported for Colombia (1-3%). Two of the three children with high blood pressure had high sodium intake and they were overweight and obese, with values above those reported for Colombian children (16%). We suggest to measure blood pressure early, and to restrict salt and sugar in food for infants and children under two years of age. Also, larger studies should be conducted to collect population data on sodium intake and develop appropriate and timely intervention strategies to reduce risks in adulthood.

La diabetes y la alimentación determinantes en la progresión de aterosclerosis / Diabetes and type of diet as determinant factor in the progression of atherosclerosis

Resumen El propósito de esta revisión es analizar la progresión bioquímica de la placa aterosclerótica y la relación que presenta con la diabetes y la alimentación. Se exponen las evidencias científicas de pacientes con diabetes, que a diferencia de pacientes no diabéticos presentan niveles más elevados de algunos ácidos grasos en la placa de ateroma (como el palmítico, linoleico y oleico), elevada incidencia de trombosis coronaria relacionada con el incremento en el tamaño de la base necrótica y la disminución del tamaño de la capa fibrosa de los ateromas. Entre ambos grupos de pacientes se expone la diferencia en el perfil de lípidos de la placa aterosclerótica, así como los cambios celulares involucrados en la formación de la misma y la influencia de la alimentación sobre su desarrollo.

Abstract The purpose of this review is to analyze the biochemical progression of atherosclerotic plaque and its association with diet and diabetes. This study shows the scientific evidence of demonstrating that diabetic patients present high levels of fatty acids like palmitic acid and linoleic acid in their atheroma plaques in comparison with non-diabetic patients. This study also establishes how patients with diabetes mellitus have a higher prevalence of atherosclerotic heart diseases in the form of Coronary Thrombosis and have different anatomopathological appearance like higher necrotic core and thin fibrotic layer than the general population. Furthermore this review describes the different anatomopathological appearance and cellular changes involved in the formation of these plaques and how diet can affect the development of these plaques.

Preditores de Placa Aterosclerótica em Assintomáticos Isquêmicos à Ecocardiografia sob Estresse Físico / Predictors of Atherosclerotic Plaque in Individuals with Asymptomatic Ischemia on Physical Stress Echocardiography

A isquemia miocárdica pode ocorrer em pacientes assintomáticos e sem história de doença arterial coronariana (DAC). A ecocardiografia sob estresse físico (EEF) é um método de boa acurácia diagnóstica, enquanto a cineangiocoronariografia (CATE) é o método padrão-ouro para detecção de DAC obstrutiva. Todavia, muitos portadores de isquemia em testes funcionais apresentam lesões não obstrutivas à CATE. Objetivo: Identificar a presença de preditores de placas ateroscleróticas obstrutivas à CATE em indivíduos assintomáticos com EEF positiva para isquemia miocárdica. Métodos: Estudo transversal com 278 pacientes assintomáticos submetidos à EEF e à CATE, divididos em grupo G1 (lesões ateroscleróticas obstrutivas ≥ 50%) e G2 (placas inferiores a 50% ou inexistentes). Variáveis quantitativas foram comparadas com os testes t de Student ou Mann-Whitney para grupos independentes, segundo a normalidade da amostra. Para variáveis categóricas, utilizou-se os testes do qui-quadrado ou exato de Fisher, quando apropriado. Para identificação de preditores independentes de lesão aterosclerótica, foi utilizada regressão logística. Resultados: O número de pacientes nos grupos G1 e G2 foi de 233 (83,3%) e 45 (16,2%), respectivamente. A média de idade foi maior no G1 (60,9 ± 9,56 anos versus 51,8 ± 10,05 anos, respectivamente, p < 0,001). O G1 em comparação ao G2 apresentou mais pacientes hipertensos (65,2% versus 48,9%, p = 0,03) e dislipidêmicos (77,3% versus 57,8%, respectivamente, p = 0,006). O G2 em comparação ao G1 apresentou maior frequência de obesidade leve (33,3% versus 14,2%, respectivamente, p = 0,002), que demonstrou ser um fator protetor para lesão aterosclerótica. Conclusão: Os preditores de placa aterosclerótica em assintomáticos isquêmicos à EEF foram idade, gênero masculino e isquemia do tipo fixa.

Myocardial ischemia may occur in asymptomatic patients without a history of coronary artery disease (CAD). Stress echocardiography (SE) is a method with good diagnostic accuracy, while coronary cineangiography (CCA) is the gold standard method to detect obstructive CAD. However, many patients with ischemia on functional tests show nonobstructive lesions on CCA. Objective: To assess the presence of predictors of obstructive atherosclerotic plaques in asymptomatic individuals with an SE positive for myocardial ischemia. Methods: Cross-sectional study with 278 asymptomatic individuals who underwent SE and CCA, divided into groups G1 (obstructive atherosclerotic lesions ≥ 50%) and G2 (plaques below 50% or nonexistent). Quantitative variables were compared with Student's t test or Mann-Whitney test for independent groups, according to the normality of the sample. For categorical variables, we used the chi-square test or Fisher's exact test, as appropriate. Logistic regression was used to identify independent predictors of atherosclerotic lesions. Results: The numbers of patients in G1 and G2 were 233 (83.3%) and 45 (16.2%), respectively. The mean age was higher in G1 (60.9 ± 9.56 years versus 51.8 ± 10.05 years, p < 0.001). G1, when compared with G2, had more patients with hypertension (65.2% versus 48.9%, respectively, p = 0.03) and dyslipidemia (77.3% versus 57.8%, respectively, p = 0.006). G2, when compared with G1, had a higher frequency of mild obesity (33.3% versus 14.2%, respectively, p = 0.002), which emerged as a protective factor for atherosclerotic lesions. Conclusion: The predictors of atherosclerotic plaques in asymptomatic patients with ischemia on SE were age, male gender, and fixed ischemia.