Diretriz Brasileira de Reabilitação Cardiovascular ­ 2020 / Brazilian Cardiovascular Rehabilitation Guideline - 2020

INTRODUÇÃO: Está cientificamente comprovado, sendo algo incorporado ao senso comum, que ser fisicamente ativo contribui para preservar e recuperar a boa saúde do corpo e da mente. Os efeitos favoráveis da reabilitação cardiovascular (RCV) com ênfase nos exercícios físicos têm sido consistentemente documentados, inclusive em meta-análises de estudos clínicos randomizados, que demonstram significativas reduções da morbimortalidade cardiovascular e global,1 bem como da taxa de hospitalização,1,2 com expressivo ganho de qualidade de vida,1,2 justificando a sua consensual e enfática recomendação pelas principais sociedades médicas mundiais.3-6 O sedentarismo, que apresenta elevada prevalência no Brasil e no mundo, está fortemente relacionado às doenças cardiovasculares (DCV) e à mortalidade precoce.7,8 Em contrapartida, maiores volumes de atividade física são positivamente associados à melhor qualidade e à maior expectativa de vida,9-13 existindo uma forte e inversa associação dos diferentes componentes da aptidão física com a mortalidade por todas as causas e com a ocorrência de eventos cardiovasculares desfavoráveis. Ou seja, quanto menor o nível de aptidão física, maior tende ser a taxa de mortalidade.14-21 Portanto, o principal objetivo da RCV com ênfase nos exercícios físicos é propiciar uma melhora dos componentes da aptidão física, tanto aeróbico quanto não aeróbicos (força/ potência muscular, flexibilidade, equilíbrio), algo que exige a combinação de diferentes modalidades de treinamento. Assim, a RCV deve proporcionar os mais elevados níveis de aptidão física passíveis de obtenção, de modo a reduzir o risco de eventos cardiovasculares e promover todos os outros benefícios a serem auferidos pela prática regular de exercícios físicos, culminando com a redução da mortalidade geral.

Exercise through a cardiac rehabilitation program attenuates oxidative stress in patients submitted to coronary artery bypass grafting.

BACKGROUND: Cardiovascular disease is the main cause of morbidity and mortality in the world and oxidative stress has been implicated in the pathogenesis. Cardiac rehabilitation in patients with coronary artery disease submitted to coronary artery bypass grafting may prevent cardiovascular events probably through the attenuation of oxidative stress. The aim of this study was to evaluate the benefits of a cardiac rehabilitation program in the control of the systemic oxidative stress. METHODS: The studied population consisted of 40 patients, with chronic stable coronary artery disease submitted to coronary artery bypass grafting, who attended a cardiac rehabilitation program. Biomarkers of oxidative stress were evaluated in the blood of these patients at different moments. RESULTS: After the onset of cardiac rehabilitation, there was a significant and progressive decrease in thiobarbituric acid reactive substances levels and protein carbonyls, an initial increase and subsequent decrease in superoxide dismutase, catalase and glutathione peroxidase activities. Also, a progressive increase of uric acid, while ferric reducing antioxidant power levels increased only at the end of the cardiac rehabilitation and a tendency to increase of glutathione contents. CONCLUSIONS: The results suggest that regular exercise through a cardiac rehabilitation program can attenuate oxidative stress in chronic coronary artery disease patients submitted to coronary artery bypass grafting.

Clinical, scintigraphic, and angiographic predictors of oxygen pulse abnormality in patients undergoing cardiopulmonary exercise testing.

BACKGROUND: The oxygen (O2 ) pulse curve obtained at cardiopulmonary exercise testing provides information on cardiorespiratory fitness and the presence of cardiovascular disease. O2 pulse abnormalities have been attributed to myocardial ischemia, among other conditions, but the predictors of abnormal O2 pulse curves are not completely known. HYPOTHESIS: Perfusion abnormalities detected by myocardial perfusion scintigraphy (MPS) may be associated with abnormal O2 pulse curves. METHODS: Forty patients with normal left ventricular function underwent cardiopulmonary exercise testing with radiotracer injection at peak exercise, followed by MPS. The O2 pulse curves were classified as (A) normal; (B) probably normal (normal slope with lower peak value); (C) probably abnormal (flat, with low peak value); or (D) definitely abnormal (descending slope), and analyzed as A/B vs C/D. Coronary artery disease (CAD) was defined as >50% stenosis. MPS perfusion scores were calculated (summed rest score [SRS], indicating myocardial fibrosis; summed difference score, indicating ischemia). RESULTS: Comparing patients with A/B vs C/D curves, the latter were more frequently female and had higher SRS. The prevalence of ischemic MPS, of any CAD, or multivessel CAD was not significantly different among patients with A/B or C/D curve patterns. On logistic regression, female sex, body mass index, and the SRS were significantly associated with C/D curves. CONCLUSIONS: Female sex, increasing body mass index, and myocardial fibrosis were significant predictors of abnormal O2 pulse curves. Myocardial ischemia and the presence and extent of CAD were not associated with the abnormal patterns of the O2 pulse curve.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation.

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test. Resumo O teste cardiopulmonar de exercício (TCPE) vem ganhando importância crescente como método de avaliação funcional tanto no Brasil quanto no Mundo. Nas suas aplicações mais frequentes, o teste consiste em submeter o indivíduo a um exercício de intensidade gradativamente crescente até a exaustão ou o surgimento de sintomas e/ou sinais limitantes. Neste exame se mensura a ventilação (VE), o consumo de oxigênio (VO2), a produção de gás carbônico (VCO2) e as demais variáveis de um teste de exercício convencional. Adicionalmente, podem ser verificadas, em situações específicas, a oximetria de pulso e as alças fluxo-volume antes, durante e após o esforço. A análise integrada dos dados permite a completa avaliação dos sistemas cardiovascular, respiratório, muscular e metabólico no esforço, sendo considerado padrão-ouro na avaliação funcional cardiorrespiratória.1-6 O TCPE permite definir mecanismos relacionados à baixa capacidade funcional, os quais podem ser causadores de sintomas como a dispneia, correlacionando-os com alterações dos sistemas cardiovascular, pulmonar e musculoesquelético. Também pode ser de grande aplicabilidade na avaliação prognóstica em cardiopatas, pneumopatas e em pré-operatório, além de auxiliar na prescrição mais criteriosa do exercício em sujeitos normais, em atletas, em cardiopatas e em pneumopatas. Assim como ocorre com o uso clínico, a pesquisa nesse campo também cresce e várias contribuições científicas de pesquisadores nacionais são publicadas em periódicos de alto fator de impacto. Sendo assim, o objetivo deste documento é fornecer uma revisão ampla da aplicabilidade do TCPE nas diferentes situações clínicas, bem como servir como guia prático na interpretação desse teste propedêutico.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation / Teste Cardiopulmonar de Exercício: Fundamentos, Aplicabilidade e Interpretação

ABSTRACT Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

RESUMO O teste cardiopulmonar de exercício (TCPE) vem ganhando importância crescente como método de avaliação funcional tanto no Brasil quanto no Mundo. Nas suas aplicações mais frequentes, o teste consiste em submeter o indivíduo a um exercício de intensidade gradativamente crescente até a exaustão ou o surgimento de sintomas e/ou sinais limitantes. Neste exame se mensura a ventilação (VE), o consumo de oxigênio (VO2), a produção de gás carbônico (VCO2) e as demais variáveis de um teste de exercício convencional. Adicionalmente, podem ser verificadas, em situações específicas, a oximetria de pulso e as alças fluxo-volume antes, durante e após o esforço. A análise integrada dos dados permite a completa avaliação dos sistemas cardiovascular, respiratório, muscular e metabólico no esforço, sendo considerado padrão-ouro na avaliação funcional cardiorrespiratória.1-6 O TCPE permite definir mecanismos relacionados à baixa capacidade funcional, os quais podem ser causadores de sintomas como a dispneia, correlacionando-os com alterações dos sistemas cardiovascular, pulmonar e musculoesquelético. Também pode ser de grande aplicabilidade na avaliação prognóstica em cardiopatas, pneumopatas e em pré-operatório, além de auxiliar na prescrição mais criteriosa do exercício em sujeitos normais, em atletas, em cardiopatas e em pneumopatas. Assim como ocorre com o uso clínico, a pesquisa nesse campo também cresce e várias contribuições científicas de pesquisadores nacionais são publicadas em periódicos de alto fator de impacto. Sendo assim, o objetivo deste documento é fornecer uma revisão ampla da aplicabilidade do TCPE nas diferentes situações clínicas, bem como servir como guia prático na interpretação desse teste propedêutico.

Avaliação do prognóstico na cardiomiopatia Chagásica através do teste cardiopulmonar de exersício / Chagas' Cardiomyopathy prognosis assessment through cardiopulmonar exercise testing

Fundamentos: A insuficiência cardíaca de etiologia chagásica (ICCh) parece ter maior mortalidade que a de outrascom disfunção sistólica. O teste cardiopulmonar de exercício (TCPE) é uma ferramenta de avaliação prognósticaainda pouco estudada na cardiopatia chagásica.Objetivo: Avaliar se o TCPE pode discriminar as diferenças prognósticas da ICCh em comparação às de etiologianão chagásica (ICNCh) e verificar quais das suas variáveis são preditoras independentes de mau prognóstico.Métodos: Análise retrospectiva de 21 pacientes com ICCh e 76 pacientes com ICNCh encaminhados ao TCPE, eseguidos quanto à sua mortalidade em dois anos.Resultados: No seguimento, houve óbito de 5 pacientes no grupo chagásico (GC) e 25 no grupo não chagásico(GNC). A curva de Kaplan-Meier não mostrou diferença na curva de sobrevida entre os grupos (p=0,43). Aregressão logística encontrou a potência circulatória como uma variável preditora independente para óbito paraambos os grupos, com uma razão de risco para o GC de 17,3 (IC95% 1,39-217,0; p=0,027) e no GNC de 4,8(IC95% 1,59-14,6; p=0,005). A curva ROC para esta variável encontrou uma área de 0,91 (IC95% 0,78-1,00; p=0,006)com um valor de corte ≤1 280 mmHg.mL.kg-1.min-1 no GC e uma área de 0,75 (IC95% 0,64-0,86; p<0,0001) com umvalor de corte de ≤1 245 mmHg.mL.kg-1.min-1 no GNC.Conclusão: A potência circulatória foi a variável associada à morte em ambos os grupos, e deve ser mais amplamenteutilizada como indicador de prognóstico na insuficiência cardíaca.

Background: Chagas heart failure (CHF) seems to have higher mortality than other systolic dysfunction conditions. Cardiopulmonaryexercise testing (CPET) is a prognostic assessment tool that is still little studied in Chagas heart disease.Objective: To assess whether CPET can discriminate the prognostic differences of CHF compared to non-Chagas heart failures(NCHF) and determine which of its variables are independent predictors of poor prognosis.Methods: Retrospective analysis of 21 patients with CHF and 76 patients with NCHF referred to CPET and followed up formortality in two years.Results: During follow-up, 5 patients died in the Chagas group (CG) and 25 in the non-Chagas group (NCG). The Kaplan-Meiercurve showed no difference in the survival curve between groups (p=0.43). Logistic regression found the circulatory power as anindependent predictor of death for both groups, with a hazard ratio for the CG of 17.3 (95% CI 1.39-217.0; p=0.027) and for theNCG of 4.8 (95% CI 1.59-14.6; p=0.005). The ROC curve for this variable found an area of 0.91 (95% CI 0.78-1.00; p=0.006) witha cutoff value ≤1280 mmHg.mL.kg-1.min-1 in the CG and an area of 0.75 (95% CI 0.64-0.86; p<0.0001) with a cutoff value of≤1245 mmHg.mL.kg-1.min-1 in the NCG.Conclusion: Circulatory power was the variable associated with death in both groups and should be more widely used as an indicatorof prognosis in heart failure.

Correlação entre função diastólica e potência aeróbica em atletas de futebol profissional / Correlation betweeen diastolic function and aerobic power in professional soccer players

Introdução: O alto consumo máximo de oxigênio (V’O2máx) dos atletas deve-se às adaptações periféricas, e principalmente miocárdicas, relacionadas ao treinamento. Embora as modificações estruturais do coração do atleta, associadas a essas adaptações, sejam bem conhecidas, há limitadas informações sobre o papel da função ventricular como preditor da capacidade de exercício. Objetivo: Identificar índices de avaliação de potência aeróbica máxima em jogadores profissionais de futebol, a partir da análise da função diastólica à ecocardiografia de repouso. Métodos: Estudo prospectivo envolvendo 66 jogadores profissionais e 39 indivíduos não atletas (controles) submetidos a exame ecocardiográfico para análise de parâmetros da função diastólica em repouso [velocidades diastólicas iniciais (E e E’), velocidade diastólica final (A) e relações E/A e E/E’] e a teste ergométrico até a exaustão para análise do V’O2máx. Resultados: Os atletas apresentaram maior relação E/A (p= 0,008) e menor velocidade de A (p= 0,023), quando comparados com os não atletas. Houve correlação do V’O2máx com a velocidade de A (r= -0,268; p= 0,037) e E’ (r= 0,306; p= 0,018) nos atletas e com a relação E/A nos atletas (r= 0,314; p= 0,014) e nos não atletas (r= 0,347; p= 0,036). Após regressão linear múltipla, apenas a relação E/A mostrou contribuição independente para o V’O2máx. Conclusão: O V’O2máx em atletas de futebol está relacionado a alguns parâmetros ecocardiográficos em repouso, sendo a relação E/A o único preditor independente da potência aeróbica máxima neste grupo.

Introduction: High maximal oxygen uptake (V’O2max) in athletes is attributed to peripheral and especially myocardial adaptations to physical training. Structural changes in the “athlete’s heart,” associated with these adjustments, are well known. However, there is limited information on the role of ventricular function as a predictor of exercise capacity. Objective: This study aimed to identify indexes for the assessment of maximal aerobic power in professional soccer players based on the analysis of diastolic function on echocardiography at rest. Methods: This prospective study involved 66 professional soccer players and 39 non-athletes (controls) who underwent echocardiographic examination for analysis of diastolic function parameters at rest [early diastolic velocities (E and E’), late diastolic velocity (A), and E/A and E/E’ ratios] and exercise test to exhaustion for analysis of V’O2max. Results: Athletes had higher E/A ratio (p= 0.008) and lower A velocity (p= 0.023) when compared with non-athletes. There was a correlation of V’O2max with A (r= -0.268, p= 0.037) and E’ (r= 0.306, p= 0.018) velocities in athletes and with E/A ratio in both athletes (r= 0.314, p= 0.014) and non-athletes (r= 0.347, p= 0.036). After multiple regression analysis, only E/A ratio had an independent contribution to V’O2max. Conclusions: V’O2max in soccer players is related to some echocardiographic parameters at rest. E/A ratio was the only independent predictor of maximal aerobic power in this group. These findings may contribute to the assessment of aerobic fitness and provide information that may be applied to training in order to improve the performance of athletes during sports activities.

Avaliação dos benefícios funcionais de um programa de reabilitação cardíaca / Evaluation of the functional benefits of a cardiac rehabilitation program

Fundamentos: Um grande número de estudos tem confirmado que o treinamento físico é um dos métodos mais eficazes para melhorar a capacidade funcional e o bem-estar dos pacientes cardiopatas. Objetivo: Avaliar os benefícios clínicos e funcionais do Programa de Reabilitação Cardíaca em pacientes encaminhados ao Centro de Cardiologia do Exercício do Instituto Estadual de Cardiologia Aloysio de Castro, Rio de Janeiro. Métodos: Foi realizado um estudo retrospectivo tipo coorte, comparativo antes e depois da participação no Programa de Reabilitação Cardíaca numa amostra de 88 indivíduos (60 homens e 28 mulheres) com idade entre37 anos e 81 anos. A maioria dos pacientes era portadora de doença coronariana estável. As principais variáveis analisadas dos testes ergométricos foram a duração doexercício, consumo de oxigênio do pico de exercício (VO2pico), o equivalente metabólico (MET), o déficit aeróbico funcional (FAI), o duplo-produto no pico do exercício(DP pico), a redução da frequência cardíaca no primeiro minuto da recuperação, a presença de isquemia, a classe funcional segundo a NYHA e a aptidão cardiorrespiratória (APCR) segundo a American Heart Association. Resultados: Houve melhora significativa da maioria das variáveis analisadas tais como da capacidade funcional,da duração do exercício, do VO2 pico, da quantidade deMET obtidos, do FAI, e da APCR (p<0,0001). Não foram observadas diferenças significativas em relação ao duplo produto(p=0,1359). Conclusão: O Programa de Reabilitação Cardíaca utilizado neste estudo proporcionou significativa melhora dos parâmetros fisiológicos, hemodinâmicos, funcionais e autonômicos dos pacientes e, consequentemente, no desempenho cardiovascular e metabólico no exercício.

Background: A great number of studies have confirmed that physical training is one of the most effective methods of improving functional capacity and well-being in patients with heart disease.Objective: To evaluate the clinical and functional benefits of the Cardiac Rehabilitation Program in patients referred to the Cardiac Exercise Center at the Aloysio de Castro State Institute of Cardiology in Rio de Janeiro, Brazil.Methods: A retrospective comparative cohort study was conducted of a sample of 88 individuals (60 men and 28 women) between 37 and 81 years old. Most of the patients had stable coronary artery disease. The main parameters analyzed for the treadmill tests wereexercise duration, peak oxygen consumption (peak VO2), metabolic equivalent (MET), functional aerobicimpairment (FAI), peak exercise double product (peak DP), reduction in heart rate for the first minute of recovery, presence of ischemia, NYHA functional class and American Heart Association cardiorespiratory fitness. Results: There was significant improvement in mostof the parameters analyzed, such as functional capacity, exercise duration, peak VO2, MET achieved, FAI and cardiorespiratory fitness (p<0.0001). There was no significant difference for the double product (p=0.1359). Conclusion: The Cardiac Rehabilitation Program used in this study provided significant improvements in the physiological, hemodynamic, functional and autonomic parameters of the patients and consequently their cardiovascular and metabolic exerciseperformance.

Avaliação clínica e funcional tardia de arritmias em crianças operadas de Tetralogia de Fallot / Late clinical and functional assessment of arrhythmias in children after repair of Tetralogy of Fallot / Evaluación clínica y funcional tardía de arritmias en niños operados de tetralogía de Fallot

FUNDAMENTO: Arritmias cardíacas são a maior causa de morte súbita tardia em pacientes operados de Tetralogia de Fallot (TF). OBJETIVO: Avaliar a ocorrência de arritmias cardíacas em crianças e adolescentes operados de TF, associando-as aos aspectos clínicos e de exames complementares. MÉTODOS: Estudo transversal em 37 pacientes submetidos a cirurgia de TF no Instituto Estadual de Cardiologia Aloysio de Castro (RJ). Após revisão de prontuários e avaliação clínica, os pacientes foram submetidos a eletrocardiograma (ECG), ecocardiograma (Eco), Holter 24h (Holter) e teste ergométrico (TE), sendo os resultados submetidos a análise estatística. RESULTADOS: Estudados 37 pacientes, 54 por cento masculinos, idade 9,7 ± 3,5 anos, seguimento médio de 4,7 ± 1,9 anos. Alterações mais prevalentes: ECG: bloqueio de ramo direito (89 por cento); Eco: insuficiência pulmonar grave (43 por cento), estenose pulmonar leve (73 por cento), hipertrofia ventricular direita (HVD) moderada (57 por cento). No TE, baixa capacidade de exercício (90 por cento), déficit cronotrópico (40 por cento), arritmias (20 por cento). Ao Holter, 59 por cento apresentaram arritmias: ventriculares 44 por cento, supraventriculares 38 por cento e ambas 24 por cento, com predomínio de extrassístoles pouco frequentes e benignas. Cinco pacientes (15 por cento) apresentaram extrassístoles polimórficas. Houve associação entre arritmia ventricular e HVD moderada e grave (p=0,026) e também com gradiente ventrículo direito-artéria pulmonar (VD/AP) > 45 mmHg (p=0,004). Através da Regressão Logística, o aumento do gradiente VD/AP foi fator preditivo independente para arritmia ventricular (p=0,017). CONCLUSÃO: Arritmias cardíacas foram um achado comum em grande parte de crianças e adolescentes após reparo cirúrgico de TF, porém pouco frequentes e benignas, na maioria dos casos. O gradiente pressórico VD-AP foi considerado forte preditor para arritmia ventricular.

BACKGROUND: Cardiac arrhythmias are the major cause of late sudden death in patients undergoing repair of Tetralogy of Fallot (TF). OBJECTIVE: To evaluate the occurrence of cardiac arrhythmias in children and adolescents undergoing repair of TF, and to associate them with clinical aspects and laboratory tests. METHODS: Cross-sectional study of 37 patients undergoing repair of TF at Instituto Estadual de Cardiologia Aloysio de Castro (Rio de Janeiro). After review of the medical records and clinical assessment, the patients underwent electrocardiography (ECG), echocardiography (Echo), 24-h Holter monitoring and exercise test (ET), whose results were subjected to statistical analysis. RESULTS: A total of 37 patients of whom 54 percent were males with a mean age of 9.7 ± 3.5 years and mean follow-up period of 4.7 ± 1.9 years were studied. The abnormalities most frequently found were: on ECG: right bundle branch block (89 percent); Echo: severe pulmonary regurgitation (43 percent), mild pulmonary stenosis (73 percent), moderate right ventricular hypertrophy (RVH, 57 percent); on ET: low exercise capacity (90 percent), impaired chronotropic response (40 percent), arrhythmias (20 percent); on Holter monitoring: arrhythmias (59 percent, of which 44 percent were ventricular, 38 percent supraventricular, and 24 percent both ventricular and supraventricular, with predominance of infrequent and benign ventricular premature beats). Five patients (15 percent) presented with multiform ventricular premature beats. There was an association of ventricular arrhythmia with moderate and severe RVH (p=0.026), as well as with right ventricle-to-pulmonary artery gradient (RV/PA) > 45 mmHg (p=0.004). The logistic regression analysis showed that increased RV/PA gradient was an independent predictor of ventricular arrhythmia (p=0.017). CONCLUSION: Cardiac arrhythmia was a common finding in a large proportion of children and adolescents after surgical repair of TF; however, it was infrequent and benign in most of the cases. The RV/PA gradient was considered a strong predictor of ventricular arrhythmia.

FUNDAMENTO: Arritmias cardíacas son la mayor causa de muerte súbita tardía en pacientes operados de Tetralogía de Fallot (TF). OBJETIVO: Evaluar la ocurrencia de arritmias cardíacas en niños y adolescentes operados de TF, asociándolas a los aspectos clínicos y de exámenes complementarios. MÉTODOS: Estudio transversal en 37 pacientes sometidos a cirugía de TF en el Instituto Estadual de Cardiología Aloysio de Castro (RJ). Tras revisión de prontuarios y evaluación clínica, los pacientes fueron sometidos a electrocardiograma (ECG), ecocardiograma (Eco), Holter 24h (Holter) y prueba ergométrica (PE), siendo los resultados sometidos al análisis estadístico. RESULTADOS: Estudiados 37 pacientes, el 54 por ciento masculinos, edad 9,7 ± 3,5 años, seguimiento promedio de 4,7 ± 1,9 años. Cambio más prevalentes: ECG: bloqueo de rama derecha (89 por ciento); Eco: insuficiencia pulmonar severa (43 por ciento), estenosis pulmonar ligera (73 por ciento), hipertrofia ventricular derecha (HVD) moderada (57 por ciento). En la PE, baja capacidad de ejercicio (90 por ciento), déficit cronotrópico (40 por ciento), arritmias (20 por ciento). Al Holter, el 59 por ciento presentó arritmias: ventriculares el 44 por ciento, supraventriculares el 38 por ciento y ambas el 24 por ciento, con predominio de extrasístoles poco frecuentes y benignas. Cinco pacientes (15 por ciento) presentaron extrasístoles polimórficas. Hubo asociación entre arritmia ventricular y HVD moderada y severa (p=0,026) y también con gradiente ventrículo derecho-arteria pulmonar (VD/AP) >45 mmHg (p=0,004). A través de la Regresión Logística, el aumento del gradiente VD/AP fue factor predictivo independiente para arritmia ventricular (p=0,017). CONCLUSIÓN: Las arritmias cardíacas fueron un hallazgo común en gran parte de los niños y adolescentes tras reparación quirúrgica de TF, sin embargo, poco frecuentes y benignas, en la mayoría de los casos. El gradiente de presión VD-AP se consideró como un fuerte predictor para arritmia ventricular.

Late clinical and functional assessment of arrhythmias in children after repair of Tetralogy of Fallot.

BACKGROUND: Cardiac arrhythmias are the major cause of late sudden death in patients undergoing repair of Tetralogy of Fallot (TF). OBJECTIVE: To evaluate the occurrence of cardiac arrhythmias in children and adolescents undergoing repair of TF, and to associate them with clinical aspects and laboratory tests. METHODS: Cross-sectional study of 37 patients undergoing repair of TF at Instituto Estadual de Cardiologia Aloysio de Castro (Rio de Janeiro). After review of the medical records and clinical assessment, the patients underwent electrocardiography (ECG), echocardiography (Echo), 24-h Holter monitoring and exercise test (ET), whose results were subjected to statistical analysis. RESULTS: A total of 37 patients of whom 54% were males with a mean age of 9.7 ± 3.5 years and mean follow-up period of 4.7 ± 1.9 years were studied. The abnormalities most frequently found were: on ECG: right bundle branch block (89%); Echo: severe pulmonary regurgitation (43%), mild pulmonary stenosis (73%), moderate right ventricular hypertrophy (RVH, 57%); on ET: low exercise capacity (90%), impaired chronotropic response (40%), arrhythmias (20%); on Holter monitoring: arrhythmias (59%, of which 44% were ventricular, 38% supraventricular, and 24% both ventricular and supraventricular, with predominance of infrequent and benign ventricular premature beats). Five patients (15%) presented with multiform ventricular premature beats. There was an association of ventricular arrhythmia with moderate and severe RVH (p=0.026), as well as with right ventricle-to-pulmonary artery gradient (RV/PA) > 45 mmHg (p=0.004). The logistic regression analysis showed that increased RV/PA gradient was an independent predictor of ventricular arrhythmia (p=0.017). CONCLUSION: Cardiac arrhythmia was a common finding in a large proportion of children and adolescents after surgical repair of TF; however, it was infrequent and benign in most of the cases. The RV/PA gradient was considered a strong predictor of ventricular arrhythmia.

Cholinergic stimulation improves autonomic and hemodynamic profile during dynamic exercise in patients with heart failure.

BACKGROUND: Parasympathetic dysfunction is an independent risk factor for mortality in heart failure for which there is no specific pharmacologic treatment. This article aims to determine the effect of pyridostigmine, an anticholinesterase agent, on the integrated physiologic responses to dynamic exercise in heart failure. METHODS AND RESULTS: Patients with chronic heart failure (n = 23; 9 female; age = 48 +/- 12 years) were submitted to 3 maximal cardiopulmonary exercise tests on treadmill in different days. The first test was used for adaptation and to determine exercise tolerance. The other tests were performed after oral administration of pyridostigmine (45 mg, 3 times/day, for 24 hours) or placebo, in random order. All patients were taking their usual medication. Pyridostigmine reduced cholinesterase activity by 30%, inhibited the chronotropic response throughout exercise, up to 60% of maximal effort (pyridostigmine = 108 +/- 3 beats/min vs. placebo = 113 +/- 3 beats/min; P = .040), and improved heart rate reserve (pyridostigmine = 73 +/- 5 beats/min vs. placebo = 69 +/- 5 beats/min; P = 0.035) and heart rate recovery in the first minute after exercise (pyridostigmine = 25 +/- 2 beats/min vs. placebo = 22 +/- 2 beats/min; P = .005), whereas peak heart rate was similar to placebo. Oxygen pulse, an indirect indicator of stroke volume, was higher under pyridostigmine during submaximal exercise. CONCLUSIONS: Pyridostigmine was well tolerated by heart failure patients, leading to improved hemodynamic profile during dynamic exercise.

Coronary risk factors in adult children of parents with coronary heart disease: a comparison survey of southeastern Brazil and southeastern United States.

A survey was performed in southeastern Brazil and in the southeastern United States to: 1) compare coronary risk factors in adult children (>18 years old) of parents with coronary heart disease enrolled in cardiac rehabilitation programs in countries with different geographic, social, and economic factors; and 2) to assess the influence of coronary heart disease of parents on alteration of lifestyle in these adult children. There were 286 biological children available for the survey (135 Brazil, 151 United States). Of those, 142 completed the survey (78 Brazil, 64 United States) for an overall compliance rate of 50% (58% Brazil, 42% United States). The following differences were noted: blood pressure > 159/90 mm Hg (23% Brazil, 15% United States [nonsignificant]); total cholesterol > 181 mg/dL (5% Brazil, 30% United States [p < 0.001]); HDL-C < 35 mg/dL (95% Brazil, 21% United States [p < 0.001]); low-fat diet (29% Brazil, 64% United States [p < 0.001]); smoke/ever (41% Brazil, 34% United States [nonsignificant]); currently smoke (72% Brazil, 18% United States [p < 0.001]); any exercise [44% Brazil, 82% United States [p < 0.001]); exercise > 90 minute/week (18% Brazil, 20% United States [nonsignificant]); improved lifestyle habits (39% Brazil, 79% United States [p < 0.001]); improved lifestyle habits related to parent's coronary heart disease (66% Brazil, 35% United States [p < 0.05]). Such differences may reflect geographic, social, and/or economic factors.

Influência da massa muscular esquelética sobre as variáveis ventilatórias e hemodinâmicas ao exercício em pacientes com insuficiência cardíaca crônica / Influence of skeletal muscle mass on ventilatory and hemodynamic variables during exercise in patients with chronic heart failure

OBJECTIVE: To assess the influence of skeletal muscle mass on ventilatory and hemodynamic variables during exercise in patients with chronic heart failure (CHF). METHODS: Twenty-five male patients underwent maximum cardiopulmonary exercise testing on a treadmill with a ramp protocol and measurement of the skeletal muscle mass of their thighs by using magnetic resonance imaging. The clinically stable, noncachectic patients were assessed and compared with 14 healthy individuals (S) paired by age and body mass index, who underwent the same examinations. RESULTS: Similar values of skeletal muscle mass were found in both groups (CHF group: 3863 ± 874 g; S group: 3743 ± 540 g; p = 0.32). Significant correlations of oxygen consumption in the anaerobic threshold (CHF: r = 0.39; P= 0.02 and S: r = 0.14; P = 0.31) and of oxygen pulse also in the anaerobic threshold (CHF: r = 0.49; P = 0.01 and S: r =0.12; P = 0.36) were found only in the group of patients with chronic heart failure. CONCLUSION: The results obtained indicate that skeletal muscle mass may influence the capacity of patients with CHF to withstand submaximal effort, due to limitations in their physical condition, even maintaining a value similar to that of healthy individuals. This suggests qualitative changes in the musculature

Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room.

OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. RESULTS: The mean age of the patients studied was 51.7 12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated.