Myocardial deformation and volume of exercise: a new overlap between pathology and athlete's heart?

Regular physical exercise induces cardiac adaptations that can overlap pathological conditions. Controversy still persists about the variability of myocardial deformation in different types and intensity of exercise. The aim of this study was to assess myocardial longitudinal deformation in athletes with different level of exercise. Two groups of young athletes involved in endurance sports characterized by high intensity dynamic component were enrolled. According to the level and the number of exercise training hours/week, two groups were defined: Group 1-high level (national/international and ≥ 20 training-hours/week; N = 60); Group 2-low level (recreational/regional and < 10 training-hours/week; N = 48). A comprehensive transthoracic echocardiogram including evaluation of global longitudinal strain (GLS) assessed by 2D speckle-tracking was performed. Athletes in Group 1 showed more pronounced cardiac remodeling and enhanced diastolic function. No significant differences were evident in left ventricle ejection fraction (LVEF) between groups. Overall, GLS (absolute values) was 18.0 ± 2.5%, but significantly lower in Group 1 compared to Group 2 (17.3 ± 2.6% vs. 18.9 ± 2.1%; p = 0.001). Thirty-three (31%) athletes had GLS below 17%, more frequently in Group 1 (79% vs. 45%; p = 0.001), with higher LV and left atrium volumes, lower E wave and A wave peak velocities and E/e' ratio. In a multivariate analysis to belong to Group 1 was the only independent variable associated with GLS < 17% (OR 6.5; 95% CI 2.4-17.4; p < 0.001). The athletes with a GLS < 17% were all men, more frequently involved in high level exercise, with higher chamber volumes and lower E/e' ratio. Left ventricular global myocardial longitudinal deformation evaluated by GLS was significantly lower in athletes with higher level of exercise. Although GLS in athletes overlap several pathological conditions, these lower values are associated with an enhanced diastolic performance that allows discrimination between physiologic adaptations and pathology.

Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes.

BACKGROUND: Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization. POPULATION AND METHODS: All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points. RESULTS: The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality. CONCLUSIONS: In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.

Ação de fungos entomopatogênicos em larvas e adultos da mosca do figo Zaprionus indianus (Diptera: Drosophilidae) / Action of entomopathogenic fungi on the larvae and adults of the fig fly Zaprionus indianus (Diptera: Drosophilidae)

A mosca do figo, Zaprionus indianus, vem se disseminando no Brasil e causou nos últimos anos perdas de até 50% na produção de figos. Uma alternativa viável de controle desta mosca pode ser a utilização de fungos entomopatogênicos. Este trabalho foi conduzido em laboratório (27±1°C, UR 70±10% e fotoperíodo de 12h) para avaliar a suscetibilidade dos estágios de larva e adulto de Z. indianus a cinco concentrações (10(8) a 10(4) conídios mL-1) de B. bassiana (URM2915; ESALQ447) e M. anisopliae (URM3349; URM4403). Não houve mortalidade larval e o período de pré-pupa não sofreu alteração em relação ao grupo controle, já o estágio de pupa foi aumentado em até três dias quando se utilizou B. bassiana. A emergência de adultos diminuiu em relação ao grupo controle: 10,6% quando as larvas foram tratadas com a maior concentração de B. bassiana URM2916 e 2,0% com M. anisopliae URM4403. No bioensaio com adultos, a mortalidade máxima atingiu 98,7% com B. bassiana e 100,0% com M. anisopliae. Os menores valores da CL50 foram de 1,09x10(5) conídios mL-1 para B. bassiana URM2916 e de 1,94x10(4) conídios mL-1 para M. anisopliae URM4403. O tempo letal médio (TL50) variou de 4,5 a 6,12 dias. Os resultados demonstraram que ambos os fungos são eficientes e mostram ser promissores agentes biocontroladores da mosca do figo, com destaque para M. anisopliae URM4403.

The "fig fly", Zaprionus indianus, has spread by in Brazil and in recent years and has caused losses of up to 50% in the production of figs. A viable alternative to control this fly may be the use of entomopathogenic fungi such. The present study was developed in laboratory (27±1°C, RH 70±10% and 12h photoperiod), to assess the susceptibility of larval and adult stages of Z. indianus to five concentrations (10(8) to 10(4) conidia mL-1) of B. bassiana (URM2915; ESALQ447) and M. anisopliae (URM3349; URM4403). There was no larval mortality and the pre-pupal period did not change compared with the control group, whereas the pupal stage was increased by up to three days when we used B. bassiana URM2916. The emergence of adults decreased compared to the control group and was 10.6% when the larvae were treated with the highest concentration of B. bassiana URM2916 and 2.0% for M. anisopliae URM4403. In the adult's bioassay, the maximum mortality reached 98.7% with B. bassiana and 100.0% with M. anisopliae. The lowest LC50 values were 1.09x10(5) conidia mL-1 for B. bassiana URM2916 and 1.94x10(4) conidia mL-1 for M. anisopliae URM4403. The medium lethal time (LT50) ranged from 4.5 to 6.12 days. The results showed that both fungi are efficient and promising biocontrol agents of fig fly, mainly M. anisopliae URM4403.

Comparison of ischemic and bleeding risk scores in non-ST elevation acute coronary syndromes.

OBJECTIVES: Compare the discriminatory performance of two validated ischemic risk scores and a bleeding risk score for in-hospital adverse events across the spectrum of non-ST elevation acute coronary syndromes (NSTE-ACS). MATERIAL AND METHODS: Single center, 516 consecutive patients admitted with the diagnosis of NSTE-ACS. The following risk scores were calculated for each patient: TIMI, GRACE and CRUSADE. The following in-hospital endpoints were used: major bleeding (as defined by the CRUSADE criteria); recurrent ischemia (re-infarction or recurrent angina); and death. Discriminatory performance was measured by the c-statistic and compared. RESULTS: There were 36 major bleeding events, 34 recurrent ischemic events and 10 deaths. TIMI RS, GRACE RS, and CRUSADE RS demonstrated fair discriminatory accuracy for major bleeding (c-statistic = 0.64, 0.58, and 0.61, respectively). GRACE and CRUSADE risk scores demonstrated a better performance than TIMI RS for predicting in-hospital death (c-statistic = 0.92 and 0.86, respectively versus c-statistic = 0.63, P < 0.001). For the combined endpoint of in-hospital death or recurrent ischemia there was no statistically significant difference between CRUSADE RS, GRACE RS, and TIMI RS (c-statistic = 0.58, 0.57, and 0.62, respectively). CONCLUSION: Both ischemic and bleeding risk scores are able to predict in-hospital bleeding, ischemic and fatal events.

[Carcinoid tumors: echocardiographic contribution to the diagnosis]. / Tumor carcinóide: contributo da ecocardiografia para o diagnóstico.

INTRODUCTION: Carcinoid tumors are rare, most commonly originating from the neuroendocrine cells in the gastrointestinal tract. Carcinoid syndrome is characterized by flushing, diarrhea, and bronchospasm. Half of these patients have carcinoid heart disease, affecting the right side of the heart, causing tricuspid and pulmonary regurgitation and stenosis and subsequently right heart failure. CASE REPORT: 73-year-old female was admitted with heart failure associated with episodes of diarrhea and flushing. The echocardiogram showed typical characteristics of carcinoid heart diasease. The CT scan of abdomen showed a small bowel mass. The 24-hour urine 5-hydroxyindoleacetic acid (5HIAA) and indium-111-pentetreotide scintigraphy confirmed the diagnosis. The patient was treated with furosemide, warfarine, digoxin and octreotide and there was clinical improvement. CONCLUSION: The echocardiogram was very useful, establishing the provisory diagnosis of a rare disease based on pathognomonic echocardiographic features.

Chronic medical comorbidities in patients with acute coronary syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) frequently present chronic noncardiovascular medical comorbidities that can influence treatment and prognosis. Compliance with therapeutic guidelines in ACS is crucial to event reduction and the presence of these comorbidities may be a determining factor in guideline adherence. OBJECTIVE: To assess the prevalence of chronic noncardiovascular medical comorbidities in patients with ACS and their impact on guideline adherence. METHODS: We studied consecutive patients admitted to the coronary care unit of our institution with a diagnosis of ACS. We identified patients with noncardiovascular comorbidities, divided into five groups: chronic renal failure, pulmonary disease, gastrointestinal disease, blood disease or cancer). We assessed complete adherence to pharmacological therapy plus reperfusion (mechanical or pharmacological) in ST-segment elevation myocardial infarction, and use of coronary angiography in non-ST segment elevation myocardial infarction. We compared guideline adherence according to the presence or absence of comorbidities and their impact on in-hospital mortality. RESULTS: The study sample consisted of 146 patients, mean age 64 +/- 13 years and 71% male. In 53% of the patients at least one comorbidity was identified: chronic renal failure in 23%, pulmonary disease in 14%, gastrointestinal disease in 20%, blood disease in 7% and cancer in 9%. Patients with comorbidities were older, and more frequently had a history of ACS, heart failure and peripheral arterial disease. Complete adherence to guidelines was worse in the group with comorbidities (56% vs. 74%; p = 0.025). The presence of noncardiovascular comorbidities was associated with higher in-hospital mortality (9% vs. 0%, p = 0.011). CONCLUSION: Noncardiovascular medical comorbidities are frequently found in patients with ACS. Adherence to therapeutic guidelines for ACS is suboptimal, particularly in patients with chronic noncardiovascular comorbidities. Moreover, the presence of such comorbidities influences short-term prognosis in ACS patients.

Miocardiopatia diabética em diabéticos sem comorbidades / Diabetes cardiomyopathy in diabetic patients without comorbidities

A miocardiopatia diabética tem-se afirmado como diagnóstico etiológico de insuficiência cardíaca. No entanto, a elevada frequência de comorbidades, no doente diabético, torna difícil a distinção da contribuição da alteração do metabolismo da glicose na fisiopatologia da insuficiência cardíaca. Objectivo: Estudar a função ventricular esquerda sistólica e diatólica em diabéticos sem comorbidades, com ecocardiografia convencional e Doppler tissular. Métodos: Foram estudados 23 doentes, com idade média de 53 + - 15 anos, sendo 10 mulheres, todos diabéticos, com pelo menos 5 anos de evolução e sem história prévia de insuficiência cardíaca, doença coronária ou hipertensão arterial grave. O grupo controle foi constituído por 18 doentes pareados para sexo e idade. A função sistólica foi avaliada através da fração de ejeção e da V máx da onda A, determinada por Doppler tissular, com amostras nos segmentos septal, lateral, inferior e anterior do anel mitral. A função diastólica foi avaliada pela razão E/A, tempo de desaceleração do fluxo transmitral (Doppler espectral pulsado), pela V máx d onda 'E, razão 'E/A' e 'E/'E obtida por meio do Doppler tissular, nos quatros segmentos anteriormente referidos. Foram avaliaddas as diferenças...

Portuguese Registry of Acute Coronary Syndromes: seven years of activity.

BACKGROUND: The Portuguese Registry of Acute Coronary Syndromes was established in 2002, with the goal of gathering data on the clinical characteristics, treatment and prognosis of Portuguese patients with acute coronary syndromes (ACS). OBJECTIVE: To report the information collected during the seven years of activity of the Portuguese Registry of ACS (from January 1, 2002 to December 31, 2008). METHODS: The Portuguese Registry of ACS is an observational, prospective and continuous registry, which started on January 1, 2002 and involved 45 Portuguese hospitals. Patients with ST-segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) were included. Information was collected on 188 variables, including data on clinical presentation, treatment and prognosis of patients with ACS. RESULTS: The registry included 22,482 patients (mean age 66 +/- 13 years, 70% male), distributed as follows: 45.4% STEMI, 41.4% NSTEMI and 13.1% UA. Reperfusion therapy was used in 63% of STEMI patients, ris- ing from 60% in 2002 to 75% in 2008, with an increasing proportion of primary angioplasty relative to fibrinolysis. Aspirin, low molecular weight heparin and glycoprotein IIb/IIIa inhibitors were used in respectively 97%, 88% and 26% of the patient population. A combination of dual antiplatelets, beta-blockers, angiotensin-converting enzyme inhibitors and statins was used in 32% of patients during hospitalization, in 26% on discharge and in 16% six months after the acute event. Coronary angiography was performed in the majority of patients (62%), followed by a coronary revascularization procedure in about a third (38%). Coronary angiography was increasingly used during the period under analysis, with a concomitant increase in revascularization procedures. In-hospital mortality was 5.2% in the overall population (7.7% in STEMI, 3.9% in NSTE-MI and 0.7% in UA), declining significantly over time. Cumulative mortality six months after the acute event was 7.5% (10.2% in STEMI, 6.6% in NSTEMI and 1.5% in UA). CONCLUSION: The Portuguese Registry of ACS has collected crucial information on the clinical characteristics, treatment and prognosis of ACS in Portugal. The reported results reveal discrepancies between the guidelines for ACS treatment and their application in clinical practice. Analysis of the results has identified several issues that require particular attention and future intervention in order to improve ACS treatment and prognosis.

Bovine papillomavirus type 4 L1 gene transfection in a Drosophila S2 cell expression system: absence of L1 protein expression

The development of a bovine papillomavirus (BPV) vaccine is an outstanding challenge. BPV protein L1 gene transfection in the Drosophila melanogaster S2 cell expression system failed to produce L1 protein notwithstanding correct L1 gene insertion. Severe genetic inbalance in the host cell line, including cytogenetic alterations, may account for the lack of protein expression.

O desenvolvimento de uma vacina para papilomavirus bovino (BPV) consiste em grande desafio. A transfecção do gene codificante da proteína L1 de BPV em sistema de células S2 de Drosophila melanogaster não logrou sucesso, apesar da correta inserção da seqüência gênica em vetor apropriado.Graves alterações genéticas na linhagem celular S2, que incluem aberrações cromossômicas, provavelmente estão relacionadas à ausência da expressão da proteína desejada.

Bovine papillomavirus type 4 L1 gene transfection in a Drosophila S2 cell expression system: absence of L1 protein expression.

The development of a bovine papillomavirus (BPV) vaccine is an outstanding challenge. BPV protein L1 gene transfection in the Drosophila melanogaster S2 cell expression system failed to produce L1 protein notwithstanding correct L1 gene insertion. Severe genetic inbalance in the host cell line, including cytogenetic alterations, may account for the lack of protein expression.

Predictors of response to cardiac resynchronization therapy--importance of left ventricular dyssynchrony.

BACKGROUND: Cardiac resynchronization therapy (CRT) is currently used in selected patients with dilated cardiomyopathy and heart failure. However, 30% of patients do not respond to CRT when selection is based on clinical and electrocardiographic criteria. Left ventricular dyssynchrony can be evaluated by tissue Doppler imaging and it has been described as a useful precdictor of response to CRT. OBJECTIVE: To evaluate whether left ventricular dyssynchrony, as measured by tissue Doppler imaging, can be used to predict response to CRT. METHODS: 23 consecutive patients (age 67 +/- 10 years, 13 male) with heart failure refractory to medical therapy and who underwent CRT were studied. Before and six months after the procedure, various characteristics - clinical (including NYHA functional class), electrocardiographic (QRS interval) and echocardiographic (left ventricular ejection fraction [EF] and respective volumes)--were evaluated. In addition, pulsed wave tissue Doppler imaging was used to assess the time interval (QS) between the beginning of the QRS complex and the beginning of the systolic wave on the Doppler signal, in the basal segments of the septal, lateral, anterior and inferior walls. Left ventricular dyssynchrony was quantified as the difference between the maximum and minimum QS interval (QS(max-min)). The patients were divide into two groups: responders, if functional class improved by at least one and EF increased by more than 10%, and non-responders for the remainder. Differences between groups were assessed and predictors of response to CRT were determined. RESULTS: CRT improved functional class by at least one in 87% of patients and EF improved from 21 +/- 6 to 33 +/- 9% (p < 0.001). QS(max-min) was reduced from 80 +/- 38 to 38 +/- 14 ms (p < 0.001). In 15 patients (65%), classified as responders, there was an improvement in functional class and an increase in EF of more than 10%. There were no differences between groups, except for QS(max-min). Patients in the responder group had greater left ventricular dyssynchrony (QS(max-min) 94 +/- 39 vs. 54 +/- 16 ms, p = 0.002). QSmix-min was an independent predictor of response to CRT and a cut-off of 60 ms identified responders with a sensitivity of 87% and specificity of 75%. CONCLUSION: Despite the good results achieved with CRT, about one third of patients do not benefit from it. Left ventricular dyssynchrony can be quantified by tissue Doppler imaging using QS(max-min) and values greater than 60 ms can identify responders to CRT.

Glucose metabolism in non-diabetic patients with stable coronary artery disease.

BACKGROUND: Diabetes and other forms of impaired glucose metabolism (IGM) can be present in patients with coronary artery disease (CAD), despite normal fasting glycemia and no prior evidence of diabetes. Undiagnosed IGM can be associated with increased risk of cardiovascular events. OBJECTIVE: To assess the prevalence of IGM in patients with CAD and without diabetes and to identify its repercussions on their cardiovascular risk profile. METHODS: Consecutive patients with CAD documented by angiography, without prior history of diabetes and fasting glycemia < 126 mg/dL, were studied. An oral glucose tolerance test (OGTT) was performed to identify and classify IGM. The patients were divided into three groups: normal if fasting glycemia < 100 mg/dL and normal OGTT; prediabetes if fasting glycemia > or = 100 mg/dL and abnormal OGTT, with 2-h glycemia > or = 140 and < 200 mg/dL; and diabetes if 2-h glycemia > or = 200 mg/dL after OGTT. For assessment of the cardiovascular risk profile, various clinical, laboratorial (including lipid profile, fasting insulinemia 2 h after OGTT, insulin resistance index and A1c hemoglobin) and angiographic characteristics were analyzed. The differences between groups were determined. RESULTS: 54 patients were studied (mean age 65 +/- 9 years, 78 % male) and IGM was identified in 37 (69%), with prediabetes in 23 (43%) and diabetes in 14 (26%). Patients with IGM had more dyslipidemia, higher levels of fasting glycemia, triglycerides and urea and lower HDL cholesterol. Metabolic syndrome was diagnosed in 12% of patients in the normal group, 44% in the prediabetes group and 50% in the diabetes group (p = 0.047). CAD was more severe in the presence of IGM, being multivessel in 84% of these patients versus 59% in the normal group (p = 0.046). CONCLUSION: In patients with CAD without clinical suspicion of diabetes, a routine OGTT can identify a significant percentage with prediabetes and diabetes, which can have a negative impact on their cardiovascular risk profile.