Effect of coenzyme Q10 supplementation on statin-related myopathic pain: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION: Coenzyme Q10 (CoQ10) has shown promising results as an adjuvant therapy to statins. However, the efficacy of this agent is still unclear. Hypothesis: The use of CoQ10 mitigates statin-related myopathic pain. METHODS: PubMed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing CoQ10 supplementation with placebo in patients taking statins. A random-effects model was employed to compute the mean difference (MD) with 95% confidence interval (CI). Statistical analysis was performed using R software 4.3.1. RESULTS: A total of 5 studies and 227 patients were included, of whom 48% were randomized to CoQ10 supplementation. Compared with placebo, CoQ10 had no effects on pain severity score (MD -0.94; 95% CI -3.80 to 1.91; p=0.5), and pain intensity score (MD -1.51; 95% CI -4.09 to 1.06; p = 0.2). Moreover, no association was found with low density lipoprotein cholesterol levels (MD -0.07; 95% CI -0.47 to 0.34; p = 0.7). CONCLUSIONS: In this meta-analysis of 5 RCTs, supplementation with CoQ10 did not yield statistically significant results. These findings suggest that CoQ10 has no impact on statin-related myopathic pain.

Telemonitoring use for uncontrolled hypertension management: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND: Within the context of uncontrolled blood pressure telemonitoring, the remote tracking of blood pressure and patient data, offers a transformative avenue. We aimed to perform a meta-analysis of the strategic redesign of healthcare services, harnessing information and communication technology (ICT) to enhance hypertension management and blood pressure control in primary care, providing timely interventions, and improving patient outcomes. METHODS: PubMed, Embase, and Cochrane databases were searched for RCTs comparing ICT with usual care in patients with uncontrolled hypertension. A random-effects model was used to calculate the risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: A total of twenty-eight studies and 13,111 patients were included, of whom 7,312 were randomized to ICT and 5,799 to usual care. Compared with standard care, ICT significantly reduced systolic blood pressure (MD -4.44 mmHg; 95% CI -5.55,-3.33; p<0.01) and diastolic blood pressure (MD -1.08 mmHg; 95% CI -1.71,-0.45; p<0.01). There was no significant difference between groups for adherence (RR 1.16; 95%CI 0.89-1.50; p=0.27). CONCLUSION: In this meta-analysis of RCTs of patients with uncontrolled hypertension, ICT was associated with a reduction in systolic and diastolic blood pressures, compared with usual care.

Randomized trial of effect of bariatric surgery on blood pressure after 5 years

BACKGROUND: Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality. OBJECTIVES: The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission. METHODS: We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle. RESULTS: A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%). CONCLUSIONS: Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years.

BACKGROUND: Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality. OBJECTIVES: The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission. METHODS: We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle. RESULTS: A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%). CONCLUSIONS: Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Advanced echocardiography techniques (AETs) to assess left atrial structure and function in individuals with resistant hypertension.

AIMS: Resistant hypertension (RH) is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is usually neglected. Advanced Echocardiography Techniques (AETs), such as Strain Analysis and three-dimensional echocardiography (3D ECHO) may be useful complementary tools to assess atrial function in patients with RH. METHODS AND RESULTS: Ninety-six eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent AETs to identify morphofunctional changes in the left atrium (LA) across different HTN phenotypes. The LA reservoir strain was significantly lower among RH than in N and CH patients (p < .001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH patients (p = .015). LA contraction strain was higher among CH than in N and RH patients (p = .02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p < .001), but not between CH and RH. N patients showed a higher fraction of passive emptying of the LA than the others (p = .02), with no difference between CH and RH. Total emptying of the LA only differed between N and RH patients, while active emptying of the LA showed no difference between the groups (p = .82). CONCLUSION: The left atrium may present early functional changes in response to HTN, which are detectable by AETs. AETs, especially S-LA, allowed to identify markers of atrial myocardial damage in both RH and CH patients.

Advanced echocardiography techniques (AETs) to assess left atrial structure and function in individuals with resistant hypertension

AIMS: Resistant hypertension (RH) is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is usually neglected. Advanced Echocardiography Techniques (AETs), such as Strain Analysis and three-dimensional echocardiography (3D ECHO) may be useful complementary tools to assess atrial function in patients with RH. METHODS AND RESULTS: Ninety-six eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent AETs to identify morphofunctional changes in the left atrium (LA) across different HTN phenotypes. The LA reservoir strain was significantly lower among RH than in N and CH patients (p < .001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH patients (p = .015). LA contraction strain was higher among CH than in N and RH patients (p = .02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p < .001), but not between CH and RH. N patients showed a higher fraction of passive emptying of the LA than the others (p = .02), with no difference between CH and RH. Total emptying of the LA only differed between N and RH patients, while active emptying of the LA showed no difference between the groups (p = .82). CONCLUSION: The left atrium may present early functional changes in response to HTN, which are detectable by AETs. AETs, especially S-LA, allowed to identify markers of atrial myocardial damage in both RH and CH patients.

Assessment of left atrial function in individuals with resistant hypertension by advanced echocardiography

OBJECTIVE: Resistant hypertension is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is commonly neglected. Strain and three-dimensional echocardiography (3D ECHO) may be useful complementary tools for assessing atrial function among hypertensive patients. DESIGN AND METHOD: 96 eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent advanced echocardiography techniques to identify specific morphofunctional changes in the left atrium (LA) throughout different HTN phenotypes. RESULTS: As shown in Figure 1, LA reservoir strain was significantly lower among RH than N and CH patients (p < 0.001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH (p = 0.015). LA contraction strain was higher among CH than N and RH (p = 0.02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p < 0.001), but not between CH and RH. N showed higher fraction of passive emptying of the LA than the others (p = 0.02), with no difference between CH and RH. Total emptying of the LA only differed between the extreme groups N and RH, being lower in the latter, while active emptying of the LA showed no difference between the groups (p = 0.82). CONCLUSIONS: Advanced echocardiography measures, especially LA strain, proved to be early markers of atrial myocardial damage in both RH and CH. We demonstrated for the first time that morphofunctional changes in the LA due to resistant hypertension may occur concomitantly and even independently from those observed in the left ventricle.

Análise funcional do átrio esquerdo na identificação da injuria hipertensiva incipiente / Functional analysis of the left atrium in the identification of incipient hypertensive injury

INTRODUÇÃO: Alterações estruturais e funcionais do ventrículo esquerdo decorrentes da hipertensão arterial são bem caracterizadas e constituem valiosos marcadores prognósticos. Embora a análise estrutural do átrio esquerdo (AE) pelo cálculo do volume atrial seja parte da avaliação ecocardiográfica de rotina, sua avaliação funcional é menos usual. O estudo da deformação do AE por meio do strain longitudinal e o cálculo da rigidez atrial esquerda podem permitir caracterizar suas alterações funcionais adaptativas ao longo do espectro pressórico. OBJETIVO: Avaliar a função atrial esquerda em diferentes fenótipos de hipertensos. METODOLOGIA: Hipertensos Resistentes (HR); Hipertensos Controlados (HC) e Normotensos (N), assim categorizados a partir da monitorização ambulatorial da pressão arterial de 24 horas, foram submetidos a avaliação ecocardiográfica transtorácica avançada, incluindo a análise de deformação miocárdica pelo strain e o cálculo da rigidez atrial esquerda. Os grupos foram comparados entre si quanto a parâmetros estruturais e funcionais do AE. RESULTADOS: 96 pacientes foram considerados elegíveis para o estudo, sendo 32 indivíduos alocados em cada grupo. O volume indexado do AE foi semelhante entre HC (30 ± 7 mL/m2 ) e HR (33 ± 10 mL/m2 ) e menor nos N (25 ± 4 mL/m2 ) ­ p < 0,05. O índice de massa ventricular esquerda foi maior nos HR (102,0 ± 24,2 g/m2 ), seguido dos HC (83,2 ± 16,8 g/m2 ) e N (67,1 ± 10,9 g/m2 ) ­ p < 0,05. Nenhum paciente do grupo N apresentou disfunção diastólica, enquanto a disfunção diastólica grau I foi observada em 32% dos HC e 52% dos HR. O strain longitudinal global do VE foi semelhante entre N (20 ± 2%) e HC (20 ± 3%), mas reduzido nos HR (17 ± 3%). A avaliação funcional do AE incluiu o strain atrial em suas 3 fases: reservatório, conduto e contração. O strain de reservatório foi semelhante entre N (34% ± 6) e HC (33% ± 6), mas reduzido nos HR (27% ± 7; p < 0,001). O strain de conduto foi maior no grupo N (19% ± 6), seguido em ordem decrescente pelo HC (16% ± 5) e HR (12% ± 5; p = 0,015). O strain de contração foi maior no grupo HC (17% ± 4), diferindo dos grupos N (15% ± 3) e HR (12% ± 5; p < 0,02). O grupo HR apresentou os maiores índices de rigidez do átrio esquerdo, seguido em ordem decrescente pelos grupos HC e N (p < 0,001). CONCLUSÃO: A função do AE apresentou diferenças significativas de acordo com o fenótipo dos hipertensos. Enquanto nos HR o AE se apresenta mais rígido e com menores índices de deformação que os HC, estes apresentam função contrátil mais intensa, mesmo quando comparados aos normotensos.

Há espaço para os betabloqueadores na terapia tripla da hipertensão arterial? / Is there room for beta-blockers in triple therapy for high blood pressure?

INTRODUÇÃO: O tratamento da hipertensão arterial (HA) se fundamenta na indicação de 3 classes terapêuticas de primeira linha: IECA/BRA; BCC; e tiazídicos (TZD). Atualmente os betabloqueadores (BB) constituem opção de primeira escolha apenas em situações clínicas específicas. Há controvérsia em relação ao impacto dos BB na redução do risco CV fora desses contextos, em parte em função da heterogeneidade da classe. O objetivo do presente estudo foi avaliar o uso dos BB como parte da terapia tripla na prática clínica de um centro de referência, estudando seu impacto no controle pressórico. MÉTODOS: Selecionamos 113 pacientes em uso de 3 classes de anti-hipertensivos consecutivamente atendidos em serviço ambulatorial público de referência no tratamento da HA. Avaliamos a taxa de uso de BB e suas principais associações, identificando as classes mais frequentemente substituídas pelos BB dentro da terapia tripla. Em modelo de regressão logística identificamos as variáveis associadas a prescrição da classe. Finalmente, estudamos o impacto do uso dos BB como parte da terapia tripla no controle pressórico em MAPA de 24h. RESULTADOS: Dos 113 pacientes em terapia tripla, 61% (N=69) estava em uso concomitante das 3 classes de primeira linha (IECA/ BRA + BCC + TZD). No restante, uma das classes era substituída por um BB (29%; 33/113), pela espironolactona (7%; 8/113), ou por outra classe anti-hipertensiva (3%; 3/113). Os BB foram a principal alternativa as classes de primeira linha, integrando a terapia tripla em 75% (33/44) dos esquemas alternativos. Em 55% dos casos (18/33) o BB foi prescrito no lugar do BCC; em 24% (8/33) no lugar do TZD; e em 6% (2/33) no lugar do IECA/BRA. Os BB mais prescritos foram o atenolol (66,7%; 22/33); o metoprolol (15,1%; 5/33); e o carvedilol (12,1%; 4/33). Foram preditores de indicação de BB: sexo feminino (OR: 4,67; IC: 1,64-16,9; p=0,008); insuficiência coronariana (OR: 3,28; IC: 1,17-9,36; p=0,023); e hipertrofia do ventrículo esquerdo (OR: 3,17; IC: 1,06-10,9; p=0,048). Os pacientes em terapia tripla com BB apresentaram frequência cardíaca média menor que aqueles sob terapia tripla sem BB (67±9 bpm versus 73±12 bpm; p=0,013). Não houve diferença estatisticamente significativa entre os dois grupos no controle pressórico pela MAPA de 24h (PATotal: 116±10 /72±9 mmHg versus 121±11 /72±9 mmHg; p=0,3/0,9). CONCLUSÕES: Na população estudada os BB constituíram a principal alternativa as classes de primeira linha como parte da terapia anti-hipertensiva tripla, mantendo equivalente controle pressórico de 24h.

Índice de Alerta Alimentar (IAA): um instrumento de triagem nutricional do hipertenso para o cardiologista / Food Alert Index (IAA): a nutritional screening tool for hypertensive patients for cardiologists

INTRODUÇÃO: O impacto da reeducação alimentar no controle da pressão arterial (PA) pode equivaler ao de uma ou mais classes de anti-hipertensivos. Apesar disso, a avaliação alimentar é comumente negligenciada na prática médica. A falta de instrumentos de mensuração clinicamente aplicáveis em ambiente de consultório é uma das possíveis explicações. Elaboramos o Índice de Alerta Alimentar (IAA) como ferramenta de triagem alimentar para o cardiologista. O objetivo do presente estudo foi avaliar uma população de hipertensos resistentes por meio do IAA e comparar o grau de concordância inter-avaliadores. MÉTODOS: O IAA é um escore que inclui 7 dimensões: aporte calórico; consumo de frutas; verduras e legumes; gordura saturada; sal; ultraprocessados; e preparo dos alimentos. A avaliação é realizada a partir de registro alimentar fotográfico (RAF) de 3 dias que o paciente encaminha por meio de aplicativo. Cada dimensão recebe uma pontuação de 0 (ótimo); 1 (intermediário); ou 2 (péssimo). A pontuação total do IAA varia de 0 a 14. Recrutamos 30 hipertensos resistentes. O RAF dos 30 pacientes foi avaliado de forma cega e independente por cardiologista sênior (S); médico residente (J); e nutricionista (N). Estudamos o grau de concordância inter-avaliadores por meio do coeficiente de concordância Kappa de Cohen; do coeficiente de correlação linear de Pearson; e de gráficos de dispersão e de Bland-Altman. Foi aceita uma margem de discordância de até 1 ponto para cada dimensão e de até 3 pontos na pontuação total. RESULTADOS. A idade média dos 30 pacientes avaliados foi 63.9 ± 9.2 anos (83,3% mulheres; IMC médio 33.1 ± 6.1; raça parda ou preta: 57,1%; anti-hipertensivos em uso: 3.9 ± 1.6; PAS média: 137.0 ± 17.4 mmHg). Foram avaliadas uma média de 11,2 fotografias por paciente. As dimensões de maior alerta (Escore 1 + 2) foram: consumo excessivo de sal (87%); excesso calórico (86,7%); e consumo de ultraprocessados (75,5%). Apenas 58,9% apresentou consumo adequado (Escore 0) de verduras e 46,7% de frutas. O Coeficiente de Correlação de Pearson entre S e N foi 0,816. Aceitando-se margem de diferença ≤3 pontos a concordância inter-avaliadores foi de 100%. O grau de concordância entre J e S/N foi significativamente menor (Correlação de Pearson: 0,455; após ajuste: 83,3% de concordância). CONCLUSÕES: O IAA apresentou alto grau de concordância inter-avaliadores, constituindo uma ferramenta promissora na prática clínica. 2/3 dos hipertensos resistentes apresentaram altos índices de alerta, sendo candidatos a acompanhamento nutricional especializado.

Morbimortalidade cardiovascular após denervação renal em hipertensos resistentes / Cardiovascular morbidity and mortality after renal denervation in resistant hypertensive patients

INTRODUÇÃO: A terapia de denervação renal (TDR) é uma opção terapêutica na hipertensão arterial resistente (HAR), mas sua eficácia no controle pressórico é modesta e seu impacto na redução do risco cardiovascular é motivo de controvérsia. Faltam estudos de longo prazo avaliando desfechos cardiovasculares em pacientes submetidos ao procedimento. OBJETIVO: Avaliar a incidência de desfechos cardiovasculares e renais a longo prazo em pacientes submetidos à TDR em comparação a um grupo controle pareado de portadores de HAR. MÉTODOS: Acompanhamos 20 pacientes com HAR submetidos à TDR entre 2012 e 2014, com uma média de seguimento de 7,3 anos, comparados a um grupo controle de 8 pacientes com média de seguimento de 4,2 anos, sendo a ocorrência de eventos ajustada para o tempo de seguimento. O desfecho primário composto incluiu: morte por todas as causas, infarto não fatal, AVC não fatal e terapia renal substitutiva. Avaliamos como desfechos secundários a incidência isolada de cada elemento do desfecho composto, além do controle pressórico avaliado pela MAPA no 1º, 3º, 6º e 12º mês e, então, anualmente até o 10º ano. A diferença na incidência dos desfechos foi aferida em modelo de regressão linear de Poisson com ligação logarítmica pelo tempo de seguimento. RESULTADOS: O grupo de pacientes submetidos à TDR (N=20; idade média: 50,9 anos; 75% do sexo feminino) apresentava tempo médio de doença de 18,4 anos, com carga significativa de fatores de risco cardiovascular (diabetes mellitus: 25%; dislipidemia: 60%; tabagismo: 15%; IAM prévio: 15%; AVC prévio: 10%). O perfil do grupo controle foi semelhante, exceto pelo tabagismo, que foi significativamente maior (75% vs 15%; p=0,005). O desfecho primário ocorreu em 8 pacientes do grupo TDR vs 3 do grupo controle. Não houve diferença entre os grupos: 1) no controle pressórico ao longo do tempo; 2) no desfecho primário composto (5,4% versus 9% pacientes/ano; p=0,642); 3) nos desfechos secundários (morte por todas as causas, p=0,36; infarto não fatal, p=0,07; AVC não fatal, p=0,28). No grupo TDR, IAM prévio foi preditor independente do desfecho primário (p=0.049), enquanto AVC prévio foi preditor de morte por todas as causas (p=0.032). CONCLUSÃO: Nesta análise de pacientes submetidos à TDR por HAR não observamos benefício de controle pressórico nem de redução do risco cardiovascular em comparação ao grupo que recebeu tratamento clínico habitual.

Sarcoidose cardíaca como manifestação de reativação em paciente com Síndrome de Löfgren / Cardiac sarcoidosis as a manifestation of reactivation in a patient with Löfgren's Syndrome

INTRODUÇÃO: Estima-se que cerca de 5% dos pacientes com sarcoidose pulmonar/sistêmica possam evoluir com manifestações cardíacas da doença, tais como distúrbios de condução, arritmias ventriculares e insuficiência cardíaca. No entanto, a verdadeira prevalência da sarcoidose cardíaca (SC) é incerta e provavelmente subestimada, uma vez que muitos indivíduos apresentam sintomas inespecíficos ou doença subclínica. RELATO DE CASO: Paciente de sexo feminino, 47 anos, abriu o quadro com artrite simétrica dos tornozelos, piorando progressivamente ao longo do tempo. Após 6 meses, notou aparecimento de nódulos subcutâneos eritematosos em membros inferiores e alterações oftalmológicas caracterizadas como uveíte. Com 18 meses de evolução e ainda sem diagnóstico, apresentou dispnéia progressiva e sintomas constitucionais. Nesse momento, a paciente foi internada. A tomografia de tórax revelou adenopatia hilar bilateral e a biópsia por vídeotoracoscopia evidenciou processo granulomatoso não caseoso. Com diagnóstico de sarcoidose, iniciou-se então tratamento com metotrexato, obtendo-se remissão do quadro ao longo de 2 anos. No entanto, 2 meses após a suspensão da medicação, a paciente passou a referir dor torácica, palpitações e episódios de bradicardia não melhor caracterizada. Ecocardiograma e Holter de 24 horas sem alterações. Ressonância magnética (RM) do coração evidenciou realce tardio mesocárdico linear em parede inferolateral e médioapical do VE. Frente a esses achados e a elevação dos níveis de Enzima Conversora da Angiotensina (ECA), optou-se por reinstituir o tratamento com metotrexato, seguido de nova remissão da doença. DISCUSSÃO: A Síndrome de Löfgren, caracterizada por adenopatia hilar bilateral, eritema nodoso e artrite, é a manifestação clínica clássica da sarcoidose.Apesar da exuberância do quadro clínico, o diagnóstico ainda é um desafio, assim como evidenciado pela longa jornada de 18 meses desta paciente até o diagnóstico. A incidência de sarcoidose cardíaca vem aumentando em função da maior disponibilidade de RM e PET Scan, chegando a ser detectada em 20-25% dos casos. A maioria dos casos atualmente são subclínicos ou oligossintomáticos, mas alguns pacientes podem desenvolver um padrão de inflamação extensa, cicatrizes miocárdicas, disfunção ventricular, bloqueio atrioventricular total e arritmias ventriculares malignas. CONCLUSÃO: A incidência de SC vem aumentando em função do diagnóstico precoce de formas mais leves. Acompanhar estes pacientes a partir da fase pré-clínica pode prevenir a evolução para estágios mais graves da doença.

Evaluation of myocardial work in patients with resistant arterial hypertension.

AIMS: Individuals with resistant arterial hypertension are particularly at risk of developing target organ damage and cardiovascular events. The advanced echocardiography technique called myocardial work (MW), through the analysis of the left ventricular pressure-strain loop, is among the possibilities for evaluating these individuals. Our study was designed to describe the behavior of MW indices in individuals with resistant arterial hypertension (RH), controlled hypertension (CH), and normal arterial pressure (N). METHODS AND RESULTS: Seventy-one patients underwent Ambulatory Blood Pressure Monitoring (ABPM) and were characterized into three groups after a medical consult: RH (subjects with hypertension on four or more antihypertensive medications despite having controlled blood pressure); CH (subjects with hypertension on up to two antihypertensive medications); and N (individuals with normal ABPM; not using any medications). Echocardiographic analysis was performed using the Vivid E95 ultrasound system and blood pressure was measured at the time of the examination and subsequently used to determine myocardial work indices. RH demonstrated lower global work efficiency (GWE, mean = .95%; p = .005) and higher global wasted work (GWW, mean = 114 mm Hg%; p = .011) compared to other groups. Left ventricular mass measured by three-dimensional echocardiography, systolic wall stress, relative wall thickness and peak systolic dispersion were inversely correlated to GWE. No difference was observed between CH and N groups regarding MW indices. On multivariate analysis, only systolic wall stress remained as an independent predictor of GWE, when controlled by 3D mass index, relative wall thickness, peak systolic dispersion, and the hypertension group. CONCLUSION: Individuals with resistant hypertension have lower global work efficiency and higher global wasted work, compared to individuals with controlled hypertension and without arterial hypertension.

Evaluation of myocardial work in patients with resistant arterial hypertension

AIMS: Individuals with resistant arterial hypertension are particularly at risk of developing target organ damage and cardiovascular events. The advanced echocardiography technique called myocardial work (MW), through the analysis of the left ventricular pressure-strain loop, is among the possibilities for evaluating these individuals. Our study was designed to describe the behavior of MW indices in individuals with resistant arterial hypertension (RH), controlled hypertension (CH), and normal arterial pressure (N). METHODS AND RESULTS: Seventy-one patients underwent Ambulatory Blood Pressure Monitoring (ABPM) and were characterized into three groups after a medical consult: RH (subjects with hypertension on four or more antihypertensive medications despite having controlled blood pressure); CH (subjects with hypertension on up to two antihypertensive medications); and N (individuals with normal ABPM; not using any medications). Echocardiographic analysis was performed using the Vivid E95 ultrasound system and blood pressure was measured at the time of the examination and subsequently used to determine myocardial work indices. RH demonstrated lower global work efficiency (GWE, mean = .95%; p = .005) and higher global wasted work (GWW, mean = 114 mm Hg%; p = .011) compared to other groups. Left ventricular mass measured by three-dimensional echocardiography, systolic wall stress, relative wall thickness and peak systolic dispersion were inversely correlated to GWE. No difference was observed between CH and N groups regarding MW indices. On multivariate analysis, only systolic wall stress remained as an independent predictor of GWE, when controlled by 3D mass index, relative wall thickness, peak systolic dispersion, and the hypertension group. CONCLUSION: Individuals with resistant hypertension have lower global work efficiency and higher global wasted work, compared to individuals with controlled hypertension and without arterial hypertension.

Out-of-office measurement of blood pressure: practice, patient adherence and impact on blood pressure control in a high-complexity public outpatient facility

INTRODUCTION: Out-of-Office Measurement of Blood Pressure (BP) is recommended in addition to office BP for the diagnosis and follow-up of hypertensive patients. Ambulatory Blood Pressure Monitoring (ABPM); Home Blood Pressure Monitoring (HBPM); and Self-Monitoring of BP (SMBP) are the currently available options and their indication may vary according to the context. The aim of the present study was to assess how Out-of-Office Measurement of BP takes place in clinical practice and its impact on BP control in a public tertiary outpatient clinic. METHODS: We evaluated 225 consecutive patients seen at a high-complexity public outpatient facility (mean age: 66.7 ± 11.9 years; female: 62.7%). All patients were routinely requested to perform SMBP according to a prespecified institutional protocol. ABPM and HBPM were indicated for selected cases at the discretion of the attending physician. Patient Adherence to Out-of-Office Measurement of BP was labeled into 5 possible categories: a) No Measurement; b) ABPM; c) HBPM; d) Adequate SMBP e) Inadequate SMBP. Patient Adherence was also stratified according to sex, age, number of antihypertensive drugs, schooling, length of follow-up at the facility, comorbidities and availability of BP monitor at home. Rates of BP control were related with Patient Adherence, as well as with the aforementioned variables. RESULTS: 87.5% of the study population reported having a BP monitor at home. However, adding up the 5 possible categories, adequate Out-of-Office Measurement of BP was available in only 46.7% of the sample (40.9% of the patients did not bring any measurement; 13.8% underwent ABPM; 32.9% adequate SMBP; 12.4% inadequate SMBP; 0% HBPM). Availability of a BP monitor at home (p<0.001) and the number of antihypertensive drugs in use (p=0.019) were strongly associated with adherence to SMBP. Prevalence of smoking was 2 folds higher (7.5% vs 3.4%) in those who returned without SMBP. Rate of BP control based on office BP was 42.6% (79.5% of the sample was under ≥3 classes of antihypertensive drugs). Out-of-office BP measurements were not associated with higher rates of BP control (p=0.377), but allowed to identify a White Coat Effect (WCE) in 1 out of 3 patients with uncontrolled BP according to office BP (WCE prevalence: 29 % among uncontrolled patients vs 3.9% among controlled ones. CONCLUSIONS: Outof-Office Measurement of BP is still an unmet need in the treatment of hypertension.

Is office blood pressure underestimating reality in pediatric obese population?

INTRODUCTION: Hypertension (HTN) diagnosis depends on the accuracy and representativeness of blood pressure (BP) obtained by different methods. In pediatric obese patients, office BP can present great variability and does not detect nighttime changes. Ambulatory Blood Pressure Monitoring (ABPM) allows recognition of HTN phenotypes and predicts HTN severity in an earlier and assertive way. OBJECTIVE: To compare HTN stages defined by office BP with ABPM, and describe prevalence of masked HTM in pediatric sample from a reference service. METHODS: Retrospective cohort of pediatric patients with primary HTN. Patients underwent a detailed clinical history and examination. BP was measured by auscultatory method with technique adequacy. BP was checked at 2 other visits (2 week interval) and the mean BP of these 3 visits was used to classify BP according recommendations. ABPM was performed with pediatric validated device, with a revised report for this analysis, according to guidelines. Mean 24-hours awake and sleep BP and load were considered to identify HTN phenotypes according to 95th percentile for sex, age and height. Diagnosis and stages of HTN based on office BP were compared with ABPM. Patients with sustained HTN had secondary causes discharged after investigation and target organ damage (TOD) was also evaluated. RESULTS: Were included 16 patients with primary HTN, mean age 13 ± 3.3 years, 62% male, 87% obese or overweight (mean weight 89 ± 28.9kg) and 75% with first degree family history of HTN. Of these, as in Figure 1, masked hypertension was detected in 37.5% (6/16), white coat HTN in 12.5% (2/16), and in 68% of the sample (11/16) ABPM classified HTN at higher stage compared to office BP. Nocturnal HTN was present in 81% (13/16). None patient had TOD and at follow-up, 12 required antihypertensive drugs, with 68% of BP control. CONCLUSION: For this obese primary hypertensive pediatric sample, ABPM seems to be essential for HTN diagnosis and stratification, evidencing frequent nocturnal changes in BP. Complementary tests to investigate obstructive sleep apnea weren't done but this could be an associated factor.

Smoking load reduction is insufficient to downregulate miR-301b, a lung cancer promoter.

Several circulating miRNAs identified in the plasma of smokers have been implicated as promoters of nasopharyngeal and lung carcinoma. To investigate the plasma profile of miRNAs in subjects who reduces the number of smoked cigarettes and who quit after six months. We accompanied 28 individuals enrolled in a Smoking Cessation Program over 6 months. At Baseline, clinical characteristics, co-morbidities, and smoking history were similar among subjects. After 6 months, two groups were defined: who successfully quitted smoking (named "quitters", n = 18, mean age 57 years, 11 male) and who reduced the number of cigarettes smoked (20-90%) but failed to quit smoking (named "smokers", n = 10, mean age 52 years, 3 male). No significant clinical changes were observed between groups at baseline and after a 6-month period, however, quitters showed significant downregulations in seven miRNAs at baseline: miR-17 (- 2.90-fold, p = 0.029), miR-20a (- 3.80-fold, p = 0.021); miR-20b (- 4.71-fold, p = 0.027); miR-30a (- 3.95-fold, p = 0.024); miR-93 (- 3.63-fold, p = 0.022); miR-125a (- 1.70-fold, p = 0.038); and miR-195 (- 5.37-fold, p = 0.002), and after a 6-month period in 6 miRNAs: miR-17 (- 5.30-fold, p = 0.012), miR-20a (- 2.04-fold, p = 0.017), miR-20b (- 5.44-fold, p = 0.017), miR-93 (- 4.00-fold, p = 0.041), miR-101 (- 4.82-fold, p = 0.047) and miR-125b (- 3.65-fold, p = 0.025). Using time comparisons, only quitters had significant downregulation in miR-301b (- 2.29-fold, p = 0.038) after 6-month. Reductions in the number of smoked cigarettes was insufficient to change the plasma profile of miRNA after 6 months. Only quitting smoking (100% reduction) significantly downregulated miR-301b related to hypoxic conditions, promotion of cell proliferation, decreases in apoptosis, cancer development, and progression as increases in radiotherapy and chemotherapy resistance.

Smoking load reduction is insufcient to downregulate miR­301b, a lung cancer promoter

Abstract Several circulating miRNAs identified in the plasma of smokers have been implicated as promoters of nasopharyngeal and lung carcinoma. To investigate the plasma profile of miRNAs in subjects who reduces the number of smoked cigarettes and who quit after six months. We accompanied 28 individuals enrolled in a Smoking Cessation Program over 6 months. At Baseline, clinical characteristics, co-morbidities, and smoking history were similar among subjects. After 6 months, two groups were defined: who successfully quitted smoking (named "quitters", n = 18, mean age 57 years, 11 male) and who reduced the number of cigarettes smoked (20­90%) but failed to quit smoking (named "smokers", n = 10, mean age 52 years, 3 male). No significant clinical changes were observed between groups at baseline and after a 6-month period, however, quitters showed significant downregulations in seven miRNAs at baseline: miR-17 (− 2.90-fold, p = 0.029), miR-20a (− 3.80-fold, p = 0.021); miR-20b (− 4.71-fold, p = 0.027); miR-30a (− 3.95-fold, p = 0.024); miR-93 (− 3.63-fold, p = 0.022); miR-125a (− 1.70-fold, p = 0.038); and miR-195 (− 5.37-fold, p = 0.002), and after a 6-month period in 6 miRNAs: miR-17 (− 5.30-fold, p = 0.012), miR-20a (− 2.04-fold, p = 0.017), miR-20b (− 5.44-fold, p = 0.017), miR-93 (− 4.00-fold, p = 0.041), miR-101 (− 4.82-fold, p = 0.047) and miR-125b (− 3.65-fold, p = 0.025). Using time comparisons, only quitters had significant downregulation in miR-301b (− 2.29-fold, p = 0.038) after 6-month. Reductions in the number of smoked cigarettes was insufficient to change the plasma profile of miRNA after 6 months. Only quitting smoking (100% reduction) significantly downregulated miR-301b related to hypoxic conditions, promotion of cell proliferation, decreases in apoptosis, cancer development, and progression as increases in radiotherapy and chemotherapy resistance.