The Yanomami indians in the INTERSALT study

OBJECTIVE: To study the distribution and inter-relationship among constitutional and biochemical variables with blood pressure (BP) in an population of Yanomami indians. To compare these findings with those of other populations. METHODS: The Yanomami indians were part of the INTERSALT, a study comprising 10,079 males and females, aged from 20 to 59 years, belonging to 52 populations in 32 countries in Africa, the Americas, Asia, and Europe. Each of the 52 centers was required to accrue 200 individuals, 25 participants in each age group. The variables analyzed were as follows: age, sex, arterial BP, urinary sodium and potassium excretion (24-hour urine), body mass index, and alcohol ingestion. RESULTS: The findings in the Yanomami population were as follows: a very low urinary sodium excretion (0.9 mmol/24h); mean systolic and diastolic BP levels of 95.4 mmHg and 61.4 mmHg, respectively; no cases of hypertension or obesity; and they have no knowledge of alcoholic beverages. Their BP levels do not elevate with age. The urinary sodium excretion relates positively and the urinary potassium excretion relates negatively to systolic BP. This correlation was maintained even when controlled for age and body mass index. CONCLUSION: A positive relation between salt intake and blood pressure was detected in the analysis of a set of diverse populations participating in the INTERSALT Study, including populations such as the Yanomami Indians. The qualitative observation of their lifestyle provided additional information.

Assessment of factors that influence weaning from long-term mechanical ventilation after cardiac surgery

OBJECTIVE: To analyze parameters of respiratory system mechanics and oxygenation and cardiovascular alterations involved in weaning tracheostomized patients from long-term mechanical ventilation after cardiac surgery. METHODS: We studied 45 patients in their postoperative period of cardiac surgery, who required long-term mechanical ventilation for more than 10 days and had to undergo tracheostomy due to unsuccessful weaning from mechanical ventilation. The parameters of respiratory system mechanics, oxigenation and the following factors were analyzed: type of surgical procedure, presence of cardiac dysfunction, time of extracorporeal circulation, and presence of neurologic lesions. RESULTS: Of the 45 patients studied, successful weaning from mechanical ventilation was achieved in 22 patients, while the procedure was unsuccessful in 23 patients. No statistically significant difference was observed between the groups in regard to static pulmonary compliance (p=0.23), airway resistance (p=0.21), and the dead space/tidal volume ratio (p=0.54). No difference was also observed in regard to the variables PaO2/FiO2 ratio (p=0.86), rapid and superficial respiration index (p=0.48), and carbon dioxide arterial pressure (p=0.86). Cardiac dysfunction and time of extracorporeal circulation showed a significant difference. CONCLUSION: Data on respiratory system mechanics and oxygenation were not parameters for assessing the success or failure. Cardiac dysfunction and time of cardiopulmonary bypass, however, significantly interfered with the success in weaning patients from mechanical ventilation.

Risk factors for acute myocardial infarction during the postoperative period of myocardial revascularization

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p=0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1% vs. 1.1%; p<0.001 and 15.7 days vs. 10.6 days; p<0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis.

Risk factors, biochemical markers, and genetic polymorphisms in early coronary artery disease

OBJECTIVE: To assess the risk factors, lipid and apolipoprotein profile, hemostasis variables, and polymorphisms of the apolipoprotein AI-CIII gene in early coronary artery disease (CAD). METHODS: Case-control study with 112 patients in each group controlled by sex and age. After clinical evaluation and nutritional instruction, blood samples were collected for biochemical assays and genetic study. RESULTS: Familial history of early CAD (64 vs 39%), arterial hypertension (69 vs 36%), diabetes mellitus (25 vs 3%), and previous smoking (71 vs 46%) were more prevalent in the case group (p<0.001). Hypertension and diabetes were independent risk factors. Early CAD was characterized by higher serum levels of total cholesterol (235 ± 6 vs 209 ± 4 mg/dL), of LDL-c (154 ± 5 vs 135 ± 4 mg/dL), triglycerides (205 ± 12 vs 143 ± 9 mg/dL), and apolipoprotein B (129 ± 3 vs 105 ± 3 mg/dL), and lower serum levels of HDL-c (40 ± 1 vs 46 ± 1 mg/dL) and apolipoprotein AI (134 ± 2 vs 146 ± 2mg/dL) [p<0.01], in addition to an elevation in fibrinogen and D-dimer (p<0.02). The simultaneous presence of the rare alleles of the APO AI-CIII genes in early CAD are associated with hypertriglyceridemia (p=0.03). CONCLUSION: Of the classical risk factors, hypertension and diabetes mellitus were independently associated with early CAD. In addition to an unfavorable lipid profile, an increase in the thrombotic risk was identified in this population. An additive effect of the APO AI-CIII genes was observed in triglyceride levels.

Subendocardial fibrosis in remote myocardium results from reduction of coronary driving pressure during acute infarction in rats

OBJECTIVE: To investigate the role of hemodynamic changes occurring during acute MI in subsequent fibrosis deposition within non-MI. METHODS: By using the rat model of MI, 3 groups of 7 rats each [sham, SMI (MI <30%), and LMI (MI >30%)] were compared. Systemic and left ventricular (LV) hemodynamics were recorded 10 minutes before and after coronary artery ligature. Collagen volume fraction (CVF) was calculated in picrosirius red-stained heart tissue sections 4 weeks later. RESULTS: Before surgery, all hemodynamic variables were comparable among groups. After surgery, LV end-diastolic pressure increased and coronary driving pressure decreased significantly in the LMI compared with the sham group. LV dP/dt max and dP/dt min of both the SMI and LMI groups were statistically different from those of the sham group. CVF within non-MI interventricular septum and right ventricle did not differ between each MI group and the sham group. Otherwise, subendocardial (SE) CVF was statistically greater in the LMI group. SE CVF correlated negatively with post-MI systemic blood pressure and coronary driving pressure, and positively with post-MI LV dP/dt min. Stepwise regression analysis identified post-MI coronary driving pressure as an independent predictor of SE CVF. CONCLUSION: LV remodeling in rats with MI is characterized by predominant SE collagen deposition in non-MI and results from a reduction in myocardial perfusion pressure occurring early on in the setting of MI.

New auxiliary indicators for the differential diagnosis of functional cardiorespiratory limitation in patients with chronic obstructive pulmonary disease and congestive heart failure

OBJECTIVE: To differentiate the nature of functional cardiorespiratory limitations during exercise in individuals with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) and to determine indicators that may help their classifications. METHODS: The study comprised 40 patients: 23 with COPD and 17 with CHF. All individuals underwent maximal cardiopulmonary exercise testing on a treadmill. RESULTS: The values of peak gas exchange ratio (R peak), peak carbon dioxide production (VCO2 peak), and peak oxygen ventilatory equivalent (V E O2 peak) were higher in the patients with CHF than in those with COPD, and, therefore, those were the variables that characterized the differences between the groups. For group classification, the differentiating functions with the R peak, VCO2 peak (L/min), and V E O2 peak variables were used as follows: group COPD: - 44.886 + 78.832 x R peak + 5.442 x VCO2 peak + 0.336 x V E O2 peak; group CHF: - 69.251 + 89.740 x R peak + 8.461 x VCO2 peak + 0.574 x V E O2 peak. The differentiating function, whose result is greater, correctly classifies the patient's group as 90%. CONCLUSION: The R peak, VCO2 peak, and V E O2 peak values may be used to identify the cause of the functional cardiorespiratory limitations in patients with COPD and CHF.

Predictive factors of complications after coronary stent implantation

OBJECTIVE: To analyze the predictive factors of complications after implantation of coronary stents in a consecutive cohort study. METHODS: Clinical and angiographic characteristics related to the procedure were analyzed, and the incidence of major cardiovascular complications (myocardial infarction, urgent surgery, new angioplasty, death) in the in-hospital phase were recorded. Data were stored in an Access database and analyzed by using the SPSS 6.0 statistical program and a stepwise backwards multiple logistic regression model. RESULTS: One thousand eighteen (mean age of 61±11 years, 29% females) patients underwent 1,070 stent implantations. The rate of angiographic success was 96.8%, the rate of clinical success was 91%, and the incidence of major cardiovascular complications was 7.9%. The variables independently associated with major cardiovascular complications, with their respective odds ratio (OR) were: rescue stent, OR = 5.1 (2.7-9.6); filamentary stent, OR = 4.5 (2.2-9.1); first-generation tubular stent, OR = 2.4 (1.2-4.6); multiple stents, OR = 3 (1.6-5.6); complexity of the lesion, OR = 2.4 (1.1-5.1); thrombus, OR = 2 (1.1-3.5). CONCLUSION: The results stress the importance of angiographic variables and techniques in the risk of complications and draw attention to the influence of the stent's design on the result of the procedure.

Effect of oscillatory breathing on the variability of the RR Intervals and its prognostic importance in individuals with left ventricular global systolic dysfunction

OBJECTIVE: To assess the effect of the oscillatory breathing on the variability of RR intervals (VRR) and on prognostic significance after one year follow-up in subjects with left ventricular global systolic dysfunction. METHODS: We studied 76 subjects, whose age ranged from 40 to 80 years, paired for age and gender, divided into two groups: group I - 34 healthy subjects; group II - 42 subjects with left ventricular global systolic dysfunction (ejection fraction < 0.40). The ECG signals were acquired during 600s in supine position, and analyzed the variation of the thoracic amplitude and the VRR. Clinical and V-RR variables were applied into a logistic multivariate model to foretell survival after one year follow-up. RESULTS: Oscillatory breathing was detected in 35.7% of subjects in vigil state of group II, with a concentration of the spectral power in the very low frequency band, and was independent of the presence of diabetes, functional class, ejection fraction, cause of ventricular dysfunction and survival after one year follow-up. In the logistic regression model, ejection fraction was the only independent variable to predict survival. CONCLUSION: 1) Oscillatory breathing pattern is frequent during wakefulness in the left ventricular global systolic dysfunction and concentrates spectral power in the very low band of V-RR; 2) it does not relate to severity and cause of left ventricular dysfunction; 3) ejection fraction is the only independent predictive variable for survival in this group of subjects.

Impact of cerebral cardiopulmonary resuscitation maneuvers in a general hospital: prognostic factors and outcomes

OBJECTIVE: To assess survival of patients undergoing cerebral cardiopulmonary resuscitation maneuvers and to identify prognostic factors for short-term survival. METHODS: Prospective study with patients undergoing cardiopulmonary resuscitation maneuvers. RESULTS: The study included 150 patients. Spontaneous circulation was re-established in 88 (58%) patients, and 42 (28%) were discharged from the hospital. The necessary number of patients treated to save 1 life in 12 months was 3.4. The presence of ventricular fibrillation or tachycardia (VF/VT) as the initial rhythm, shorter times of cardiopulmonary resuscitation maneuvers and cardiopulmonary arrest, and greater values of mean blood pressure (BP) prior to cardiopulmonary arrest were independent variables for re-establishment of spontaneous circulation and hospital discharge. The odds ratios for hospital discharge were as follows: 6.1 (95% confidence interval [CI] = 2.7-13.6), when the initial rhythm was VF/VT; 9.4 (95% CI = 4.1-21.3), when the time of cerebral cardiopulmonary resuscitation was < 15 min; 9.2 (95% CI = 3.9-21.3), when the time of cardiopulmonary arrest was < 20 min; and 5.7 (95% CI = 2.4-13.7), when BP was > 70 mmHg. CONCLUSION: The presence of VF/VT as the initial rhythm, shorter times of cerebral cardiopulmonary resuscitation and of cardiopulmonary arrest, and a greater value of BP prior to cardiopulmonary arrest were independent variables of better prognosis.

Prevalence of dyslipidemia and risk factors in Campos dos Goytacazes, in the Brazilian State of Rio de Janeiro

OBJECTIVE: To determine the prevalence of dyslipidemias in adults in the city of Campos dos Goytacazes, in the Brazilian state of Rio de Janeiro, and to identify its relation to risk factors. METHODS: Cross-sectional, population-based, observational study with sampling through conglomerates and stratified according to socioeconomic levels, sex, and age, with 1,039 individuals. Risk factors, familial history, blood pressure, anthropometric measurements, glucose, triglycerides and cholesterol were determined. RESULTS: The following prevalences were observed: of dyslipidemias 24.2%; of hypercholesterolemia, 4.2%; of elevated LDL-C, 3.5%; of low HDL-C, 18.3%; and of hypertriglyceridemia, 17.1%. The following mean levels were observed: cholesterol, 187.6± 33.7 mg/dL; LDL-C, 108.7±26.8 mg/dL; HDL-C, 48.5±7.7 mg/dL; and triglycerides, 150.1±109.8 mg/dL. The following variables showed a positive correlation with dyslipidemia: increased age (P<0.001), male sex (P<0.001), low familial income (P<0.001), familial history (P<0.01), overweight/obesity (P<0.001), waist measure (P<0.001), high blood pressure (P<0.001), and diabetes mellitus (P<0.001). The following variables had no influence on dyslipidemias: ethnicity, educational level, smoking habits, and sedentary lifestyle. CONCLUSION: The frequency of lipid changes in the population studied was high, suggesting that measures for the early diagnosis should be taken, in association with implementation of programs for primary and secondary prevention of atherosclerosis.

Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome

OBJECTIVE: To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. METHODS: This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration , extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. RESULTS: Of all patients, 12 (12.5%) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. CONCLUSION: The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation.

Demographic characteristics of the population undergoing cine coronary angiography at the Instituto do Coração of the Medical School of USP from 1986 to 1995

OBJECTIVE: To obtain information about the profile and behavior of a population with ischemic heart disease undergoing cine coronary angiography and to determine disease severity. METHODS: Retrospective study assessing patients hospitalized at InCor from 1986 to 1995, in which the variables age, sex, and number of major coronary arteries with obstruction degree > 40% were analyzed. RESULTS: We studied 18,221 patients and observed a significant increase in the number of females (22.8% to 25.2%, P=0.001) and an increase in age (57.1±29.3 to 60.4±10.7 years, P=0.0001). A significant increase in the incidence of multivessel disease was observed, which was more frequent among males (69.2% and 64.5%) and among the older patients (59.8±9.8 and 56.8±10.7 years, P=0.0001). A reduction in the incidence of single-vessel disease was also observed (66.2% vs 69.2% and 33.8% vs 30.5%, respectively, P<0.0001). CONCLUSION: A change in the profile of the population studied was observed as follows: patients undergoing cine coronary angiography at InCor were older, had a greater number of impaired major coronary arteries, and the number of females affected increased, leading to indices suggestive of a poorer prognosis.

Right ventricular structure and function as possible determinants of surgical outcome 30 years after repair of tetralogy of Fallot

OBJECTIVE: To identify the variables that may be involved in the persistence of symptoms (functional class II, III, or IV vs. I) in patients being followed up for 30 years after surgical repair of tetralogy of Fallot. METHODS: Fifty-three patients (27 women), who underwent corrective surgery for tetralogy of Fallot between 1960 and 1970, were studied. Their ages ranged from 7 months to 26 years. At the end of follow-up, 13 patients were asymptomatic and the remaining were in functional class II (N=24), III (N=15), and IV (N=1). To differentiate asymptomatic from symptomatic patients, the following variables were analyzed: age at surgery, need for widening the pulmonary ring and trunk, need for a second (2nd OP) or 3rd operation, residual defect of the interventricular septum, residual regurgitation of the pulmonary valve, systolic gradient through the right ventricular outflow tract, right ventricular dilation or hypertrophy (RVH), cardiothoracic index (CTI), right and left ventricular ejection fraction (RVEF/LVEF), and arrhythmias. RESULTS: The univariate analysis showed an association between the presence of symptoms and the 2nd OP (P=0.03), an increase in the CTI (P=0.0001), moderate to severe RVH (P=0.002), and dilation (P=0.0003). In the logistic regression model, the combination of the 2nd OP (P=0.008), the RVH (P=0.002), and the reduction in RVEF (P=0.01) determined the presence of symptoms. CONCLUSION: Despite the surgical treatment, right ventricular remodeling and performance were the major determinants in the late follow-up of tetralogy of Fallot.

Comparative study of smokers, ex-smokers, and nonsmokers who have experienced myocardial infarction

OBJECTIVE: To assess the impact of smoking on in-hospital morbidity and mortality in patients who have experienced acute myocardial infarction and to assess the association between smoking and other cardiovascular risk factors and clinical data. METHODS: A prospective cohort study analyzed 121 patients, including 54 smokers, 35 ex-smokers, and 32 nonsmokers. RESULTS: Using the chi-square test (P<0.05), an association between smoking and the risk factors sex, age, and diabetes was documented. Among the morbidity and mortality variables, only acute pulmonary edema showed a statistically significant difference (OR=9.5; 95% CI), which was greater in the ex-smoker group than in the nonsmoker group. CONCLUSION: An association between smoking and some cardiovascular risk factors was observed, but no statistical difference in morbidity and mortality was observed in the groups studied, except for the variable acute pulmonary edema.

Lipid profile and cardiovascular risk in two Amazonian populations

OBJECTIVE: To compare the lipid profiles and coronary heart disease risks of 2 Brazilian Amazonian populations as follows: a riverside population (village of Vigia) and an urban population (city of Belém in the state of Pará). METHODS: Fifty individuals controlled for age and sex were assessed in each region, and the major risk factors for coronary heart disease were analyzed. RESULTS: According to the National Cholesterol Education Program (NCEP III) and using the Framingham score, both populations had the same absolute risk of events (Vigia = 5.4 ± 1 vs Belém = 5.7 ± 1), although the population of Vigia had a lower consumption of saturated fat (P<0.0001), a greater consumption of mono- and polyunsaturated fat (P<0.03), in addition to lower values for body mass index (25.4± 0.6 vs 27.6 ± 0.7 kg/m², P<0.02), of biceps skin fold (18.6 ± 1.1 vs 27.5 ± 1.3 mm, P<0.0001), of triceps skin fold (28.7 ± 1.2 vs 37.3 ± 1.7 mm, P<0.002), and of total cholesterol (205 ± 5 vs 223 ± 6 mg/dL, P< 0.03) and triglycerides (119 ± 9 vs 177 ± 18 mg/dL, P<0.005). Both populations did not differ in regard to HDL-C (46 ± 1 vs 46 ± 1 mg/dL), LDL-C (135 ± 4 vs 144 ± 5 mg/dL) and blood pressure (SBP 124 ± 3 vs 128 ± 3 mmHg; DBP 80 ± 2 vs 82 ± 2 mmHg). CONCLUSION: The riverside and urban populations of Amazonia had similar cardiovascular risks. However, the marked difference in the variables studied suggests that different strategies of prevention should be applied.