A red wine intervention does not modify plasma trimethylamine N-oxide but is associated with broad shifts in the plasma metabolome and gut microbiota composition

BACKGROUND

Gut microbiota profiles are closely related to cardiovascular diseases through mechanisms that include the reported deleterious effects of metabolites, such as trimethylamine N-oxide (TMAO), which have been studied as diagnostic and therapeutic targets. Moderate red wine (RW) consumption is reportedly cardioprotective, possibly by affecting the gut microbiota.

OBJECTIVES

To investigate the effects of RW consumption on the gut microbiota, plasma TMAO, and the plasma metabolome in men with documented coronary artery disease (CAD) using a multiomics assessment in a crossover trial.

METHODS

We conducted a randomized, crossover, controlled trial involving 42 men (average age, 60 y) with documented CAD comparing 3-wk RW consumption (250 mL/d, 5 d/wk) with an equal period of alcohol abstention, both preceded by a 2-wk washout period. The gut microbiota was analyzed via 16S rRNA high-throughput sequencing. Plasma TMAO was evaluated by LC-MS/MS. The plasma metabolome of 20 randomly selected participants was evaluated by ultra-high-performance LC-MS/MS. The effect of RW consumption was assessed by individual comparisons using paired tests during the abstention and RW periods.

RESULTS

Plasma TMAO did not differ between RW intervention and alcohol abstention, and TMAO concentrations showed low intraindividual concordance over time, with an intraclass correlation coefficient of 0.049 during the control period. After RW consumption, there was significant remodeling of the gut microbiota, with a difference in β diversity and predominance of Parasutterella, Ruminococcaceae, several Bacteroides species, and Prevotella. Plasma metabolomic analysis revealed significant changes in metabolites after RW consumption, consistent with improved redox homeostasis.

CONCLUSIONS

Modulation of the gut microbiota may contribute to the putative cardiovascular benefits of moderate RW consumption. The low intraindividual concordance of TMAO presents challenges regarding its role as a cardiovascular risk biomarker at the individual level. This study was registered at clinical trials.gov as NCT03232099.

Sex Differences in Cardiovascular Disease Mortality in Brazil between 1996 and 2019

BACKGROUND

cardiovascular diseases (CVD) are Brazil's leading causes of death in women and men. This study analyzed age-adjusted death rate (DRaj) trends from all causes of death (ACD), CVD, ischemic heart disease (IHD), and stroke in women and men aged 35 to 74 years from 1996 to 2019.

METHODS

We analyzed DRaj trends for all causes of death (ACD), CVD, IHD, and stroke. Data were from the Ministry of Health mortality database. Joinpoint Regression Program™ performed trend analysis and adjustments in death rates. Average annual percentage change (AAPC) determined the intensity of changes.

RESULTS

In women, DRaj reduced for ACD (AAPC = -1.6%); CVD (AAPC = -2.6%); IHD (AAPC = -1.9%); and stroke (AAPC = -4.6%) (p < 0.001 for all). In men, ACD reduced from 1996 to 2004 (AAPC = -0.9%; p < 0.001), from 2012 to 2019 (AAPC = -1.9%; p < 0.001), and unchanged from 2004 to 2012; CVD (AAPC = -2.1%); IHD (AAPC = -1.5%); stroke (AAPC = -4.9%) (p < 0.001 for all) reduced from 1996 to 2019. From 1996 to 2019, the male/female ratio for ACD remained unchanged. CVD increased from 1.58 to 1.83, IHD from 1.99 to 2.30, and stroke from 1.52 to 1.83.

CONCLUSION

ACD, CVD, IHD, and stroke were reduced more significantly in women, and the ratio of CVD, IHD, and CVD in men and women increased more in men. Future studies will be needed to determine the main factors responsible for a better outcome in women.

P2683Beneficial effects of red wine intake upon gut microbiota and parallel effects upon plasma metabolomics

Background

Evidence suggests that red wine (RW) components can influence favorably gut microbiota. However, Interactions of RW, gut microbiota and plasma metabolomics remain unclear.

Purpose

The goal of this study was to assess the effects upon gut microbiota and plasma metabolomic profile of short-term, moderate RW intake in patients (pts) with documented coronary artery disease (CAD)

Methods

Forty-two males aged 60.4±5.4 years (SD) with documented CAD by angiography underwent a randomized, crossover, controlled, interventional trial. They were assigned to either RW treatment or abstinence from any alcoholic beverage, as control. Each treatment was preceded by a 2-week washout period. During the RW intervention, subjects ingested 250 ml of RW per day/ 5 days a week/ 3 weeks. Fasting blood samples and fecal samples were collected 4 times, after washout and at the end of each 3-week intervention. Gut microbiota was analysed by 16 S rRNA gene sequences and plasma metabolomics was performed by Ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy. Twenty pts chosen randomly had their global metabolic profiles examined at all visits. Diet was carefully controlled and quantified by a 3 day/week questionnaire at beginning and end of the study. Prebiotics, probiotics were not allowed during the study. Patients in need for antibiotic therapy were not included.

Results

In the RW period compared to abstinence, fecal metagenomic revealed a decrease in abundance of Collinsella, a bacterial genus correlated with atherosclerosis; an increase in Eubacterium, genus related to fiber digestion and bile acid metabolism; and a significant increase in alpha diversity (p<0.05 for all). In plasma, trimethylamine N-oxide (TMAO), fell non-significantly post RW consumption. HDL and resveratrol increased after RW consumption (p<0.05). Plasma metabolomic analysis of 20 pts revealed microbiome related changes associated with RW consumption: decreased levels of phenylalanine, benzoate, tyrosine and tryptophan; lower levels of primary bile acids (BA) cholate, taurocholate, and also secondary BA deoxycholate and lithocholate sulfate. In parallel, RW elevated androgenic steroids and decreased beta oxidation (p<0.05 for all). Simultaneously total energy, proteins, carbohydrates and fat components of the diet did not change significantly.

Conclusions

Moderate RW ingestion augmented microbiota diversity, increased the proportion of putative anti-atherosclerotic bacteria and influenced plasma metabolomics. RW influenced energy metabolism through gut microbiota related plasma changes in amino acids, nucleotide profile, bile acids, androgenic steroids and beta-oxidation. These findings furnish some novel insight into mechanisms whereby RW may mitigate atherosclerosis.

Acknowledgement/Funding

FAPESP (Fundacao de Amparo à Pesquisa do Estado de Sao Paulo), IBRAVIN (Instituto Brasileiro do Vinho), Banco Bradesco SA

Red wine consumption, coronary calcification, and long-term clinical evolution

Coronary artery calcification (CAC) is associated with atherosclerotic complications. However, elevated CAC may not always imply a worse prognosis. Herein, we report the clinical evolution of long-term red wine (RW) drinkers in relation to CAC. We followed 200 healthy male habitual RW drinkers and compared them to 154 abstainers for a period of 5.5 years. The initial evaluation included coronary computed tomography angiography (CTA), clinical, demographics, and laboratory data. CAC was quantified by the Agatston score. The follow-up process was conducted by telephone calls and/or hospital record review. The composite end-point of total death, acute myocardial infarction (AMI), or coronary revascularization (or major adverse cardiac event - MACE) was assessed. The RW drinkers ingested 28.9±15 g of alcohol/day for 23.4±12.3 years. They had higher high-density lipoprotein and low-density lipoprotein, but lower C-reactive protein than abstainers. Age, total cholesterol, triglycerides, glucose, and liver enzymes were similar. History of diabetes was lower among drinkers, but other risk factors were similar. However, drinkers had higher CAC than abstainers; the mean value was 131.5±362 in drinkers vs 40.5±320 in abstainers (P<0.001). The median and interquartile range were 15 (0.0–131.5) in RW drinkers and 1 (0.0–40.5) in abstainers (P=0.003). During the follow-up, MACE was significantly lower in drinkers than in abstainers, despite their higher CAC. The difference was driven mainly by AMI (0 vs 6; P<0.03). Greater CAC values in this setting did not predict worse prognosis. A possible underlying mechanism is lesion calcification, which leads to plaque stabilization and less clinical events.

Ten-Year Follow-Up of Off-Pump and On-Pump Multivessel Coronary Artery Bypass Grafting: MASS III

It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.

Mortality due to Cardiovascular Diseases in Women and Men in the Five Brazilian Regions, 1980-2012

Background:

Studies have shown different mortalities due to cardiovascular diseases (CVD), ischemic heart disease (IHD) and cerebrovascular diseases (CbVD) in the five Brazilian regions. Socioeconomic conditions of those regions are frequently used to justify differences in mortality due to those diseases. In addition, studies have shown a reduction in the differences between the mortality rates of the five Brazilian regions.

Objective:

To update CVD mortality data in women and men in the five Brazilian regions.

Methods:

Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and Ministry of Health. Risk of death was adjusted by use of the direct method, with the 2000 world standard population as reference. We analyzed trends in mortality due to CVD, IHD and CbVD in women and men aged ≥ 30 years in the five Brazilian regions from 1980 to 2012.

Results:

Mortality due to: 1) CVD: showed reduction in the Northern, West-Central, Southern and Southeastern regions; increase in the Northeastern region; 2) IHD: reduction in the Southeastern and Southern regions; increase in the Northeastern region; and unchanged in the Northern and West-Central regions; 3) CbVD: reduction in the Southern, Southeastern and West-Central regions; increase in the Northeastern region; and unchanged in Northern region. There was also a convergence in mortality trends due to CVD, IHD, and CbVD in the five regions.

Conclusion:

The West-Central, Northern and Northeastern regions had the worst trends in CVD mortality as compared to the Southeastern and Southern regions. (Arq Bras Cardiol. 2016; [online].ahead print, PP.0-0)

Trends in Mortality Rate from Cardiovascular Disease in Brazil, 1980-2012

Background

Studies have questioned the downward trend in mortality from cardiovascular diseases (CVD) in Brazil in recent years.

Objective

to analyze recent trends in mortality from ischemic heart disease (IHD) and stroke in the Brazilian population.

Methods

Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. Risk of death was adjusted by the direct method, using as reference the world population of 2000. We analyzed trends in mortality from CVD, IHD and stroke in women and men in the periods of 1980-2006 and 2007-2012.

Results

there was a decrease in CVD mortality and stroke in women and men for both periods (p < 0.001). Annual mortality variations for periods 1980-2006 and 2007-2012 were, respectively: CVD (total): -1.5% and -0.8%; CVD men: -1.4% and -0.6%; CVD women: -1.7% and -1.0%; DIC (men): -1.1% and 0.1%; stroke (men): -1.7% and -1.4%; DIC (women): -1.5% and 0.4%; stroke (women): -2.0% and -1.9%. From 1980 to 2006, there was a decrease in IHD mortality in men and women (p < 0.001), but from 2007 to 2012, changes in IHD mortality were not significant in men [y = 151 + 0.04 (R² = 0.02; p = 0.779)] and women [y = 88-0.54 (R² = 0.24; p = 0.320).

Conclusion

Trend in mortality from IHD stopped falling in Brazil from 2007 to 2012.

Coronary artery plaque burden and calcium scores in healthy men adhering to long-term wine drinking or alcohol abstinence

Observational studies suggest there are clinical benefits to moderate red wine (RW) consumption. However, the effects on coronary vasculature and overall lifestyle are unclear. We investigated whether a lifestyle of regular long-term RW consumption is associated with changes in coronary plaque burden, calcium score, carotid intima/media thickness, endothelial function, and metabolic variables, compared with alcohol abstinence. Healthy volunteers were evaluated by coronary computed tomography angiography (CTA) as well as carotid and brachial artery ultrasound. Nutritional status, psychological status, and metabolic variables were assessed. The study included 101 drinkers [aged 58.9 ± 7.3 years (means ± SD)], from wine brotherhoods, and 104 abstainers, from Anglican, Evangelical and Catholic churches both in the city of São Paulo, Brazil. No significant differences in demographics were noted. Lesion prevalence per patient assessed by coronary CTA and classified as absent (0), 1-25, 26-49, and ≥ 50% stenosis was similar between groups. When analyzed by individual arteries, i.e., left anterior descending, circumflex, and right coronary, prevalence was also not different. On the other hand, calcium scores were higher among drinkers than abstainers (144.4 ± 362.2 vs 122.0 ± 370.3; P<0.01). However, drinkers reported less history of diabetes and exercised more. RW drinkers consumed 2127.9 ± 387.7 kcal/day while abstainers consumed 1836.0 ± 305.0 (P<0.0001). HDL cholesterol was significantly higher among drinkers compared to abstainers (46.9 ± 10.9 vs 39.5 ± 9.0 mg/dL; P<0.001), while fasting plasma glucose was lower (97.6 ± 18.2 vs 118.4 ± 29.6 mg/dL; P<0.02). Liver enzymes were normal in both groups. In conclusion, long-term wine drinkers displayed a similar plaque burden but greater calcium score than abstainers, despite a more atherogenic diet, and the mechanisms for the increased calcium scores in the former remain speculative.

Synergistic anti-inflammatory effect: simvastatin and pioglitazone reduce inflammatory markers of plasma and epicardial adipose tissue of coronary patients with metabolic syndrome

BACKGROUND

The inappropriate secretion of adipocytokines plays a critical role in chronic inflammatory states associated with obesity-linked type 2 diabetes and atherosclerosis. The pleiotropic actions of simvastatin and pioglitazone on epicardial adipose tissue (EAT) are unknown. This study assessed the anti-inflammatory actions of simvastatin and pioglitazone on EAT in patients with coronary artery disease (CAD) and metabolic syndrome (MS).

METHODS

A total of 73 patients with multivessel CAD who underwent elective bypass grafting were non-randomly allocated to one of four subgroups: Control (n = 17), simvastatin (20 mg/day, n = 20), pioglitazone (15 mg or 30 mg/day, n = 18), or simvastatin + pioglitazone (20 mg/day + 30 mg/day, respectively, n = 18); 20 valvar patients were also included. EAT samples were obtained during surgery. The infiltration of macrophages and lymphocytes and cytokines secretion were investigated using immunohistochemical staining and compared to plasma inflammatory biomarkers.

RESULTS

Simvastatin significantly reduced plasma interleukin-6, leptin, resistin and monocyte chemoattractant protein-1 (p < 0.001 for all); pioglitazone reduced interleukin-6, tumoral necrose factor-alpha, resistin and matrix metalloproteinase-9 (p < 0.001 for all). Simvastatin + pioglitazone treatment further reduced plasmatic variables, including interleukin-6, tumoral necrose factor-alpha, resistin, asymmetric dimethylarginine and metalloproteinase-9 vs. the control group (p < 0.001). Higher plasma adiponectin and lower high sensitivity C-reactive protein concentrations were found simultaneously in the combined treatment group. A positive correlation between the mean percentage systemic and tissue cytokines was observed after treatments. T- and B-lymphocytes and macrophages clusters were observed in the fat fragments of patients treated with simvastatin for the first time.

CONCLUSIONS

Pioglitazone, simvastatin or combination treatment substantially reduced EAT and plasma inflammatory markers in CAD and MS patients. These tissue effects may contribute to the control of coronary atherosclerosis progression.

Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update

BACKGROUND

Cardiovascular diseases (CVD) are the leading causes of death in our population. There was a progressive decrease in mortality due to CVD up to 2005.

OBJECTIVE

To update the trends in mortality from cardiovascular diseases in Brazil and in the metropolitan region of São Paulo (MRSP) from 1990 to 2009.

METHODS

Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk of death was adjusted by the direct method, having as reference the world population in 2000.

RESULTS

There was a progressive decrease in the risk of death from ischemic heart disease (IHD) and stroke in Brazil and in the MRSP. From 1990 to 2009, there was a decrease in mortality from IHD and stroke in men and women in Brazil and in the MRSP. There was a greater reduction in mortality from IHD in men in the MRSP than in Brazil (36.24% vs. 23.35%, p <0.001) and in women in the MRSP (44.55% vs. 29.5%; p <0.001). The highest reduction in stroke mortality was observed in men in the MRSP, when compared to Brazil (42.43% vs. 34.9%, p = 0.036) and an equal reduction in women in the MRSP and in Brazil (42.98% vs. 36.15%, p = 0.082). The decrease in mortality was significant for all age groups.

CONCLUSION

We observed a progressive decrease in mortality from CVD, IHD and stroke in Brazil and in the MRSP. In spite of this decrease, we still have high rates of mortality from these diseases.

Red wine and equivalent oral pharmacological doses of resveratrol delay vascular aging but do not extend life span in rats

OBJECTIVE

To investigate, in male Wistar rats, the effects of long-term moderate red wine (RW) consumption (equivalent to ∼0.15 mg% resveratrol RS), or RS in low (L, 0.15 mg%) or high (H, 400 mg%) doses in chow.

BACKGROUND

Both RW and RS exhibit cardioprotection. RS extends lifespan in obese rats. It is unclear whether RW consumption or low-dose RS delay vascular aging and prolong life span in the absence of overt risk factors.

METHODS

Endpoints were aerobic performance, exercise capacity, aging biomarkers (p53,p16,p21, telomere length and telomerase activity in aortic homogenates), vascular reactivity. Data were compared with controls (C) given regular chow.

RESULTS

Expressions of p53 decreased ∼50% ∼with RW and LRS (p < 0.05 vs. C), p16 by ∼29% with RW (p < 0.05 vs. C) and p21 was unaltered. RW and LRS increased telomere length >6.5-fold vs. C, and telomerase activity increased with LRS and HRS. All treatments increased aerobic capacity (C 32.5 ± 1.2, RW 38.7 ± 1.7, LRS 38.5 ± 1.6, HRS 38.3 ± 1.8 mlO(2) min(-1) kg(-1)), and RW or LRS also improved time of exercise tolerance vs. C (p < 0.05). Endothelium-dependent relaxation improved with all treatments vs. C. Life span, however, was unaltered with each treatment vs. C = 673 ± 30 days, p = NS.

CONCLUSIONS

RW and LRS can preserve vascular function indexes in normal rats, although not extending life span. These effects were translated into better aerobic performance and exercise capacity.

Influence of metal alloy and the profile of coronary stents in patients with multivessel coronary disease

BACKGROUND

In Brazil, despite the recommendations of the Brazilian Society of Hemodynamics and Interventional Cardiology, the National Health System has not yet approved the use of drug-eluting stents. In percutaneous coronary interventions performed in the public and part of the private health care system, bare metal stents are used as the only option. Therefore, new information on bare metal stents is of great importance. The primary endpoint was to evaluate the influence of the alloy and the profile of coronary stents on late loss and restenosis rates 6 months after implantation in patients with multivessel coronary disease.

METHODS

Single center, randomized and prospective study comparison of cobalt-chromium versus stainless steel stent implantation in 187 patients with multivessel coronary disease. At least one cobalt-chromium and one stainless steel stent were implanted per patient.

RESULTS

Mean age of patients was 59.5 + 10.1 years with a prevalence of males (66.3%) and patients with acute coronary syndrome (56%). Baseline clinical characteristics were similar with hypertension in 146 (78%), dyslipidemia in 85 (45.5%) and diabetes in 68 (36.4%). Two hundred and twenty-nine cobalt-chromium and 284 stainless steel stents were implanted. Angiographic variables showed no statistically significant difference. Angiographic follow-up to 6 months after implantation showed similar late loss and restenosis rates.

CONCLUSION

The use of two different alloys, stainless steel and cobalt-chrome stents, in the same patient and in the same vessel produced similar 6-month restenosis and late loss rates.

Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS III Trial

BACKGROUND

Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body's response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes.

METHODS AND RESULTS

In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P=0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P<0.001), in the length of ICU stay (19.5±17.8 versus 43±17.0 hours; P<0.001), time to extubation (4.6±6.8 versus 9.3±5.7 hours; P<0.001), hospital stay (6±2 versus 9±2 days; P<0.001), higher incidence of atrial fibrillation (35 versus 4% of patients; P<0.001), and blood requirements (31 versus 61% of patients; P<0.001), respectively. The number of grafts per patient was higher in the ONCAB than the OPCAB group (2.97 versus 2.49 grafts/patient; P<0.001).

CONCLUSIONS

No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.

[Clinical and angiographic profile in coronary artery disease: hospital outcome with emphasis on the very elderly]

BACKGROUND

knowing the risk factors and clinical manifestations of coronary artery disease (CAD) allows us to intervene more effectively with a particular population.

OBJECTIVE

to identify clinical and angiographic profiles of patients undergoing cardiac catheterization, treated at a tertiary hospital and treated by percutaneous coronary interventions (PCI).

METHODS

the study of 1,282 patients who underwent 1,410 cardiac catheterizations, selected from March/2007 to May/2008 from a database in a general hospital for diagnosis of coronary artery disease (CAD). Risk factors, indication for examination, technical details of PCI and in-hospital outcomes were prospectively collected.

RESULTS

there were 688 (54.0%) males, mean age 65.4 ± 10.9 years and 20.0% above 75 years age. The most frequent clinical condition was acute coronary syndrome (ACS) without ST-segment elevation (STS) (38.7%). The multi artery CAD occurred in 46.4%, PCI was indicated in 464 patients, 547 target lesions were treated (type B2 or C, 86.0%), and of these, 14.0% treated with drug eluting stents. Among those with AMI with STS, primary PCI was performed in 19.0% of the patients, from these, 77.0% were transferred from the origin hospitals late (late PCI) and had not received prior thrombolytic, and 4.0% had PCI rescue. Angiographic success was achieved in 94.2% of PCIs. Death occurred in 5.6% of patients, with average age of 75.2 ± 10.2 years.

CONCLUSION

the prevalence of elderly (20.1% being > 75 years) and male was observed. From the risk factors for CAD, the most common were systemic hypertension and dyslipidemia. There was a predominance of ACS. Age > 75 years old, multiarterial CAD and chronic renal failure were predictors of in-hospital deaths.

Epidemiologic transition in mortality rate from circulatory diseases in Brazil

BACKGROUND

Circulatory diseases (CD) are the major cause of death in Brazil, being cerebrovascular diseases (CVD) predominant. In developed countries ischemic heart diseases (IHD) predominate.

OBJECTIVE

The objective of the present study was to investigate the ratio between cerebrovascular diseases/ischemic heart diseases (CVD/IHD) in males and females who were 30 years of age and older.

METHODS

Population estimates and mortality data for CD, IHD and CVD were provided by the Ministry of Health for the period between 1980 and 2005. The risk of death from IHD and CVD per 100,000 Brazilians and CVD/IHD ratio were analyzed in 10-year age ranges as of 30 years of age. The risk of death was adjusted by direct method by using 1960 world population as the standard population.

RESULTS

It was observed that the risk of death from IHD and CVD increased exponentially as age advanced. CVD was the major cause of death in Brazil until 1996, when IHD took the lead. In the period between 1980 and 2005 a 33.25% reduction in death risk from CD was observed in the Brazilian population. In that same period, the metropolitan area of the capital city of São Paulo reported a 45.44% reduction. The CVD/IHD ratio was shown to be higher among younger women - from 2.53 in 1980 down to 2.04 in 2005 in the Brazilian population, and from 2.76 in 1980 down to 1.96 in the metropolitan area of the capital city of São Paulo, with decreasing figures for subsequent age ranges. Among males, the CVD/IHD ratio was close to < 1 in all age ranges.

CONCLUSION

A transition in death risk from CD could be observed in Brazil, with current predominance of IHD.

Influenza vaccination and cardiovascular mortality in women and men at least 60 years of age in the metropolitan area of sao paulo, Brazil

OBJECTIVES

Influenza (flu) vaccination has been associated with a reduction in cardiovascular mortality in a metropolitan area of Brazil. Nevertheless, it is unknown whether sex influences this outcome. The aim of the study was analyze the cardiovascular disease (CVD) mortality in women and men before and after the initiation of a flu vaccination program.

METHODS

We analyzed the mortality of ischemic heart disease (IHD), stroke, and external causes (EC) in women and men at least 60 years of age in the metropolitan area of São Paulo before and after the initiation of a flu vaccination program. Estimates of the population were obtained from the Brazilian Institute of Geography and Statistics and the mortality data from the Ministry of Health for the period between 1980 and 2006. The risk of death was adjusted by the direct method using the 1960 world standard population.

RESULTS

Change in trend in mortality after vaccination was significant only for IHD (-9.3% vs -30.2%; P = .022) and remained unchanged for stroke (-31.4% vs -25.3%; P =.931) and EC (-8.5% vs -1.2%; P = .941). The decline in IHD pre- (1980-1995) and post-vaccination (1996-2006) was greater in women (-3.8% vs -28.8%; P = .001) than in men (-12.9% vs -30.4%; P = .054).

CONCLUSION

Flu vaccination was associated with a significant reduction of IHD mortality, more so in women than in men.

[Analysis of Brazilian Public Health System values for complete percutaneous myocardial revascularization in multi-arterial patients]

BACKGROUND

The Brazilian Public Health System (SUS, acronym in Portuguese) establishes that coronary angioplasty with the double implant stent must not exceed 20% of the angioplasties, resulting in the need of assigning most of the procedures in patients with multiarterial disease.

OBJECTIVE

The objective of the present study was to assess the paid values by the SUS in order to obtain the complete percutaneous myocardial revascularization in the SUS patients with the multiarterial disease, related to the number of necessary procedures and of implanted stents.

METHODS

A total of 141 patients with multiarterial coronary disease, submitted to a successful complete revascularization, were included by the stent implant with coronariography in a 6-month period of post-implant. The complete revascularization was defined as the percutaneous treatment of all stenosis > 70% in vessels with diameter > 2 mm. For the costs analysis, the values from the Sistema de Informações Hospitalares (SIH) of the SUS table were considered as R$ 2,263.77, for the procedure; and R$ 2,034.23, per implanted stent.

RESULTS

In the period from 7/2006 to 12/2007, 416 stents were implanted in 141 patients. The mean age was of 59.7 +/- 9.9 years old, prevailing the male sex (68.1%). The number of vessels was 356 and the lesions number corresponded to 416. In order to obtain the complete revascularization by the coronary stent implant, it was necessary to stagger in up to four procedures. The mean time between the 1st and 2nd, 2nd and 3rd and 3rd and 4th angioplasties was of 45.8 +/- 37.7; 55.4 +/- 55.3 and 33.5 +/- 19.1 days, respectively.

CONCLUSION

The complete percutaneous revascularization in patients from the SUS with the multiarterial coronary disease, carried out in most of them staggered, causes considerable elevation of public expenses due to the increase of procedures' number.

Trends in ischemic heart disease and stroke death ratios in brazilian women and men

OBJECTIVE

Cardiovascular diseases are the main cause of death in women and men in Brazil, but the trends for the death ratios for ischemic heart disease and stroke in women and men remain unknown.

METHOD

In this study, the trends for the death ratios among women and men who were over 30 years of age were analyzed from 1980 to 2005. Data were collected for both the Brazilian population and the metropolitan area of São Paulo. Estimates of the population size and data for mortality were then obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk for death was adjusted using a direct method.

RESULTS

Death rates due to cardiovascular disease, ischemic heart disease, and stroke have declined in both Brazil and the metropolitan region of São Paulo. A linear regression analysis revealed a similar trend for ischemic heart disease and demonstrated a male/female ratio of 1.653 ± 0.001 (r=0.228; p=0.262) in Brazil and 1.763 ± 0.008 (r=0.863; p<0.001) in São Paulo. Comparisons between the slopes of the linear regressions showed an increased ischemic heart disease ratio in men/women in São Paulo in comparison to those in Brazil (p<0.0001). The linear regression showed an increasing trend for the male/female stroke ratio of 1.252 ± 0.004 (r=0.776; p<0.0001) in Brazil and 1.331 ± 0.006 (r=0.580; p=0.002) in São Paulo. Comparisons between the regressions for the stroke ratio were similar for men/women in São Paulo compared to Brazil (p=0.244).

CONCLUSION

We observed an increased trend in the ratio for ischemic heart disease death in men compared to women. Improvements in the control of risk factors and treatments for both men and women are mandatory to reduce the number of ischemic heart disease-related deaths in Brazil.

Angiotensin-converting enzyme and apolipoproteins genes polymorphism in coronary artery disease

BACKGROUND

Association between angiotensin-converting enzyme (ACE) as well as apolipoprotein (apo) AI, B, and E polymorphisms and dyslipidemia and coronary artery disease (CAD) is controversial.

HYPOTHESIS

This study assessed the distribution of ACE insertion/deletion, apo AI A/G mutation, apo B signal peptide insertion/deletion, apo B XbaI restriction fragment length, and apo E polymorphisms in 388 nondiabetic patients.

METHODS

The study population included 112 patients with stable CAD, 139 patients with acute myocardial infarction (AMI), and 137 age-matched control subjects.

RESULTS

Univariate analysis showed higher prevalence of XbaI X+/X+ genotype in patients with CAD (p = 0.02). Angiotensin-converting enzyme and apo polymorphisms were not associated with lipid levels or severity of CAD. When all genotypes known to be related to CAD; such as ACE DD, apo AI GG, apo B del/del, and XbaI X+X+, and E4 allele of apo E, were pooled, again no significant differences among groups were seen. Multivariate regression analysis disclosed traditional risk factors and elevated levels of apo B for men and reduced levels of apo AI for women as independent variables for CAD.

CONCLUSIONS

In addition to traditional coronary risk factors, apo B and AI could be considered predictors of CAD. No association between either form of CAD and polymorphisms was noted.

Qualidade de vida em portadores de doença arterial coronária: comparação entre gêneros

OBJECTIVE

To analyze the quality of life of people with coronary artery disease (CAD) who underwent distinct therapeutic interventions and compare the possible differences between genders.

METHODS

This study comprised 542 subjects, 376 men (58.5 +/- 8.7 years) and 166 women (61.8 +/- 9.2 years), with CAD who underwent surgical, medical treatment or angioplasty. Quality of life was assessed with The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) administered at the beginning of treatment and after 6 and 12 months. The applied statistical method was the ANOVA test.

RESULTS

Those who underwent surgical treatment had scores of 46, 63, 68, for physical components; 52, 65, 62 for medical treatment, and 57, 66, 70 for angioplasty, respectively, in the initial, six, and twelve months phases. For mental components, results were 58, 71, 74 for the surgical intervention; 61, 69, 69 for the medical treatment, 64, 74, 74 for angioplasty. The differences over time and between treatments reached a statistical significance (p<0.001). In comparing genders, physical component scores in men were 56*, 69, 77*, and 41*, 64, 62* in women, respectively; mental component scores in men were 61*, 73, 80* and 51*, 68, 62* in women (*p<0.0001).

CONCLUSIONS

Subjects who underwent surgical treatment had the most favorable evolution. Men when compared to women had a better quality of life in the beginning of treatment with a progressive improvement after six and twelve months, while women, after an improvement at six months, presented a decrease at twelve.

Comparison of serum lipid values in patients with coronary artery disease at <50, 50 to 59, 60 to 69, and >70 years of age

We evaluated the relation between lipids and precocity of coronary artery disease (CAD) in the real world as characterized by increasing statin use. The highest mean values of total cholesterol, low-density lipoprotein cholesterol, triglycerides, non-high-density lipoprotein (HDL) cholesterol, and ratio of triglycerides to HDL cholesterol were found when CAD was detected in patients who were <50 years of age (p <0.01 for all); the opposite occurred for HDL cholesterol (p <0.01). Triglycerides and ratio of triglycerides to HDL cholesterol were the most powerful, independent variables related to precocity of CAD.

Compensatory enlargement of human coronary arteries identified by magnetic resonance imaging

The aim of the present study was to evaluate the role of magnetic resonance imaging (MRI) for the non-invasive detection of coronary abnormalities and specifically the remodeling process in patients with coronary artery disease (CAD). MRI was performed in 10 control healthy subjects and 26 patients with angiographically proven CAD of the right coronary (RCA) or left anterior descending (LAD) artery; 23 patients were within two months of acute coronary syndromes, and 3 had stable angina with a positive test for ischemia. Wall thickness (WT), vessel wall area (VWA), total vessel area (TVA), and luminal area (LA) were measured. There were significant increases in WT (mean +/- SEM, RCA: 2.62 +/- 0.75 vs 0.53 +/- 0.15 mm; LAD: 2.21 +/- 0.69 vs 0.62 +/- 0.24 mm) and in VWA (RCA: 30.96 +/- 17.57 vs 2.1 +/- 1.2 mm(2); LAD: 19.53 +/- 7.25 vs 3.6 +/- 2.0 mm(2)) patients compared to controls (P < 0.001 for each variable). TVA values were also greater in patients compared to controls (RCA: 44.56 +/- 21.87 vs 12.3 +/- 4.2 mm(2); LAD: 31.89 +/- 11.31 vs 17.0 +/- 6.2 mm(2); P < 0.001). In contrast, the LA did not differ between patients and controls for RCA or LAD. When the LA was adjusted for vessel size using the LA/TVA ratio, a significant difference was found: 0.33 +/- 0.16 in patients vs 0.82 +/- 0.09 in controls (RCA) and 0.38 +/- 0.13 vs 0.78 +/- 0.06 (LAD) (P < 0.001). As opposed to normal controls, positive remodeling was present in all patients with CAD, as indicated by larger VWA. We conclude that MRI detected vessel wall abnormalities and was an effective tool for the noninvasive evaluation of the atherosclerotic process and coronary vessel wall modifications, including positive remodeling that frequently occurs in patients with acute coronary syndromes.

Stroke and ischemic heart disease mortality trends in Brazil from 1979 to 1996

Stroke and ischemic heart disease (IHD) mortality rates were analyzed in Brazilian subjects older than 30 years of age from 1979 to 1996. Population estimates were based on census surveys. Mortality data were obtained from the Ministry of Health. For stroke, the age-adjusted death rate (ADR) dropped from 200 to 164 and from 168 to 130 deaths/100,000 population in men and women, respectively (p < 0.001), in the interval study. For IHD, the ADR dropped from 194 to 164 and from 119 to 105 deaths/100,000 population in men and women, respectively (p < 0.001), in the same time period. Mortality from stroke and IHD combined was greater in men for all age groups (p < 0.001). Stroke was the most frequent cause of death in both women and men except for men aged between 40 and 69 years, in whom IHD was more common. Stroke and IHD were the main causes of death in the Brazilian population.

Effect of Controlling Hypercholesterolemia on Myocardial Ischemia

Hypercholesterolemia causes myocardial ischemia, even in the absence of obstructive coronary artery lesions. Reductions in cholesterol are associated with improved clinical outcomes that may reflect reversal of endothelial dysfunction, lesion regression, or both. This review explores experimental and clinical evidence that supports these observations. These include: 1) mechanisms by which hypercholesterolemia (and other risk factors for coronary artery disease) causes endothelial dysfunction; 2) the role that hypercholesterolemia and endothelial dysfunction play in atherogenesis, lesion complications, and clinical ischemic syndromes; and 3) compelling data that illustrate the benefits of cholesterol control. The latter include transformation of the plaque lipid composition to a more favorable profile, improved blood pressure control, normalization of exercise test results, improved exercise tolerance, and reversal or prevention of myocardial perfusion abnormalities. Collectively, these data support the notion that control of cholesterol is important to both the prevention and treatment of cardiac disease.) (c)2001 CHF, Inc.

Clustering of traditional risk factors and precocity of coronary disease in women

BACKGROUND

Women usually develop coronary artery disease (CAD) 10 years later than men do. CAD in women is associated with menopausal status and the number and intensity of risk factors. But, when the age gap between men and women narrows, less is known about the influence of risk factors on CAD.

METHODS

We assessed the prevalence of traditional risk factors in 850 men and 468 women with stable CAD who had mean age, 58.3+/-8.6 and 58.8+/-10.3 years (P=NS), respectively.

RESULTS

Univariate analysis of risk factors showed that body mass index (BMI), hypertension (all three stages), diabetes, triglycerides (> or =2.8 mmol/l), cholesterol (> or =6.2 mmol/l) and family history were more prevalent in women. Smoking and previous myocardial infarction (MI) were more prevalent in men. Multivariable analysis disclosed hypertension, diabetes, dyslipidemia and family history as independent risk factors for women with stable CAD and smoking and previous MI as independent risk factors for men.

CONCLUSION

Clustering of traditional risk factors may explain the precocity of CAD in women who are near in age to men.

Trends in death from circulatory diseases in Brazil between 1979 and 1996

OBJECTIVE

To analyze the trends in mortality due to circulatory diseases in men and women aged > or =30 years in Brazil from 1979 to 1996.

METHODS

We analyzed population count data obtained from the IBGE Foundation and mortality data obtained from the System of Information on Mortality of the DATASUS of the Ministry of Health.

RESULTS

Circulatory diseases, ischemic heart disease, and cerebrovascular disease were the major causes of death in men and women in Brazil. The standardized age coefficient for circulatory disease in men aged > or =30 years ranged from 620 to 506 deaths/100,000 inhabitants and in women from 483 to 383 deaths/100,000 inhabitants for the years 1979 and 1996, respectively. In men, the mean coefficient for the period was 586.25 deaths with a significant trend towards a decrease (P<0.001) and a decline of 8.25 deaths/year. In women, the mean coefficient for the period was 439.58 deaths, a significant trend towards a decrease (P<0.001) and a rate of decline of 7.53 deaths/year. The same significant trend towards a decrease in death (P<0.001) was observed for ischemic heart disease and cerebrovascular disease. Risk of death from these causes was always higher for men of any age group (P<0.001). Cerebrovascular disease was the primary cause of death in women.

CONCLUSION

Although circulatory diseases have been the major cause of mortality in men and women in the Brazilian population, with a greater participation by cerebrovascular diseases, a trend towards a decrease in the risk of death from these causes is being observed.

Perioperative myocardial infarction in a patient with tuberculous constrictive pericarditis in the absence of coronary artery disease

A 34-year-old man developed severe heart failure due to constrictive pericarditis. Pericardiectomy was carried on and the patient died 12 hours after surgery. Necropsy revealed an extensive hemorrhagic myocardial infarction involving the lateral free wall of the left ventricle in the absence of coronary artery disease. In addition, necropsy revealed tuberculosis as the etiology of constrictive pericarditis. Thus, myocardial infarction may occur in constrictive pericarditis in the setting of pericardiectomy and absence of coronary artery disease.

Angiotensin-converting enzyme and apolipoprotein B polymorphisms in coronary artery disease

The association between angiotensin-converting enzyme (ACE) as well as apolipoprotein B polymorphisms and dyslipidemia and coronary artery disease (CAD) is controversial. We assessed the distribution of ACE insertion and/or deletion, apolipoprotein B signal peptide insertion and/or deletion, and apolipoprotein B XbaI restriction fragment length polymorphisms in 388 nondiabetic patients. We studied 112 patients with angiographically defined asymptomatic CAD or with stable functional classes I and II angina and 139 patients with acute myocardial infarction who were age matched to 137 control subjects. Univariate analysis showed higher prevalence of Xba50% reduction of lumen diameter. Overall, multivariable regression disclosed traditional risk factors and elevated levels of apolipoprotein B for men and reduced levels of apolipoprotein AI for women as independent variables for CAD. After adjustment for the most important subset of risk factors (age, hypertension, hypercholesterolemia, and smoking), apolipoprotein B XbaI polymorphism was disclosed as an independent variable for CAD. Apolipoprotein B XbaI was also selected as an independent variable for acute myocardial infarction after adjusting for age, hypertension, hypercholesterolemia, and smoking. Thus, in addition to traditional coronary risk factors, apolipoproteins B and AI, and apolipoprotein B XbaI polymorphism could be considered predictors of CAD.

[Drug treatment for stable coronary artery disease at primary and tertiary medical centers]

PURPOSE

To observe the distribution of the main drugs used in patients with stable coronary heart disease, in primary and tertiary medical care centers (MCC).

METHODS

We studied 300 consecutive out patients at the Hetat Institute with the diagnosis of stable coronary artery disease, 205 (68%) males and 95 (32%) female, aged from 31 to 80 (mean 58 +/- 8.0) years old. Drug intake was evaluated.

RESULTS

We observed that the use of nitrates (48% vs 55%; p = NS) and calcium antagonists (46% vs 37%; p = NS), respectively in both primary and tertiary MCC was similar. The beta blockers were used more often in the primary MCC (50% vs 35%; p = 0.02). Angiotensin converting enzyme inhibitors (11% vs 42%; p < 0.001), diuretics (30% vs 49%; p = 0.002) and aspirin (44% vs 76%; p = 0.0001) were more frequently used in the tertiary MCC.

CONCLUSION

We observed similar frequency of use of nitrates and calcium antagonists in both centers. There was a higher use of beta blockers in primary MCC. The angiotensin converting enzyme inhibitors and antiplatelet agents were more used in the tertiary MCC. In relation to the updated literature, the best pharmacotherapy to coronary artery disease should be optimized in both centers.

[Assessment of the myocardial functional reserve in patients with left ventricular aneurysm by radionuclide ventriculography. Response to isotonic exercise]

PURPOSE

To evaluate global and regional left ventricular (LV) ejection fractions (EF) by radionuclide ventriculography in patients with LV aneurysm at rest and during isotonic exercise.

METHODS

Twenty patients were studied by radionuclide ventriculography at rest and during exercise. All patients had been submitted to cineangiography and showed LV aneurysm post myocardial infarction.

RESULTS

Patients were divided according to LV EF in two groups: one with EF > or = 40% and the other with < 40% EF. Both groups showed normal response of global EF to exercise: mean rest EF was 40 +/- 14% and mean exercise EF was 45 +/- 14% (p < 0.01). When groups were considered separately, EF values showed the same behavior. Half of the patients showed normal response to exercise and the other half showed abnormal response. These changes were not associated with resting EF values, but were due to regional EF of lateral wall, that changed from 44 +/- 7 to 48 +/- 7% in the group of patients with normal LV EF response to stress and from 50 +/- 5 to 46 +/- 5% in those with abnormal response (p < 0.01).

CONCLUSION

The evaluation of regional ventricular EF by radionuclide ventriculography during exercise better discriminates functional reserve in patients with LV aneurysm than resting global EF. These findings could help the decision making of the therapeutic approach in this specific group of patients.

[Fatal myocardial infarction in a young patient due to coronary arteritis]

A 34 year-old male patient suffered an acute anterior wall infarction at age 32. Myocardial ischemia was demonstrated later by stress testing and thallium myocardial scintigraphy. Coronary arteriography revealed a proximal 90% obstruction of the left anterior descending artery. The patient was submitted to percutaneous transluminal coronary angioplasty. The procedure was unsuccessful as the catheter could not progress through the obstruction. On follow-up, there was less than ideal adherence to medical treatment and the patient complained of occasional atypical non-effort related chest pain. Two years later the patient suffered a large fatal myocardial infarction. Necropsy disclosed that the cause of myocardial infarction was severe coronary arteritis of left circumflex artery with giant cell granulomas.

[Effort angina in an adult patient with anomalous origin of the left coronary artery]

Anomalous origin of the left main coronary artery from the pulmonary artery in a 50 year-old patient whose initial symptom was effort angina during the last 8 months. The clinical features and treatment are also discussed.