DIA MUNDIAL DO CORAÇÃO

DIA MUNDIAL DO CORAÇÃO
(Artigo enviado para o jornal ZH mas não publicado)
Como o fazem anualmente desde 1999 a Federação Mundial de Cardiologia, junto com a OMS, a UNESCO e a Organização dos Esportes para o Desenvolvimento e Paz da ONU, designaram o dia 24 de setembro neste ano como o Dia Mundial do Coração.
O tema é: “Quão Jovem está seu Coração?” com o propósito de incentivar hábitos saudáveis de vida para evitar o envelhecimento precoce do sistema cardiovascular.
Em todo o mundo as doenças crônicas – entre as quais se situam as cardiovasculares – se constituem em problema de saúde pública, cada vez mais importante na medida em que as pessoas vivem mais e o coração e o resto do sistema vascular se deterioram prematuramente. Este não é um triste privilégio de países ricos e ditos desenvolvidos. As populações mais pobres e menos desenvolvidas, em toda a parte, terminam adoecendo mais e vivendo menos. A falta de perspectiva na vida, a ignorância e a miséria fazem mal para a saúde em todos os seus aspectos e em qualquer lugar.
Recentemente através de um grupo de trabalho concluímos um estudo para avaliar o impacto econômico das Doenças Cardiovasculares em quatro países: África do Sul, Brasil, China e Índia. O componente brasileiro está situado no Instituto de Educação e Pesquisa do Hospital Moinhos de Vento.
O ano de 2004 contava com dados suficientes para efetuar os cálculos necessários. Naquele ano o Produto Interno Bruto do Brasil foi de mais de um trilhão e setecentos bilhões de Reais. E ficou em torno de 30 bilhões o impacto global estimado destas doenças, (medicamentos, hospitalizações, licenças, aposentadorias e perda de produção). Conta-se uma de cada três mortes; e só de anos de vida saudável perdidos por ano (incapacidade e morte precoce) são cerca de 5 milhões a cada ano.
Outros dois estudos, comparando as regiões do país e comparando os distritos de Porto Alegre, mostraram também nítida correlação negativa com o nível de desenvolvimento da população residente depois de corrigidos possíveis fatores de confusão. Quanto menos educada e mais pobre a população, mais mortes por doenças do coração e mais cedo.
Não basta tratar depois que os sintomas aparecem. É preciso prevenir e não são suficientes os especialistas, consultórios e hospitais. O esforço precisa ser coletivo, na família, na escola, nas empresas, no trabalho, no lazer, nos “shoppings” – onde haja espaço onde as pessoas possam se reunir em busca de melhor qualidade de vida.
Este é um problema também nosso, é mais grave entre os mais pobres, caro de tratar, impacta na produção e pode ser prevenido. Nosso Estado foi pioneiro no Brasil incorporando há 30 anos as doenças cardiovasculares e outras crônicas na agenda da saúde pública. Vamos fazer de Porto Alegre também uma cidade de corações jovens. Investir em saúde é também um investimento econômico.

Aspirin: Primary Prevention

American Journal of Cardiology:
(Recommended by Marcelo Gustavo Colominas [mgcolominas@hotmail.com]
"Until recently, 5 major studies have formed the basis for the use of aspirin (acetylsalicylic acid) in primary prevention of cardiovascular (CV) events. Despite these data, the role of aspirin in primary prevention has not been established firmly. Six randomized trials have evaluated the benefits of aspirin for the primary prevention of CV events: the British Doctors’ Trial, the Physicians’ Health Study, the Thrombosis Prevention Trial, the Hypertension Optimal Treatment study, the Primary Prevention Project, and the Women’s Health Study. The combined sample consists of 47,293 subjects on aspirin and 45,580 not on aspirin or placebo. A meta-analysis of these 6 trials assessed 6 CV end points: total coronary heart disease (CHD), nonfatal myocardial infarction (MI), total CV events, stroke, CV mortality, and all-cause mortality. No covariate adjustment was performed and appropriate tests for treatment effect, heterogeneity, and study size bias were applied. Using odds ratios and confidence intervals, the meta-analysis suggested superiority of aspirin for total CHD, nonfatal MI, and total CV events (p ≤0.001 in each case), with a nonsignificant trend (0.07 <>0.05). Given the study size and cohort, aspirin decreased the risk of CV events in this large patient sample. In conclusion, primary prevention with aspirin decreased the risk of total CHD, nonfatal MI, and total CV events, but there were no significant differences in the incidences of stroke or CV mortality."

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today: "BOSTON, Sept.20 -- Low-dose aspirin for cardioprotection may cause one extra case per year of gastrointestinal ulcers in every 50 aspirin users, but only in certain high-risk groups, researchers reported.
The study, reported in the Sept. 20 issue of BMC Medicine, is intended as a physician alert, because as the researchers noted, it was not possible to weigh gastrointestinal complications, such as bleeding or perforated ulcers, against actual cardiovascular risks.
For men older than 70 with a history of peptic ulcer, the excess risk was estimated at 20 extra cases per 1,000 aspirin users per year, said Sonia Hernández-Diaz, M.D., of the Harvard School of Public Health here and Luis A.G. Rodriguez of Centro Español de Investigación Farmacoepidemiológica in Madrid. "

Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion

American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. A Report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Developed in Collaboration With the Heart Rhythm Society
WRITING COMMITTEE MEMBERS, Cynthia M. Tracy, Masood Akhtar, John P. DiMarco, Douglas L. Packer, Howard H. Weitz, TASK FORCE MEMBERS, Mark A. Creager, David R. Holmes, Jr, Geno Merli, George P. Rodgers, ynthia M. Tracy, and Howard H. Weitz
Circulation published 20 September 2006,
10.1161/CIRCULATIONAHA.106.178893
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.106.178893v1?papetoc

Cardiac Cell Therapy -- Mixed Results from Mixed Cells

NEJM -- Cardiac Cell Therapy -- Mixed Results from Mixed Cells: "Despite substantial advances in treatment, ischemic cardiac injury and the ventricular dysfunction it can provoke remain major causes of morbidity and mortality throughout the world. The endogenous regenerative capacity of the heart appears inadequate to repair injured myocardium, leading to the cumulative loss of cardiomyocytes over the lifetime of a patient. This may contribute to the prevalence of heart failure as a diagnosis at hospital admission — particularly among the elderly.
For these reasons, experiments in animals suggesting that the transfer of cells derived from bone marrow (BMC) could dramatically improve cardiac function after infarction through regeneration of the myocardium1 or neovascularization2 generated tremendous excitement. In addition, they stimulated clinical studies suggesting that this approach is feasible, safe, and potentially effective in humans.3,4 In this issue of the Journal, Schächinger et al.,5 Assmus et al.,6 and Lunde et al.7 — following authors of other recent reports8,9 — provide a realistic perspective on this approach while leaving room for cautious optimism and underscoring the need for further study (Table 1). "

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today: "BOSTON, Sept. 19 -- Androgen deprivation with a GnRH agonist for local or regional prostate cancer is associated with an increased risk of diabetes, coronary heart disease, heart attack, and sudden cardiac death, according to researchers here.
An observational analysis of more than 73,000 men with local or regional disease showed that treatment with a gonadotropin-releasing hormone (GnRH) agonist increases the risk of diabetes by 44%, with smaller increases in the risks of cardiovascular disease, according to Nancy Keating, M.D., of Harvard Medical School and Brigham and Women's Hospital.
As they make treatment decisions about locoregional disease, 'patients and physicians need to be aware of the elevated risk' of a GnRH agonist, Dr. Keating said. "

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory:

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory: A Scientific Statement From the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology -- Kern et al. 114 (12): 1321 -- Circulation: "With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care."

CT Angiography Warrants Paradigm Shift in Nuclear Cardiology

ASNC: CT Angiography Warrants Paradigm Shift in Nuclear Cardiology - CME Teaching Brief® - MedPage Today: "'The first test in the future of the evaluation of the patient, be it symptomatic or asymptomatic, will be a CTA rather than a stress test because it's more accurate, provides more information, and avoids patients having unnecessary cardiac catheterizations which follows in a substantial number of patients who undergo stress testing because of the high false positive rate,'"

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today: "SENDAI, Japan, Sept. 12 -- Cup after cup of green tea earned a high grade for reducing all-cause and cardiovascular mortality in a study here, but cancer mortality drew a blank.
Compared with participants who consumed less than one cup of green tea a day, those who drank five or more cups had a risk of all-cause mortality that was 16% lower during 11 years of follow-up and 26% lower for cardiovascular deaths during seven years of follow-up, according to a report in the Sept. 13 issue of JAMA."

Would You Still Recommend Drug-Eluting Stents? -

Survey: Would You Still Recommend Drug-Eluting Stents? - CME Teaching Brief® - MedPage Today: "Drug-eluting stents essentially eliminated short-term restenosis as a complication of coronary angioplasty, but suddenly the coated devices have come under a cloud for possible late-term risks.
Cardiologists attending the European Society of Cardiology/World Congress of Cardiology in Barcelona last week were shocked by meta-analyses data that raised serious questions about the long-term safety of the devices.
This Medpage Today survey asks for your opinion about whether you still have confidence in the elective use of drug-eluting stents. "
Additional Stent Coverage from ESC:
Meta-Analyses Find Increased Death and MI with Cypher Stent
Real World Trial Confirms Drug-Eluting Stents Better in Small Vessels
Investigational Drug-Eluting Stent Superior to Taxus
Drug-Eluting Stent Debate Develops Fever Pitch http://www.medpagetoday.com/2005MeetingCoverage/2005ESCCongress/dh/4075

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council o

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in Collaboration With the Councils on Cardiovascular Disease in the Young and Cardiovascular Nursing -- Pate et al. 114 (11): 1214 -- Circulation: "Schools have played a central role in the provision of physical activity to American children and youth for more than a century. Physical education (PE) has been an institution in American schools since the late 1800s,1 and school sports have been a growing component of the educational enterprise since the early 1900s. Traditionally, students have engaged in physical activity during recess breaks in the school day and by walking or riding bicycles to and from school. However, as we move into the 21st century, alarming health trends are emerging, suggesting that schools need to renew and expand their role in providing and promoting physical activity for our nation’s young people.

Over the past 20 years, obesity rates in US children and youth have skyrocketed. Among children ages 6 to 11, 15.8% are overweight (≥95th percentile body mass index [BMI] for age) and 31.2% are overweight or at risk for overweight (≥85th percentile BMI for age).2 Among adolescents ages 12 to 19, 16.1% are overweight (≥95th"

Atrial fibrillation ablation: State of the art

Atrial fibrillation ablation: State of the art: "Atrial fibrillation (AF) is a common and recurrent arrhythmia that can result in significant morbidity and mortality [1]. Pharmacological therapy used to control rate or to achieve and maintain normal sinus rhythm is of limited efficacy, and can result in serious side effects including proarrhythmia and death [2-4]. Although ablation of the AV node and implantation of a permanent pacemaker can provide effective rate control, this loss of atrioventricular synchrony renders the patient dependent on the pacemaker and will require lifelong anticoagulation therapy. "

Framingham Gene Hunt

DATABASE:
(from: http://www.sciencemag.org/content/vol313/issue5792/netwatch.dtl)
The race to find the genes behind common ailments is heating up as many research groups scan patients' entire genomes for markers linked to disease. When it opens later this month, the Genomic Medicine Database (GMED) from Boston University (BU) will showcase such results from 1320 participants in the famed Framingham Heart Study, which has followed the health of a small Massachusetts town for 50 years. You can peruse the chromosomes for possible associations between about 10 traits--such as hypertension and high cholesterol levels--and 100,000 genetic markers, known as SNPs. Click to zoom in on the genes near a SNP. The BU team is posting data before publication so that other researchers can quickly seek to replicate the findings, says GMED co-curator Marc Lenburg. "Our hope is that others will follow our lead" and share unpublished data, he says.
gmed.bu.edu

Treatment of elderly patients with minor ischaemic attacks is inadequate

Treatment of elderly patients with minor ischaemic attacks is inadequate -- 333 (7567): 0 -- BMJ: "Patients aged 80 or older with transient ischaemic attack or minor ischaemic stroke have an increased incidence of symptomatic carotid stenosis but are substantially underinvestigated and undertreated. Fairhead and Rothwell (p 525) compared the management of a total of over 680 000 patients undergoing carotid imaging either in a vascular study (in which all patients were investigated as per published guidelines) or in routine clinical practice in secondary care services. In the group aged 80, rates of carotid imaging, diagnosis of > 50% symptomatic stenosis, and carotid endarterectomy were substantially lower in routine clinical practice. "

Drug-Eluting Stent Debate

ESC/WCC: Drug-Eluting Stent Debate Develops Fever Pitch - CME Teaching Brief® - MedPage Today: "BARCELONA, Spain, Sept 5 -- The long-term safety of drug-eluting stents suddenly eclipsed all other concerns this week at the world's largest gathering of cardiologists.
Many of the more than 25,000 cardiologists meeting here are shaking their heads in disbelief at the meta-analysis data that raised serious questions about the long-term safety of the coated devices.
The two meta-analyses reported Sunday at the Europeans Society of Cardiology/World Congress of Cardiology have highlighted 'the dark side of drug-eluting stents,' as Robert Harrington, M.D., of Duke put it.
Dr. Harrington's 'dark-side' is the finding that first generation drug-eluting stents are associated with an increased risk of late stent thrombosis, an increased cardiac mortality, an increased risk of myocardial infarction, and an increased risk of all cause mortality.
But even as every hallway buzzed with the grim potentialities, should the meta-analyses be borne out by prospective randomized studies, a new positive report emerged about the drug-eluting stents. This was a report of an investigational device showing that that it was superior to one of the two already approved stents.
That device is just one of a handful of second- and third- generation drug-eluting stents wending their way through the approval process.
Weighing the darker and the brighter sides of drug eluting stents has been the focus of heated discussions here, inside and outside the sessions.
An estimated six million of the first generation drug eluting stents-Cypher, a sirolimus-eluting stent, and Taxus, which elutes paclitaxel-have been implanted.
The meta-analyses reported here found that Cypher had significant risks compared with bare metal stents" /.../

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal: ", Spain - A pooled data analysis of antihypertensive treatment with the still-investigational oral renin inhibitor aliskiren (Rasilez, Novartis) in more than 8000 patients suggest that the drug reduces blood pressure (BP) effectively regardless of age or gender, is well tolerated, and appears to be additive to most other antihypertensive agents, with the exception of angiotensin receptor blockers [1].
Dr Matthew R Weir (University of Maryland School of Medicine, Baltimore) presented the pooled analysis of results to date with this new antihypertensive agent.
'Obviously, the hope is that the mechanism of action will provide an incremental opportunity in a sense to tame the renin angiotensin system and better facilitate risk reduction with regard to cardiovascular and kidney disease progression,' he concluded. "

How Sudden Is Sudden Cardiac Death

How Sudden Is Sudden Cardiac Death? -- Müller et al., 10.1161/CIRCULATIONAHA.106.616318 -- Circulation: "Background--Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event.
Methods and Results--Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n=323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour.
Conclusions--SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

Key words: death, sudden • resuscitation • myocardial infarction • defibrillation "

EUROACTION: Cardiologists should champion prevention as well as cure

EUROACTION: Cardiologists should champion prevention as well as cure:

"Sep 3, 2006
Lisa Nainggolan
Barcelona, Spain - Results from the largest-ever European-wide preventive cardiology project, EUROACTION, show that a nurse-led multidisciplinary team approach, together with the support and involvement of a patient's family, can generate significant lifestyle improvements and risk-factor reductions in coronary patients and those at risk of developing cardiovascular disease.
The message for cardiologists, says lead investigator Dr David Wood (Imperial College, London, UK), "is that you need to match your PCIs with a preventive program." Wood presented the results of EUROACTION today at the hotline session during the World Congress of Cardiology 2006.
"What we now know is that there has been a collective failure of medical practice to address lifestyle and risk-factor targets. We have clearly demonstrated that this nurse-led program works in a wide range of European countries, in ordinary general hospitals and GP surgeries," he told heartwire. "On the basis of these impressive results, we are going to talk to the national cardiology societies to discuss how we can implement this," he added.
Dr Thomas A Pearson (University of Rochester, NY), who was the discussant for the study, said EUROACTION "will become the benchmark to improve upon. It joins a list of landmark studies of implementation of what we already know from intervention studies."
Eight countries and almost 9000 patients
EUROACTION spanned eight countries—Denmark, France, Italy, the Netherlands, Poland, Spain, Sweden, and the UK—and 24 hospital and general practice centers, in a cluster randomized trial. It addressed the cardiovascular health of more than 8500 patients—half of whom already had coronary heart disease (recruited in hospitals) and half of whom were deemed high risk (from GP practices)—and compared outcomes with "usual-care" patients.
Unusually, partners were also included, something Pearson said was "particularly novel." The EUROACTION nurses performed complete lifestyle and risk-factor assessment of patients and partners and then supported them in making lifestyle changes. Advice was issued according to European preventive cardiology guidelines published in 2003 [1].
In hospitals, this involved regular one-to-one meetings as well as group workshops with members of a multidisciplinary team (including dieticians, physiotherapists, and cardiologists). For the high-risk patients, advice was given by nurses and GPs alone.
Significant improvements were observed after one year, not only in the EUROACTION patients but also in their partners, compared with patients treated by usual care and their partners, across a number of key lifestyle and risk factors.
Significantly more patients in both groups met physical-activity targets, reduced weight, reached blood-pressure goals, and improved use of cardioprotective therapies compared with usual-care patients.
For diet, significant improvements were seen in all three areas—increasing consumption of fruits and vegetables, eating more oily fish, and reducing saturated fat intake—in the coronary patients. For the high-risk patients, only fruit and vegetable intake was significantly improved compared with usual-care patients.
Hospital patients achieved significant reductions in waist circumference, but the GP patients did not, compared with usual care. For LDL-cholesterol levels, the opposite was true—the high-risk GP patients achieved significant reductions but the hospital coronary patients did not, compared with usual-care patients.
Smoking cessation was not significantly improved in either group compared with usual-care patients, but the hospital patients "came quite close with a p-value of 0.06," Wood told heartwire.
Even though significance was not achieved in some key areas, the trends were all in the right direction, he noted, adding that the study was underpowered.
Pearson observed that this "is a difficult kind of research to do. It's a different kettle of fish from efficacy studies."
The partners varied in their abilities to achieve targets but came out significantly better than the partners of the usual-care patients for fruit and vegetable consumption and physical activity.
Cost-effectiveness analysis planned
Wood also revealed that EUROACTION included a cost-effective analysis, with results expected in six months.
"This unique project has shown we can raise standards of preventive cardiology care for coronary and high-risk metabolic patients and their families in everyday care," he commented.
European Society of Cardiology president Dr Michal Tendera said: "It is now up to us to follow the EUROACTION example and work to establish similar prevention programs in every general hospital and GP practice so that patients across Europe can achieve the best possible care."
Source
De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2003; 24 (17): 1601-1610.
Related link
EuroAction Demonstration Project in Preventive Cardiology

The Worsening Landscape of Cardiovascular Disease

Cardiosource: "Title:
The Worsening Landscape of Cardiovascular Disease
Author: Suzanne Hughes, MSN, RN
Author Disclosure: Johnson & Johnson
Merck advisory board, AstraZeneca speakers' bureau, Guidant Corporation consultant

Author: Alfred A. Bove, M.D., Ph.D., F.A.C.C.
Author Disclosure: Stock Options, Consulting Fees: Insight Telehealth.
Date: 8/30/2006

While we have witnessed a decline in the number of deaths from cardiovascular disease (CVD) in the last 20-30 years, the trends for the future look much less bright. For some years, the increasing incidence of obesity was considered to be a consequence of prosperity, and obesity was even debated as an acceptable lifestyle. However, as the epidemiology of obesity became more apparent and the incidence began to reach astronomic levels, the consequences of obesity with its accompanying metabolic derangements, sometimes in the form of type 2 diabetes, or in the form of the metabolic syndrome, and now being understood as an obesity-induced rise in insulin resistance, have become more apparent./.../
"