Publications by authors named "Joao Carlos Hueb"

24 Publications

  • Page 1 of 1

Cardiovascular benefits of a home-based exercise program in patients with sickle cell disease.

PLoS One 2021 12;16(5):e0250128. Epub 2021 May 12.

Department of Internal Medicine, Sao Paulo State University Julio de Mesquita Filho-Unesp, Botucatu, Sao Paulo, Brazil.

Background: Physical inactivity is an important risk factor for cardiovascular disease. The benefits of exercise in patients with chronic diseases, including cardiovascular diseases, are well established. For patients with sickle cell disease, medical recommendation was to avoid physical exercise for fear of triggering painful crises or increasing the impairment of the cardiopulmonary function. Only recently, studies have shown safety in exercise programs for this population. Despite that, there is no report that assess the effects of physical exercise on cardiac parameters in patients with sickle cell disease.

Objective: This study aimed to evaluate the impact of regular physical exercise (a home-based program) on cardiovascular function in patients with sickle cell disease.

Design: A quasi-randomized prospective controlled trial.

Setting: During the years 2015 and 2016, we started recruiting among adult patients treated at a Brazilian Center for Patients with Sickle Cell Disease to participate in a study involving a home exercise program. The experimental (exercise) and control groups were submitted to clinical evaluation and cardiovascular tests before and after the intervention. Analysis of variance was applied to compare groups, considering time and group factors.

Participants: Twenty-seven adult outpatients with a sickle cell disease diagnosis.

Interventions: Exercise group (N = 14): a regular home-based aerobic exercise program, three to five times per week not exceeding give times per week, for eight weeks; no prescription for the control group (N = 13).

Main Outcome Measures: Echocardiographic and treadmill test parameters.

Results: The exercise group showed significant improvement in cardiovascular tests, demonstrated by increased distance traveled on a treadmill (p<0.01), increased ejection fraction (p < 0.01) and improvement of diastolic function assessed by mitral tissue Doppler E' wave on echocardiography (p = 0.04). None of the patients presented a sickle cell crisis or worsening of symptoms during the exercise program.

Conclusion: The selected home-based exercise program is safe, feasible, and promotes a favorable impact on functional capacity and cardiovascular function in sickle cell disease patients.
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May 2021

Carotid Artery Atherosclerotic Profile as Risk Predictor for Restenosis After Coronary Stenting.

Arq Bras Cardiol 2021 04;116(4):727-733

Universidade Estadual Paulista Julio de Mesquita Filho - Faculdade de Medicina Campus de Botucatu, Botucatu, SP - Brasil.

Background: The incidence of restenosis of the coronary artery after a bare-metal stent implant has been lower than in simple balloon angioplasty; however, it still shows relatively high rates.

Objective: The aim of this study was to find new risk indicators for in-stent restenosis using carotid ultrasonography, that, in addition to the already existing indicators, would help in decision-making for stent selection.

Methods: We carried out a cross-sectional prospective study including 121 consecutive patients with chronic coronary artery disease who had undergone percutaneous coronary intervention with repeat angiography in the previous 12 months. After all cases of in-stent restenosis were identified, patients underwent carotid ultrasonography to evaluate carotid intima-media thickness and atherosclerosis plaques. The data were analyzed by Cox multiple regression. The significance level was set a p<0.05.

Results: Median age of patients was 60 years (1st quartile = 55, 3rd quartile = 68), and 64.5% of patients were male. Coronary angiography showed that 57 patients (47.1%) presented in-stent restenosis. Fifty-five patients (45.5%) had echolucent atherosclerotic plaques in carotid arteries and 54.5% had echogenic plaques or no plaques. Of patients with who had echolucent plaques, 90.9% presented coronary in-stent restenosis. Of those who had echogenic plaques or no plaques, 10.6% presented in-stent restenosis. The presence of echolucent plaques in carotid arteries increased the risk of coronary in-stent restenosis by 8.21 times (RR=8.21; 95%CI: 3.58-18.82; p<0.001).

Conclusions: The presence of echolucent atherosclerotic plaques in carotid artery constitutes a risk predictor of coronary instent restenosis and should be considered in the selection of the type of stent to be used in coronary angioplasty.
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April 2021

Hypertrophic Cardiomyopathy: A Review.

Arq Bras Cardiol 2020 11;115(5):927-935

Universidade Estadual Paulista Júlio de Mesquita Filho - Faculdade de Medicina de Botucatu - UNESP, Botucatu, SP - Brasil.

Hypertrophic cardiomyopathy (HCM) is the most common heart disease with a genetic origin, and its main characteristic is left ventricular hypertrophy that occurs in the absence of other conditions that trigger this change. HCM may present from asymptomatic forms to manifestations of sudden cardiac death and severe heart failure. Contemporary high-resolution imaging methods and more accurate clinical scores have been used and developed to provide a prognostic assessment and adequate functional assessments, as well as to allow for the stratification of clinical severity. These aspects will be addressed in this review, along with other classic topics inherent to the study of this disease.
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November 2020

Cardiovascular Risk in Individuals with Inflammatory Bowel Disease.

Clin Exp Gastroenterol 2020 24;13:107-113. Epub 2020 Apr 24.

Department of Internal Medicine, Botucatu Medical School at Sao Paulo State University (UNESP), Botucatu, Brazil.

Background: Inflammatory bowel disease (IBD) patients present a higher risk of developing cardiovascular diseases due to the presence of chronic inflammation, which plays an essential role in atherogenesis. Therefore, the aim of the study was to evaluate the cardiovascular risk between patients with IBD and healthy control individuals.

Materials and methods: A total of 52 consecutive IBD outpatients from a tertiary hospital and 37 healthy controls were enrolled. Data collected included age, sex, smoking status, presence of comorbidities, disease activity, ongoing medical treatment, body mass index, arterial blood pressure, and cardiovascular risk. The cardiovascular risk was based on the Framingham risk score and ultrasonography variables, such as the carotid intima-media thickness and the presence of atherosclerotic plaque in the carotid. Multivariate logistic regression or multiple linear regression analysis was performed at a significance level of 5%.

Results: No differences were observed between groups with regard to age, sex, smoking status, comorbidities, blood pressure, body mass index, lipid profile, and Framingham risk score. In the IBD group, fasting glucose [95 (86.2-107.3) mg/dL vs 86 (79-100) mg/dL, p=0.041], carotid intima-media thickness (0.69±0.12 mm vs 0.63±0.12 mm, p=0.031), and atherosclerotic carotid plaque (25% vs 5.4%, p=0.032) were higher compared with those in the control group. Multivariate logistic regression analysis showed that patients with IBD presented a 6.45-fold higher risk of carotid atherosclerotic plaque (odds ratio: 6.45; 95% confidence interval: 1.035-40.216; p<0.046).

Conclusion: Patients with IBD are at an increased risk of atherosclerosis and, consequently, an increased risk for cardiovascular diseases.
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April 2020

Relationship of spontaneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study.

Ultrasound J 2020 Feb 11;12(1). Epub 2020 Feb 11.

Department of Neuroscience and Behavior, Ribeirão Preto School of Medicine, USP-Univ São Paulo, Ribeirão Preto, Brazil.

Introduction: The presence of microembolic signals (MES) during the acute phase of stroke is poorly understood, and its role and clinical application in relation to risk stratification and prognosis in patients remain uncertain. We assessed the prevalence of spontaneous MES in acute stroke and their relationship with risk stratification, stroke recurrence, morbidity, and mortality.

Patients And Methods: This was a prospective cohort study conducted in the Stroke Unit. The MES presence was evaluated by transcranial Doppler (TCD) in patients with ischemic stroke within 48 h. The outcomes (risk stratification, morbidity, mortality, and recurrence of a stroke) were followed up for 6 months. The relationship between risk stratification and MES was obtained by odds ratios and that between MES and stroke recurrence, morbidity, and mortality using multiple logistic regression; considering statistical significance at P < 0.05.

Results: Of the 111 patients studied, 70 were men (63.1%) and 90 were white (81.1%), with a median age of 68 years. The MES frequency was 7%. There was a significant relationship between MES and symptomatic carotid disease (OR = 22.7; 95% CI 4.1-125.7; P < 0.001), a shorter time to monitoring (OR = 12.4; 95% CI  1.4-105.4; P = 0.02), and stroke recurrence (OR = 16.83; 95% CI 2.01-141; P = .009).

Discussion: It was observed that the stroke recurrence adjusted for prior stroke was higher and earlier among patients with MES detection. In conclusion, MES demonstrated a significant correlation with symptomatic carotid disease and a shorter DELAY until monitoring, and could be a predictor for the early recurrence of stroke in the long term.
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February 2020

Impact of a Supervised Twelve-Week Combined Physical Training Program in Heart Failure Patients: A Randomized Trial.

Cardiol Res Pract 2019 3;2019:1718281. Epub 2019 Sep 3.

Medical Department, São Carlos Federal University (UFSCar), São Carlos, São Paulo State, Brazil.

Purpose: The aim of this study was to compare the effects of supervised combined physical training and unsupervised physician-prescribed regular exercise on the functional capacity and quality of life of heart failure patients.

Methods: This is a longitudinal prospective study composed of 28 consecutive heart failure with reduced ejection fraction patients randomly divided into two age- and gender-matched groups: trained group ( = 17) and nontrained group ( = 11). All patients were submitted to clinical evaluation, transthoracic echocardiography, the Cooper walk test, and a Quality of Life questionnaire before and after a 12-week study protocol. Categorical variables were expressed as proportions and compared with the chi-square test. Two-way ANOVA was performed to compare the continuous variables considering the cofactor groups and time of intervention, and Pearson correlation tests were conducted for the associations in the same group.

Results: No significant differences between groups were found at baseline. At the end of the protocol, there were improvements in the functional capacity and ejection fraction of the trained group in relation to the nontrained group ( < 0.05). There was time and group interaction for improvement in the quality of life in the trained group.

Conclusions: In patients with heart failure with reduced ejection fraction, supervised combined physical training improved exercise tolerance and quality of life compared with the unsupervised regular exercise prescribed in routine medical consultations. Left ventricular systolic function was improved with supervised physical training.
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September 2019

Aerobic Exercise Training and Nontraditional Cardiovascular Risk Factors in Hemodialysis Patients: Results from a Prospective Randomized Trial.

Cardiorenal Med 2019 9;9(6):391-399. Epub 2019 Oct 9.

Division of Nephrology, Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil.

Introduction: Chronic kidney disease (CKD) patients have a high incidence of cardiovascular diseases (CVD) which increases their morbidity and mortality. A sedentary lifestyle in CKD is directly linked to the onset of CVD. Physical activity can bring beneficial effects to CKD patients.

Aims: The aim of this study was assess the impact of aerobic training on nontraditional cardiovascular risk factors in CKD patients on hemodialysis.

Materials And Methods: This is a prospective, controlled, and randomized clinical trial with analysis of intention to treat. Thirty patients underwent an exercise treadmill test, an arterial stiffness evaluation, echocardiography and analysis of endothelial reactivity, and carotid ultrasound and laboratorial tests, including analysis of serum aldosterone. The intervention group (IG) (n =15) underwent aerobic exercise during hemodialysis 3 times a week for 4 months. The control group (CG) (n =15) had no intervention. All of the patients were reassessed after 4 months.

Results: In the IG, there was a statistically significant improvement in flow-mediated vasodilation (FMV; p = 0.002) and a reduction in left ventricular hypertrophy (p = 0.006) and serum aldosterone (p = 0.016). There was an increase in C-reactive protein in the CG (p = 0.002).

Conclusion: This aerobic training protocol was able to improve endothelial function with enhanced FMV and reduce left ventricular hypertrophy and serum aldosterone, which could have a positive impact on the reduction of nontraditional cardiovascular risk factors in CKD patients on hemodialysis.
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July 2020

Influence of Intradialytic Aerobic Training in Cerebral Blood Flow and Cognitive Function in Patients with Chronic Kidney Disease: A Pilot Randomized Controlled Trial.

Nephron 2018 7;140(1):9-17. Epub 2018 Jun 7.

Background And Objectives: Changes in cerebral blood flow may play an important role in cognitive impairment among hemodialysis (HD) patients. Physical activity has a promising role in delaying cognitive impairment in general population, but there are only a few studies in HD to confirm this finding. We aimed to evaluate the effects of intradialytic aerobic training on cerebral blood flow and cognitive impairment in HD.

Design, Setting, Participants, And Measurements: This is a pilot, controlled, randomized trial. Fifteen patients underwent intradialytic aerobic training 3 times a week for 4 months. The control group was comprised of another 15 patients.

Results: Trained patients had a statistically significant improvement of cognitive impairment and basilar maximum blood flow velocity. The proportion of arteries with increased flow velocity was statistically significant between groups.

Conclusions: Intradialytic aerobic training improves cognitive impairment and cerebral blood flow of patients in HD, suggesting a possible mechanism improving cognitive impairment by physical training in HD. These data still need to be confirmed by major trials.
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September 2019

Frequency of Subclinical Atherosclerosis in Brazilian HIV-Infected Patients.

Arq Bras Cardiol 2018 May 9;110(5):402-410. Epub 2018 Apr 9.

Faculdade de Medicina de Botucatu (UNESP), Botucatu, SP - Brazil.

Background: AIDS as well as atherosclerosis are important public health problems. The longer survival among HIV-infected is associated with increased number of cardiovascular events in this population, and this association is not fully understood.

Objectives: To identify the frequency of subclinical atherosclerosis in HIV-infected patients compared to control subjects; to analyze associations between atherosclerosis and clinical and laboratory variables, cardiovascular risk factors, and the Framingham coronary heart disease risk score (FCRS).

Methods: Prospective cross-sectional case-control study assessing the presence of subclinical atherosclerosis in 264 HIV-infected patients and 279 controls. Clinical evaluation included ultrasound examination of the carotid arteries, arterial stiffness by pulse wave velocity (PWV) and augmentation index (AIx), laboratory analysis of peripheral blood, and cardiovascular risk according to FCRS criteria. The significance level adopted in the statistical analysis was p < 0.05.

Results: Plaques were found in 37% of the HIV group and 4% of controls (p < 0.001). Furthermore, carotid intima-media thickness was higher in the HIV group than in controls (p < 0.001). Patients with carotid plaque had higher fasting glucose, total cholesterol, low-density lipoprotein cholesterol, and triglycerides than those without plaques. The presence of HIV, adjusted for age, overweight/obesity, and smoking increased by almost fivefold the risk of atherosclerotic carotid plaque (OR: 4.9; 95%CI: 2.5-9.9; p < 0.001). Exposure to protease inhibitors did not influence carotid intima-media thickness, was not associated with carotid plaque frequency, and did not alter the mechanical characteristics of the arterial system (PWV and AIx).

Conclusions: HIV-infected patients are at increased risk of atherosclerosis in association with classical cardiovascular risk factors. Treatment with protease inhibitors does not promote functional changes in the arteries, and shows no association with increased frequency of atherosclerotic plaques in carotid arteries. The FCRS may be inappropriate for this population.
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May 2018

Association of Pulmonary Hypertension With Inflammation and Fluid Overload in Hemodialysis Patients.

Iran J Kidney Dis 2017 Jul;11(4):303-308

Division of Pulmonology, Botucatu School of Medicine, Sao Paulo State University, Botucatu, Brazil.

Introduction: Pulmonary hypertension (PH) has been reported in hemodialysis patients, but data regarding its pathogenesis are scarce. This study aimed to evaluate the role of fluid overload in PH and its interrelationships with the usual biomarkers of micro-inflammatory state in hemodialysis patients.

Materials And Methods: In is a cross-sectional and prospective study, 119 consecutive hemodialysis patients at a Brazilian referral university hospital were evaluated between March 2007 and February 2013. Based on the presence of echocardiographic parameters of PH, patients were allocated to two groups of the PH group and the non-PH group. Clinical parameters, site and type of vascular access, bio-impedance, and laboratory findings were compared between the two groups and a logistic regression model was elaborated.

Results: Pulmonary hypertension was found in 23 (19.0%) of 119 patients. The groups significantly differed in extracellular water, ventricular thickness, left atrium diameter, and ventricular filling. Additionally, laboratory data associated with PH were alpha-1-acid glycoprotein (140.0 ± 32.9 versus 116.0 ± 35.5; P < .001); C-reactive protein (median, 1.1 versus 1.6; P = .01) and B-type natriuretic peptide (median, 328 versus 77; P = .03). The adjusted logistic regression model, including alpha-1-acid glycoprotein and B-type natriuretic peptide, showed significant associations for both (odds ratio, 1.023; 95% confidence interval, 1.008 to 1.043;  P = .004 and odds ratio, 3.074; 95% confidence interval, 1.49-6.35; P = .002, respectively).

Conclusions: Pulmonary hypertension, cardiac hypertrophy, fluid overload, and inflammation were associated to each other in hemodialysis patients, providing insight into its pathogenesis. Longitudinal studies are warranted.
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July 2017

Association Between Left Ventricle Diastolic Dysfunction and Unfavorable Prognostic Markers in Patients with Aortic Insufficiency.

J Clin Diagn Res 2017 Jun 1;11(6):OC09-OC11. Epub 2017 Jun 1.

Professor, Department of Internal Medicine, Botucatu Medical School, Botucatu, São Paulo, Brazil.

Introduction: The presence of symptoms, systolic dysfunction and Left Ventricle (LV) dilation are considered unfavourable prognostic markers in Aortic Valve Insufficiency (AVI). The role of diastolic dysfunction, which is considered unfavourable outcome marker in cardiac pathologies, is not well established in AVI.

Aim: To evaluate if the presence of diastolic dysfunction may be associated with unfavourable prognostic markers in AVI patients.

Materials And Methods: A cross-sectional prospective study was performed on 22 patients with moderate or severe AVI. They underwent clinical evaluation and transthoracic echocardiography. Associations between clinical, epidemiological and echocardiographic were evaluated by Student t-test for normally distributed variables or Mann-Whitney test for non-normal distribution. Comparison between proportions was performed by Chi-square test.

Results: There was an association between increased LV filling pressure, assessed by E' and E/E' of Mitral Tissue Doppler, and impaired LV systolic function, respectively: R = 0.563, R2 = 0.281; p = 0.008 and R = 0.639, R2 = 0.378; p = 0.002. The LV indexed mass also was inversely associated with the LV ejection fraction (R = 0.62, R2 = 0.35 and p = 0.003).

Conclusion: There was an association of LV diastolic dysfunction and ventricular hypertrophy with impaired left ventricle systolic function. Increased LV filling pressure and LV indexed mass should be considered in the management of AVI patients.
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June 2017

Evaluating respiratory musculature, quality of life, anxiety, and depression among patients with indeterminate chronic Chagas disease and symptoms of pulmonary hypertension.

Rev Soc Bras Med Trop 2017 Mar-Apr;50(2):194-198

Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brasil.

Introduction:: Chagas disease (CD) is progressive and incapacitating, especially when cardiopulmonary function is affected. For example, respiratory muscle weakness can cause dyspnea upon exertion and fatigue, which may be exacerbated when it is associated with pulmonary hypertension (PH). The present study aimed to evaluate respiratory musculature, quality of life, anxiety, and depression among patients with indeterminate chronic CD and symptoms of PH.

Methods:: All individuals completed a clinical evaluation, spirometry, a 6-min walking test, respiratory musculature testing using maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax), the Hospital Anxiety and Depression Scale, and the SF-36 questionnaire.

Results:: We evaluated 107 patients who were assigned to a control group with only CD (G1, 8 patients), a group with CD and possible PH (G2, 93 patients), and a group with CD and echocardiography evidence of PH (G3, 6 patients). The three groups had similar values for PImax and PEmax. Compared to the G1 and G2 groups, the G3 group covered significantly less distance during the 6-min walking test and had a significantly shorter predicted distance (p < 0.05 vs. the G1 group). All three groups had similar values for their spirometry results, Hospital Anxiety and Depression Scale scores, and SF-36 questionnaire results.

Conclusions:: Patients with indeterminate chronic CD and symptoms of PH did not experience significant impairment in the studied variables, with the exception of the 6-min walking test, which suggests a low exercise tolerance.
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July 2017

Higher Carotid Intima-Media Thickness in Subclinical Hypothyroidism Associated with the Metabolic Syndrome.

Metab Syndr Relat Disord 2016 10 26;14(8):381-385. Epub 2016 May 26.

1 Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University , UNESP, Botucatu, Brazil .

Background: The subclinical hypothyroidism (SH) and the metabolic syndrome (MS) have been associated with increased risk of atherosclerosis and cardiovascular disease (CVD). The measurement of carotid intima-media thickness (IMT) is capable of detecting early signs of atherosclerotic disease. The goal of the study was to compare the carotid IMT of patients with SH with and without the MS.

Methods: Twenty-nine SH patients were subdivided into two groups: one with MS (SH + MS) and one without MS (SH - MS). The study also assessed a group of euthyroid patients (n = 31), also subdivided into two groups: one with MS (EU + MS) and one without MS (EU - MS). The clinical and laboratory data and the mean and maximum carotid IMT of the groups were compared.

Results: Maximum (P = 0.012) and mean (P = 0.025) IMT were higher in the SH + MS group than in the SH-MS group. Maximum IMT was higher in the SH + MS group than in the EU + MS group (P = 0.048). Maximum IMT was positively correlated with fasting glucose (FG; R = 0.621; P < 0.01) and body mass index (R = 0.258; P = 0.041) and negatively correlated with low-density lipoprotein cholesterol (LDL-C) (R = -0.297; P = 0.017). Mean IMT was positively correlated with FG (R = 0.580; P < 0.01), systolic blood pressure (R = 0.292; P = 0.02), and triglycerides (R = 0.250; P = 0.048) and negatively correlated with LDL-C (R = -0.288; P = 0.022).

Conclusions: SH + MS patients have higher IMT than SH - MS or EU + MS patients, suggesting that SH may be one more CVD risk factor in patients with the MS.
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October 2016

Left ventricular mass behaviour in hemodialysis patients during 17 years.

J Bras Nefrol 2015 Jul-Sep;37(3):341-8

Universidade Estadual Paulista, BR.

Introduction: Ventricular hypertrophy is frequent in dialysis patients and is associated with an ominous prognosis. It is not knowledge if this ventricular change is growing or decreasing in hemodialysis patients.

Objective: To assess left ventricular hypertrophy behaviour during 17 years in patients of a university dialysis center, as well as to verify the possible causes of this behavior.

Methods: There was performed a retrospective longitudinal study that evaluated the echocardiographic left ventricular mass in hemodialysis patients in our dialysis facility over 17 years. Examinations of 250 patients aged 18 years or more who underwent routine echocardiography were included.

Results: There was a progressive reduction of ventricular mass over studied period. This reduction was associated with blood pressure reduction. In multivariate analysis, ventricular mass was associated with blood pressure and hemoglobin.

Conclusion: Left ventricular hypertrophy underwent significant reduction over 17 years in our hemodialysis patients. The factors associated with this reduction that could be identified in the current study were the progressive reduction of blood pressure and hemoglobin increase.
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August 2017

Evaluation of the Temporal Acoustic Window for Transcranial Doppler in a Multi-Ethnic Population in Brazil.

Ultrasound Med Biol 2015 Aug 9;41(8):2131-4. Epub 2015 May 9.

Ribeirão Preto Medical School, Department of Neuroscience and Behavior, University of São Paulo, São Paulo, Brazil.

The aim of this study was to relate the presence of a temporal acoustic window (TAW) to the variables sex, age and race. This observational study was conducted in patients under etiologic investigation after stroke, sickle-cell anemia and hospitalization in an intensive therapy neurologic unit. TAW presence was confirmed by bilateral assessment by two neurologists via transcranial Doppler (TCD). Multiple logistic regression was performed to explain the presence of the window as a function of sex, age and race. In 20% of the 262 patients evaluated, a TAW was not present. The incidence of TAW presence was greater in men (odds ratio [OR] = 5.4, 95% confidence interval [CI] = 2.5-11.7, p < 0.01); lower with increased age (OR = 0.9, 95% CI = 0.92-0.97, p < 0.01); and lower among those of African and Asian descent (OR = 0.32, 95% CI = 0.14-0.70, p = 0.005). On the basis of the results, more men than women had TAWs, and the decrease in TAWs was associated with increased age and African or Asian descent.
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August 2015

Carotid artery atherosclerotic profile as a predictor of the aorta atherosclerotic profile in patients with cerebrovascular events.

Cerebrovasc Dis 2013 30;36(1):26-32. Epub 2013 Jul 30.

Department of Internal Medicine, Botucatu Medical School - Universidade Estadual Paulista, São Paulo State University, São Paulo, Brazil.

Background: It is well known that the presence of atheroma of the thoracic aorta is a risk factor for cerebrovascular events. We sought to evaluate whether the presence and the morphology of atherosclerotic plaque in the carotid artery detected by duplex ultrasonography is associated with disease in the proximal aorta visualized by transesophageal echocardiogram in patients with a cerebrovascular event.

Methods: We carried out a cross-sectional prospective study including 147 consecutive patients with prior stroke or transient ischemic attack (TIA). Neurological evaluations were performed by an expert neurologist using clinical and tomographic diagnostic criteria including the definition of etiology and whether the patient suffered from stroke or TIA. Transthoracic and transesophageal echocardiograms and carotid artery duplex ultrasonography were performed by the same examiner. Patients with and without plaque in the carotid artery were compared using Student's t test or the χ2 test. Regression analysis was used to determine whether the presence of plaque in the carotid artery was predictive of the presence of plaque in the proximal aorta and to analyze the relationship between the echogenicity of carotid and aortic plaques. The significance level was set at p < 0.05.

Results: All 147 patients (95 men) were included in the analysis. Patients' ages ranged from 23 to 85 years (65 ± 12.4 years). Most of the patients (58.5%) were Caucasian, while 41.5% were African-Brazilian. Arterial hypertension, diabetes and tobacco use were more frequent among patients with atherosclerotic plaque in the aorta. A normal carotid intima-media thickness halved the risk of atherosclerotic plaque in the aorta [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23-0.91; p = 0.026]. The presence of carotid plaque increased the risk of aortic plaque by 70-fold (OR 73.2, 95% CI 25.6-2,018.6; p < 0.001) in univariate analysis. The absence of atherosclerotic plaque in the carotid artery reduced the risk of plaque in the aorta to almost 0 (OR 0.014, 95% CI 0.004-0.041; p < 0.001). Considering the 86 patients with both aortic and carotid plaques, the presence of hypoechoic plaque in the carotid artery was a predictor of hypoechoic plaque in the aorta (OR 10.1, 95% CI 3.3-31.2; p < 0.001).

Conclusions: The carotid artery atherosclerotic profile defined by ultrasonography is a strong predictor of the atherosclerotic profile of the proximal aorta. This should be taken into consideration before referring patients with acute cerebrovascular events for transesophageal echocardiogram.
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April 2014

Disproportionate pregnancy-induced myocardial hypertrophy in women with essential hypertension.

Am J Hypertens 2013 Jun 8;26(6):816-21. Epub 2013 Mar 8.

Department of Internal Medicine, Botucatu Medical School-Unesp, São Paulo State University, São Paulo, Brazil.

Background: Pregnancy and arterial hypertension (AH) have a prohypertrophic effect on the heart. It is suspected that the 2 conditions combined cause disproportionate myocardial hypertrophy. We sought to evaluate myocardial hypertrophy (LVH) and left ventricular function in normotensive and hypertensive women in the presence or absence of pregnancy.

Methods: This prospective cross-sectional study included 193 women divided into 4 groups: hypertensive pregnant (HTP; n = 57), normotensive pregnant (NTP; n = 47), hypertensive nonpregnant (HTNP; n = 41), and normotensive nonpregnant (NTNP; n = 48). After clinical and echocardiographic evaluation, the variables were analyzed using 2-way analysis of variance with pregnancy and hypertension as factors. Left ventricular mass (LVM) was compared using nonparametric analysis of variance and Dunn's test. Predictors of LVH and diastolic dysfunction were analyzed using logistic regression (significance level, P < 0.05).

Results: Myocardial hypertrophy was independently associated with hypertension (odds ratio (OR) = 11.1, 95% confidence interval (CI) = 3.2-38.5; P < 0.001) and pregnancy (OR = 6.1, 95% CI = 2.6-14.3; P < 0.001) in a model adjusted for age and body mass index. Nonpregnant women were at greater risk of LVH in the presence of AH (OR = 25.3, 95% CI = 3.15-203.5; P = 0.002). The risk was additionally increased in hypertensive women during pregnancy (OR = 4.3, 95% CI = 1.7-10.9; P = 0.002) in the model adjusted for stroke volume and antihypertensive medication. Although none of the NTNP women presented with diastolic dysfunction, it was observed in 2% of the NTP women, 29% of the HTNP women, and 42% of the HTP women (P < 0.05).

Conclusions: Hypertension and pregnancy have a synergistic effect on ventricular remodeling, which elevates a woman's risk of myocardial hypertrophy.
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June 2013

Inflammation, diabetes, and chronic kidney disease: role of aerobic capacity.

Exp Diabetes Res 2012 9;2012:750286. Epub 2012 Apr 9.

Division of Nephrology, Department of Internal Medicine, Botucatu Medical School, São Paulo State University, 18618-000 Botucatu, SP, Brazil.

The persistent inflammatory state is common in diabetes and chronic kidney disease (CKD). These patients present exercise intolerance and increased arterial stiffness. Long-term aerobic exercise has been associated with better arterial compliance, antidiabetic and antiinflammatory benefits. We assessed the hypothesis that in patients with diabetes and CKD, better aerobic capacity is associated with less inflammatory state and arterial stiffness. Thirty-nine CKD patients (17 in hemodialysis) were evaluated. According to CKD etiology two patient groups were obtained: group of diabetics (GD) was formed by 11 patients and nondiabetics (GND) formed by 28 patients. Central blood pressure and arterial stiffness were evaluated by Sphygmocor device. Carotida intima-media thickness (CA-IMT) was evaluated by ultrasonography. Aerobic capacity was measured by estimated VO(2)max according to treadmill test by Bruce protocol. The GD showed a higher frequency of C-reactive protein above laboratory cutoff (P = 0.044), higher frequency of male gender, and a non significant higher value of VO(2)max (P = 0.099). The CA-IMT was similar. Only better aerobic capacity was associated with lower frequency of high C-reactive protein when adjusted to diabetes and gender in a logistic regression model. In conclusion, aerobic capacity was associated with inflammatory state, in CKD patients, independently of diabetes presence.
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July 2012

Impact of hypertension on ventricular remodeling in patients with aortic stenosis.

Arq Bras Cardiol 2011 Sep 29;97(3):254-9. Epub 2011 Jul 29.

Hospital das Clínicas, Faculdade de Medicina de Botucatu-Unesp, Botucatu, SP, Brasil.

Background: Left ventricular hypertrophy (LVH) is a marker of increased cardiovascular risk and is frequently associated with both arterial hypertension (AH) and aortic stenosis (AoS). Also, these two maladies may co-exit in a same patient. However, in these cases, it is not clear the impact of each one in LVH.

Objective: To evaluate LVH and ventricular geometry in patients with AS associated or not with arterial hypertension.

Methods: This was a retrospective, observational and transversal study, including 298 consecutive patients with echocardiographic diagnosis of AoS. LVH was defined as myocardial mass > 224 g for men and > 162 g for women. Patients were classified as having mild (peak gradient < 30 mmHg), moderate (between 30 and 50 mmHg) or severe (> 50 mmHg) AoS and separated into two subgroups: with and without hypertension.

Results: AH was associated with increased ventricular mass in all three levels of aortic stenosis (mild AS: 172 ± 45 g vs 223 ± 73 g, p < 0.0001 moderate AoS: 189 ± 77 g vs 245 ± 81 g, p = 0.0313 severe AoS: 200 ± 62 g vs 252 ± 88 g, p = 0.0372), and increased risk of LVH (OR = 2.1 CI95%:1.2-3.6 p = 0.012). Regarding to geometric remodeling, hypertensive patients with severe AS presented a significant increase in frequency of concentric hypertrophy, when compared with those without hypertension (p = 0.013).

Conclusion: Hypertension is an additional factor of increased left ventricular mass in patients with AS. Also, hypertension was influential in ventricular geometry.
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September 2011

Primary idiopathic chylopericardium--case report.

Arq Bras Cardiol 2009 Jun;92(6):e40-3, e67-70

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brasil.

The accumulation of chyle in the pericardial space, or chylopericardium, is a condition occurring most frequently after trauma, cardiac and thoracic surgery, or in association with tumors, tuberculosis or lymphangiomatosis. When its precise cause cannot be identified, it is called primary or idiopathic chylopericardium. This is a rare clinical entity. We report the case of a surgically treated 20-year-old female patient. A brief review of the literature and comments on the clinical presentation, etiopathogenesis, ancillary diagnostic tests and treatment options are also presented.
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June 2009

Cerebral ischemia as initial neurological manifestation of atrial myxoma: case report.

Arq Neuropsiquiatr 2006 Sep;64(3A):660-3

Botucatu Medical School, UNESP, Botucatu, SP, Brazil.

Cerebral infarctions of cardiac etiology are observed in around 20% of patients with ischemic stroke. Cerebral ischemia is the first clinical manifestation in 1/3 of cases of atrial myxomas. Although almost half of patients with atrial myxoma show changes at neurological exam, non-hemorrhagic cerebral infarction is seen in computed tomography in practically all cases. We present the case of a 40 year-old woman whose first clinical manifestation of atrial myxoma was an ischemic stroke. We point out to the possibility of silent cerebral infarction in atrial myxoma patients.
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September 2006

Cardiac hemangioma of the right atrium.

Eur J Echocardiogr 2008 Jan;9(1):52-3

Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), CEP18618-000, Botucatu, São Paulo, Brazil.

Primary cardiac tumors are rare, with an incidence range between 0.001% and 0.030% at autopsy. Recent technical advances have facilitated diagnosis and surgical treatment of such lesions. Patients with a resectable tumor usually have a good prognosis, but patients with an unresectable tumor may have a poor prognosis. This report shows a case of right atrial hemangioma growing like an extracardiac mass, with cardiac tamponade the only clinical presentation.
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January 2008

Association between atherosclerotic aortic plaques and left ventricular hypertrophy in patients with cerebrovascular events.

Stroke 2006 Apr 9;37(4):958-62. Epub 2006 Mar 9.

Department of Internal Medicine, otucatu Medical School-Unesp, Sao Paulo, Brazil.

Background And Purpose: The purpose of this research was to evaluate whether an association exists between the presence of atherosclerotic plaque in the thoracic aorta and left ventricular hypertrophy (LVH) in patients with a cerebrovascular event.

Methods: We included 116 consecutive patients (79 men; mean age, 62+/-12.4 years) with previous history of stroke or transient ischemic attack in a cross-sectional study. Transthoracic echocardiogram was performed to diagnose LVH and transesophageal echocardiogram for the detection of atheromas of the thoracic aorta. Continuous variables were analyzed by Student t or Mann-Whitney tests and categorized variables by Goodman test. From the significant association of LVH and age with atheromatous disease of the aorta, an adjustment to the multivariate logistic model was made using high blood pressure history or age as covariates. All of the statistical tests were carried out at a level of 5% significance.

Results: Almost half of the patients (43.1%) presented atherosclerotic lesions in the aorta. LVH was present in 90.0% of patients with plaque and in only 30.3% of patients without plaque. Using high blood pressure as a covariate, the risk of patients with LVH presenting atherosclerotic plaque in the aorta was 18.23-fold greater than the risk for patients without LVH (95% CI, 5.68 to 58.54; P<0.0001). Adding age into the model, the risk increased to 26.36 (95% CI, 7.14 to 97.30; P<0.0001).

Conclusions: LVH detected by conventional echocardiogram is associated with high risk of atherosclerotic plaque in the aorta and would be used as a criterion for indication of transesophageal echocardiography in patients with previous stroke or transient ischemic attack LVH.
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April 2006