Intensive treatment of hyperglycemia in the acute phase of myocardial infarction: the tenuous balance between effectiveness and safety: a systematic review and meta-analysis of randomized clinical trials

In acute myocardial infarction (AMI), each 18 mg/dl (1 mmol/L) increment is associated with a 3% increase in mortality rates. All strategies applied for reducing blood glucose to this date, however, have not presented encouraging results. We searched the Medline (PubMed) and Cochrane Library databases for randomized clinical trials (RCTs) from 1995 to 2017 that used the intensive strategy or GIK therapy for blood glucose control during the acute stage of the AMI. We included eight studies. In order to identify the effects of GIK or insulin therapy, we calculated a overall risk ratio (RR) with meta-analysis of fixed and random effects models. A two-tail p-value of 36 mg/dL) in relation to the estimated average blood glucose (estimated by HbA1c) were associated with higher mortality, whereas lower reductions in blood glucose ( 36 mg/dL) em relação à glicemia estimada média se associaram à maior mortalidade, enquanto reduções menores não se associaram com seu incremento ou redução. A redução glicêmica na fase aguda em relação à glicemia estimada média foi mais efetiva e segura na faixa em torno de 18 mg/dL. Esta meta-análise levanta a hipótese de haver um limite tênue entre efetividade e segurança para a redução glicêmica na fase aguda, sendo que os alvos não devem exceder uma redução maior do que 36 mg/dL de glicemia

In comparison to the myocardial perfusion scintigraphy, a treadmill stress test is a viable, efficient and cost effective option to predict cardiovascular events in elderly patients

OBJETIVO: Definir o valor prognóstico e a custo-efetividade do teste ergométrico (TE) em comparação à cintilografia de perfusão miocárdica com dipiridamol (DIP) em indivíduos com > 75 anos de idade. MÉTODOS: Foram avaliados, consecutiva e prospectivamente, 66 pacientes (40% homens), com média de idade de 81 ± 5 anos. Desses pacientes, 57% eram hipertensos, 38% eram dislipidêmicos e 28%, diabéticos. O protocolo de Bruce para rampa foi adaptado, obtendo-se o valor prognóstico do TE pelo escore de Duke. RESULTADOS: A duração do TE, o porcentual da freqüência cardíaca máxima preconizada e o duplo produto no pico do exercício foram, respectivamente, de 7 ± 3 minutos, 95 ± 9% e 24.946 ± 4.576 (bpm x mmHg). O TE e a DIP apresentaram resultados positivos para isquemia miocárdica similares (21% vs 15%, respectivamente). A concordância entre os testes foi de 88% (Kappa 0,63, p 75 years of age. METHODS: Consecutive and prospective assessment of 66 patients (40% male) aged 81 ± 5 years of which 57% were hypertensive, 38% had dyslipidemia and 28% were diabetics. The Bruce protocol was adapted for a tilt treadmill and the TST prognostic value was obtained using the Duke treadmill score. RESULTS: The TST duration, recommended maximum heart rate percentage and double product at peak exercise were respectively: 7 ± 3 minutes, 95 ± 9% and 24,946 ± 4,576 (bpm x mmHg). The TST and DIP presented similar positive results for myocardial ischemia (21% vs 15%, respectively). The correlation between the tests was 88% (Kappa 0.63, p<0.01). During 685 ± 120 days of follow-up, nine major events occurred: 6 deaths, 2 acute coronary syndromes and 1 myocardial revascularization. The variables associated with the major events were: age (83 ± 6 vs 80 ± 4 years; p=0.048), male gender (78% vs 33%; p=0.02), ST segment depression (1 ± 1 mm vs 0.25 ± 0.6 mm; p= 0.01), high or intermediate risk determined by the Duke treadmill score - combined in one group (44% vs 2%; p=0.001) and abnormal DIP (44% vs 10%, p= 0.02). CONCLUSION: For this elderly population, the TST was an efficient and viable option with a similar diagnostic value in comparison to the DIP. However, the TST was more accurate in the prediction of major events and offers a lower cost

Statin short-term inhibition of insulin sensitivity and secretion during acute phase of ST-elevation myocardial infarction

Hyperglycemia during myocardial infarction (MI) has a strong and direct association with mortality. In stable patients and experimental models, statins favor the elevation of glycaemia. The present study investigated whether short-course treatment with statins during MI can influence glucose homeostasis and thus the clinical outcome. In this prospective study, euglycemic hyperinsulinemic clamp (EHC) was performed at second (D2) and sixth (D6) day after MI in patients randomized to simvastatin (S)10 or 80 mg/day during hospitalization (n = 27). In addition, patients (n = 550) were treated without (WS) or with simvastatin (S) at 20, 40 or 80 mg/day had HOMA2S on admission (D1) and fifth (D5) day after MI. According to EHC, insulin sensitivity increased by 20 +/- 60% in S10 and decreased by -6 +/- 28% in S80 (p = 0.025). Consistently, the changes in HOMA2S between D1 and D5 were 40 +/- 145% (WS), 22 +/- 117% (S20), 16 +/- 61% (S40) and -2% +/- 88% (S80) (p = 0.001). In conclusion, statin during the acute phase of MI reduces insulin sensitivity in a dose-dependent manner.9CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO - CNPQ301465/2017-

Omega-3 intake is associated with attenuated inflammatory response and cardiac remodeling after myocardial infarction

Myocardial infarction (MI) elicits an intense acute inflammatory response that is essential for cardiac repair. However, an excessive inflammatory response also favors myocardial apoptosis, cardiac remodeling, and cardiovascular mortality. Omega-3 polyunsaturated fatty acids (-3) bear anti-inflammatory effects, which may mitigate the inflammatory response during MI. This study investigated whether -3 intake is associated with attenuation of the MI-related inflammatory response and cardiac remodeling. ST-elevation MI (STEMI) patients (n=421) underwent clinical, biochemical, nutritional, 3D echocardiogram, Cardiac Magnetic Resonance imaging (CMRi) at 30 days and 3D echocardiogram imaging at six months after the MI. Blood tests were performed at day one (D1) and day five (D5) of hospitalization. Changes in inflammatory markers (D5-D1) were calculated. A validated food frequency questionnaire estimated the nutritional consumption and -3 intake in the last 3months before admission. The intake of -3 below the median (<1.7g/day) was associated with a short-term increase in hs-C-reactive protein [OR:1.96(1.24-3.10); p=0.004], Interleukin-2 [OR:2.46(1.20-5.04); p=0.014], brain-type natriuretic peptide [OR:2.66(1.30-5.44); p=0.007], left-ventricle end-diastolic volume [OR:5.12(1.11-23.52)]; p=0.036] and decreases in left-ventricle ejection fraction [OR:2.86(1.47-6.88); p=0.017] after adjustment for covariates. No differences were observed in the extension of infarcted mass obtained by CMRi. These findings suggest that a reduced daily intake of -3 may intensify outcome-determining mechanisms after STEMI, such as acute inflammatory response and late left ventricular remodeling.18CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO - CNPQ308550/2010-

Prevalence, treatment, and control of dyslipidemia in diabetic participants of two Brazilian cohorts: a place far from heaven

Diabetes is one of the leading causes of cardiovascular mortality. Over the last years, mortality has decreased significantly, more in individuals with diabetes than in healthy ones. That is mostly due to the control of other cardiovascular risk factors. The objective of our study was to analyze the dyslipidemia control in two diabetes cohorts. Patients from two distinct cohorts were studied, 173 patients from the BHS (Brasilia Heart Study) and 222 patients from the BDS (Brazilian Diabetes Study). The data on dyslipidemia control were studied in both different populations. All patients had diabetes. There are significant differences concerning comorbidities between the LDL-C and BDS groups. The average glycated hemoglobin is of 8.2 in the LDL-C > 100 group in comparison with 7.7 and 7.5 in the 70-100 and 100 groups (54.3% and 54.9%, respectively; p = 0.005). Diastolic pressure is higher in the group with LDL > 100, with an average of 87 mmHg, in comparison with 82.6 mmHg and 81.9 mmHg in the 70-100 and 100 has the greatest percentage of smokers (8.7%) in comparison with the groups with LDL between 70-100 and 100 groups, respectively (p < 0.001). The data in our study have shown that the dyslipidemia control in diabetic patients is inadequate and there is a tendency of direct association between lack of blood glucose control and lack of dyslipidemia control, in addition to the association with other cardiovascular risk factors, such as diastolic hypertension and smoking. This worsened control might be related to the plateau in the descending curve of mortality, and investments in this regard can improve the cardiovascular health in diabetic patients.6513

Os Açores e os impérios : séculos XV a XX

[...]. Os Açores não constituem simplesmente um elo da correspondência transatlântica. Aliás, possuem uma identidade bem complexa. Com efeito, se a História evidencia muito a mundividência, apresentando as ilhas como o centro do Mundo, já a literatura ressalta muito o isolamento, resultante do afastamento dos continentes e da descontinuidade territorial, apresentando as ilhas como o fim do Mundo. Curiosamente, a política e os políticos, talvez com maior sentido do pragmatismo e da oportunidade, agem em função das circunstâncias. De facto, proclamam a projecção da universalidade, quando reivindicam mais capacidade de auto-governo, mas insistem na pobreza da ultraperifericidade, quando exigem mais contrapartidas financeiras. Apesar da divergência das perspectivas, atentemos mais na universalidade dos Açores, que historicamente influi na definição das dinâmicas do Atlântico, conferindo maior projecção à Europa

The I405V and Taq1B polymorphisms of the CETP gene differentially affect sub-clinical carotid atherosclerosis

Background: Cholesteryl ester transfer protein (CETP) plays a major role in lipid metabolism, but studies on the association of CETP polymorphisms with risks of cardiovascular disease are inconsistent. This study investigated whether the CETP gene I405V and Taq1B polymorphisms modified subclinical atherosclerosis in an asymptomatic Brazilian population sample. Methods: The polymorphisms were analyzed using polymerase chain reaction in 207 adult volunteers. Serum lipid profiles, oxLDL Ab titers, C-reactive protein and tumor necrosis factor-a concentrations and CETP and phospholipid transfer protein (PLTP) activities were determined, and common carotid artery intima-media thickness (cIMT) was measured using ultrasonography. Results: No differences in cIMT were observed between the presence or absence of the minor B2 and V alleles in either polymorphism. However, inverse correlations between mean cIMT and CETP activity in the presence of these polymorphisms were observed, and positive correlations of these polymorphisms with PLTP activity and oxLDL Ab titers were identified. Moreover, logistic multivariate analysis revealed that the presence of the B2 allele was associated with a 5.1-fold (CI 95%, OR: 1.26 - 21.06) increased risk for cIMT, which was equal and above the 66th percentile and positively interacted with age. However, no associations with the V allele or CETP and PLTP activities were observed. Conclusions: None of the studied parameters, including CETP activity, explained the different relationships between these polymorphisms and cIMT, suggesting that other non-determined factors were affected by the genotypes and related to carotid atherosclerotic disease.The authors thank “Fundação de Amparo à Pesquisa do Estado de São\ud Paulo- FAPESP” (grant number 2006/60585-9) and “Coordenação de\ud Aperfeiçoamento de Pessoal de Nível Superior- CAPES” for the financial\ud support; Mirian Danelon, from the Clinical Biochemistry Laboratory, and\ud Aparecida Sousa from the Lipids Laboratory/Núcleo de Medicina e Cirurgia\ud Experimental of the School of Medical Sciences (FCM)/Unicamp for the\ud technical support; Helymar Machado from FCM´s Research Chamber for the\ud statistical analysis

Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology: 2019

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