Search

OBJECTIVE: Hypertension (AH) is a risk factor for cardiovascular diseases and health education associated with educational technology can be used to improve adherence behavior. To evaluate the influence of educational strategy in an individual guidance program associating educational technology in the virtual learning environment (VLE) in the Distance Learning (DL) modality for hypertensive patients to be promoted by nurses and to verify the effect of the white coat and the quality of life in patients at a state in São Paulo. METHODS: Randomized clinical study with AVA Group (study group, 10 patients) and Control Group (16 patients). Both groups participated in six consultations with the nurse during 120 days with intervals of 20 days. At the beginning of the study (randomization) and at the end, the following instruments were applied: Morisky test and WHOQOL and Ambulatory Blood Pressure Monitoring (ABPM) was performed. Only the study group had remote access to the VLE, ​​consisting of six specific educational modules, with release at each meeting. RESULTS: There was no statistical significance between the two groups regarding sociodemographic and hemodynamic variables. There was statistical significance at the end of the study between the groups in the Morisky Test (p = 0.001) and in the WHOQOL Social Domain 3 (p = 0.001) favorable to the AVA Group. As for the effect of the white coat, there was no reduction in the phenomenon at the end of the study. CONCLUSION: The strategy promoted an improvement in adherence behavior in the AVA Group.

Hypertension is often associated with metabolic changes. The sustained increase in sympathetic activity is related to increased blood pressure and metabolic changes. Environmental stimuli may be related to increased sympathetic activity, blood pressure, and metabolic changes, especially in genetically predisposed individuals. The aim of this study was to evaluate the response of fatty acids to physical and mental stress in healthy volunteers and the hemodynamic, hormonal, and metabolic implications of these stimuli. Fifteen healthy individuals with a mean age of 31 ± 7 years, of both sexes, were evaluated. They were assessed at baseline and after combined physical and mental stress (isometric exercise test, Stroop color test). Blood samples were collected at baseline and after stimulation for glucose, insulin, fatty acid, and catecholamine levels. Blood pressure, heart rate, cardiac output, systemic vascular resistance, and distensibility of the large and small arteries were analyzed. The data obtained at baseline and after stimuli were from the same individual, being the control itself. Compared to baseline, after physical and mental stress there was a statistically significant increase (p, Arterial hypertension is highly prevalent worldwide. The real mechanisms of pathophysiology are not well understood. Stress, the sympathetic nervous system, and the release of fatty acids seem to play an important role in the pathophysiology of hypertension.

INTRODUCAO: Intervencoes educacionais, que incluem aumento no nivel de atividade fisica e controle da hipertensao arterial, podem ser estrategias eficazes e de baixo custo. OBJETIVO: Avaliar os efeitos de um programa educacional no controle da pressao arterial (PA), desempenho fisico e qualidade de vida (QV) de hipertensos. MATERIAIS E METODOS: Estudo de intervencao, controlado, nao randomizado, com adultos hipertensos, ambos os generos, acompanhados ambulatoriamente. O programa multiprofissional constituiu-se de 12 encontros com orientacoes sobre DCV e mudancas no estilo de vida. Aplicou-se o teste de caminhada dos seis minutos (TC6M), questionarios QV Minnesota e Internacional de Atividade Fisica (IPAQ) e medidas de PA. Utilizou-se os testes t-Student pareado ou de Wilcoxon e ANOVA para medidas repetidas. RESULTADOS: Participaram 20 pacientes, 82% mulheres, 62±11 anos. Houve reducao da pressao arterial sistolica (147,0 vs 126,0) e diastolica (85,0 vs 70,0), aumento na distância percorrida (458±83 vs 499±77 p

Metabolic, inflammatory, and autonomic nervous system (ANS) dysfunction are present in patients with heart failure. However, whether these changes are due to left ventricular dysfunction or heart failure etiology is unknown. We evaluated metabolism and inflammatory activity in patients with idiopathic dilated cardiomyopathy (IDC) and Chagas cardiomyopathy (CHG) and their correlation with the ANS. Forty-six patients were divided into 3 groups: IDC, CHG, and control. We evaluated adiponectin, leptin, insulin, interleukin-6, and tumor necrosis factor-alpha. ANS were analyzed by heart rate variability in time and frequency domains on a 24-hour Holter monitor. Levels of glucose, cholesterol, leptin, and adiponectin did not show differences between groups. Insulin levels were lower in CHG group (5.4 ± 3.3 μU/mL) when compared with control (8.0 ± 4.9 μU/mL) and IDC (9.9 ± 5.0 μU/mL) groups (p = 0.007). Insulin was positively associated with LFr/HFr ratio (r = 0.562; p = 0.029) and with the LFr component (r = 0.562; p = 0.029) and negatively associated with adiponectin (r = –0.603; p = 0.017) in CHG group. The addition of an adiponectin unit reduced average insulin by 0.332 μg/mL. Insulin levels were decreased in the CHG group when compared with the IDC group and were associated with ANS indexes and adiponectin levels.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

The cytokine tumor necrosis factor-alpha (TNF-α) is elevated in resistant hypertension (RH), but the effects of a TNF-α inhibitor in this population is unknown.The aim of this trial was to evaluate whether a single dose of infliximab controlled by placebo acutely reduces blood pressure (BP) in RH subjects.A double-blind, placebo-controlled, crossover trial was conducted, and randomized RH subjects received either infliximab or placebo. The primary endpoint was the change in mean BP levels relative to the baseline immediately after the infusion obtained by continuously beat-to-beat non-invasive hemodynamic assessment. Secondary endpoints included changes in office, ambulatory and central BP measurements; endothelial function; and inflammatory biomarkers after 7 days. The level of significance accepted was alpha=0.05.Ten RH subjects were enrolled. The primary endpoint analysis showed an acute decrease in mean BP values (mean of differences ± standard deviation = -6.3 ± 7.2 mmHg, p=0.02) from baseline, after the application of infliximab compared with placebo. Diastolic BP levels (-4.9 ± 5.5 mmHg, p=0.02), but not systolic BP levels (-9.4 ± 19.7 mmHg, p=0.16), lowered after infliximab infusion. No further significant differences were identified in either the other hemodynamic parameters or in secondary endpoints, except for TNF-α levels, which increased continuously after infliximab infusion. No adverse events were reported during the protocol.A single-dose of infliximab decreased the mean and diastolic BP levels immediately after its infusion, when compared to the placebo in RH. The anti-TNF-α therapy was found to be safe and well-tolerated. The results of this proof-of-concept are hypothesis-generating and need to be further investigated. (Arq Bras Cardiol. 2021; 116(3):443-451).A citocina fator de necrose tumoral alfa (TNF-α) é elevada na hipertensão resistente (HAR), mas os efeitos dos inibidores de TNF-α nessa população ainda são desconhecidos.O objetivo deste estudo foi avaliar se uma única dose de infliximabe controlada por placebo reduz a pressão arterial (PA) de forma aguda em pacientes com HAR.Realizamos um estudo cruzado, randomizado, duplo-cego e controlado por placebo em que pacientes com HAR receberam infliximabe ou placebo. O desfecho primário foi a alteração dos níveis de PA média em relação ao basal imediatamente após a infusão, obtida por avaliação hemodinâmica não invasiva contínua, batimento a batimento. Os desfechos secundários incluíram alterações em medidas de PA central, ambulatorial e em consultório, na função endotelial, e nos biomarcadores inflamatórios após 7 dias. O nível de significância aceito foi alfa=0,05.Foram incluídos dez portadores de HAR. O resultado do desfecho primário demonstrou uma redução aguda dos níveis de PA média (média das diferenças ± desvio padrão = -6,3 ± 7,2 mmHg, p=0,02) em relação ao basal, após o uso de infliximabe, em comparação com o placebo. Os níveis de PA diastólica (-4,9 ± 5,5 mmHg, p=0,02), mas não os níveis de PA sistólica (-9,4 ± 19,7 mmHg, p=0,16), reduziram após a infusão de infliximabe. Não foram identificadas diferenças significativas nos demais parâmetros hemodinâmicos, nem nos resultados dos desfechos secundários, com exceção dos níveis de TNF-α, que aumentaram continuamente após o uso de infliximabe. Não foram relatados eventos adversos durante o protocolo.Uma dose única de infliximabe reduziu os níveis de PA média e diastólica imediatamente após sua infusão, em comparação com placebo em HAR. A terapia com anti-TNF-α foi considerada segura e bem tolerada. Os resultados desse estudo prova de conceito são geradores de hipótese e precisam ser investigados em maior detalhe. (Arq Bras Cardiol. 2021; 116(3):443-451).

BackgroundThe metabolic syndrome (MetS) is an obesity-driven disorder with pandemic proportions and limited treatment options. Oxidative stress, low-grade inflammation and altered autonomic regulation, are important components of MetS pathophysiology. We recently reported that galantamine, an acetylcholinesterase inhibitor and an FDA-approved drug (for Alzheimer’s disease) alleviates the inflammatory state in MetS subjects. Here we examined the effects of galantamine on oxidative stress in parallel with inflammatory and cardio-metabolic parameters in subjects with MetS.MethodsThe effects of galantamine treatment, 8 mg daily for 4 weeks, followed by 16 mg daily for 8 weeks or placebo were studied in randomly assigned subjects with MetS (n=22 per group) of both genders. Oxidative stress, including superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase activities, lipid and protein peroxidation, and nitrite levels were analyzed before and at the end of the treatment. In addition, plasma cytokine and adipokine levels, insulin resistance (HOMA-IR) and other relevant cardio-metabolic indices were analyzed. Autonomic regulation was also examined by heart rate variability (HRV) before treatment, and at every 4 weeks of treatment.ResultsGalantamine treatment significantly increased antioxidant enzyme activities, including SOD (+1.65 USOD/mg protein, [95% CI 0.39 to 2.92], P=0.004) and CAT (+0.93 nmol/mg, [95% CI 0.34 to 1.51], P=0.011), decreased lipid peroxidation (thiobarbituric acid reactive substances, -5.45 pmol/mg, [95% CI -10.97 to 0.067], P=0.053) and systemic nitrite levels (-0.05 nit/mg protein, [95% CI -0.21 to 0.10], P=0.038) compared with placebo. In addition, galantamine significantly alleviated the inflammatory state and insulin resistance, and decreased the low frequency/high frequency ratio of HRV, following 8 and 12 weeks of drug treatment.ConclusionLow-dose galantamine alleviates oxidative stress, alongside beneficial anti-inflammatory, and metabolic effects, and modulates autonomic regulation in subjects with MetS. These findings are of considerable interest for further studies with galantamine to ameliorate MetS pathophysiology.

Objectives: The aim of this study was to determine if carvedilol improved structural and functional changes in the left ventricle and reduced mortality in patients with hypertensive heart disease. Methods: Blood pressure, heart rate, echocardiographic parameters, and laboratory variables, were assessed pre and post treatment with carvedilol in 98 eligible patients. Results: Carvedilol at a median dose of 50 mg/day during the treatment period in hypertensive heart disease lowered blood pressure 10/10 mmHg, heart rate 10 beats/min, improved left ventricular ejection fraction from baseline to follow-up (median: 6 years) (36%–47%)) and reduced left ventricular end-diastolic and end-systolic dimensions (62 vs 56 mm; 53 vs 42 mm, respectively, all p-values Conclusion: Carvedilol reduced cardiac dimensions and improved left ventricular ejection fraction and cardiac remodeling in patients with hypertensive heart disease. These treatment-related changes had a favorable effect on survival.

Untreated obstructive sleep apnea (OSA) is common in patients with hypertension and may impair blood pressure (BP) and target-organ damage responses to antihypertensive therapy. In this study, we recruited hypertensive patients who underwent treatment with a 30-day regimen of hydrochlorothiazide 25 mg plus enalapril (20 mg BID) or losartan (50 mg BID) and were assessed with a baseline clinical evaluation, polysomnography, 24-hour ambulatory BP monitoring, and carotid-femoral pulse wave velocity. All the examinations except for polysomnography were repeated at 6 and 18 months of follow-up. We studied 94 hypertensive patients (mean age, 55±9 years). The frequency of OSA was 55%. Compared with baseline, we did not observe significant differences between groups in 24-hour BP, daytime systolic and diastolic BPs, or night-time systolic BP at 6 and 18 months. The BP control rate at 24 hours (P =0.027). There were no differences in the number and class of antihypertensive medications prescribed during follow-up. In terms of arterial stiffness, patients with OSA had higher pulse wave velocity than did patients without OSA at baseline (10.3±1.9 versus 9.2±1.7 m/s; P =0.024), but both groups had similar decreases in pulse wave velocity during follow-up. In conclusion, with combined antihypertensive treatment aimed at controlling BP, hypertensive patients with OSA had similar 24-hour BP and arterial stiffness to those without OSA.

Background: Recent evidence suggests that obstructive sleep apnea (OSA) is common in patients with metabolic syndrome (MetS) and may contribute to metabolic deregulation, inflammation, and atherosclerosis in these patients. In clinical practice, however, OSA is frequently underdiagnosed. We sought to investigate the clinical predictors of OSA in patients with MetS. Methods: We studied consecutive patients newly diagnosed with MetS (Adult Treatment Panel-III). All participants underwent clinical evaluation, standard polysomnography, and laboratory measurements. We performed a logistic regression model, including the following variables: gender, age >50 years, neck and waist circumferences, hypertension, diabetes, body mass index (BMI) >30 kg/m2, high risk for OSA by Berlin questionnaire, presence of excessive daytime somnolence (Epworth Sleepiness Scale), abnormal serum glucose, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Results: We studied 197 pa...

BACKGROUND Metabolic syndrome (MetS) is an obesity-driven condition of pandemic proportions that increases the risk of type 2 diabetes and cardiovascular disease. Pathophysiological mechanisms are poorly understood, though inflammation has been implicated in MetS pathogenesis. The aim of this study was to assess the effects of galantamine, a centrally acting acetylcholinesterase inhibitor with antiinflammatory properties, on markers of inflammation implicated in insulin resistance and cardiovascular risk, and other metabolic and cardiovascular indices in subjects with MetS. METHODS In this randomized, double-blind, placebo-controlled trial, subjects with MetS (30 per group) received oral galantamine 8 mg daily for 4 weeks, followed by 16 mg daily for 8 weeks or placebo. The primary outcome was inflammation assessed through plasma levels of cytokines and adipokines associated with MetS. Secondary endpoints included body weight, fat tissue depots, plasma glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), cholesterol (total, HDL, LDL), triglycerides, BP, heart rate, and heart rate variability (HRV). RESULTS Galantamine resulted in lower plasma levels of proinflammatory molecules TNF (-2.57 pg/ml [95% CI -4.96 to -0.19]; P = 0.035) and leptin (-12.02 ng/ml [95% CI -17.71 to -6.33]; P < 0.0001), and higher levels of the antiinflammatory molecules adiponectin (2.71 μg/ml [95% CI 1.93 to 3.49]; P < 0.0001) and IL-10 (1.32 pg/ml, [95% CI 0.29 to 2.38]; P = 0.002) as compared with placebo. Galantamine also significantly lowered plasma insulin and HOMA-IR values, and altered HRV. CONCLUSION Low-dose galantamine alleviates inflammation and insulin resistance in MetS subjects. These findings support further study of galantamine in MetS therapy. TRIAL REGISTRATION ClinicalTrials.gov, number NCT02283242. FUNDING Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq), Brazil, and the NIH.

1. Definicao do Problema […] 3a Diretriz de Avaliacao Cardiovascular Perioperatoria da Sociedade Brasileira de Cardiologia

OBJECTIVES: We explored whether high blood pressure is associated with metabolic, inflammatory and prothrombotic dysregulation in patients with metabolic syndrome. METHODS: We evaluated 135 consecutive overweight/obese patients. From this group, we selected 75 patients who were not under the regular use of medications for metabolic syndrome as defined by the current Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults criteria. The patients were divided into metabolic syndrome with and without high blood pressure criteria (≥130/≥85 mmHg). RESULTS: Compared to the 45 metabolic syndrome patients without high blood pressure, the 30 patients with metabolic syndrome and high blood pressure had significantly higher glucose, insulin, homeostasis model assessment insulin resistance index, total cholesterol, low-density lipoprotein-cholesterol, triglycerides, uric acid and creatinine values; in contrast, these patients had significantly lower high-density lipoprotein-cholesterol values. Metabolic syndrome patients with high blood pressure also had significantly higher levels of retinol-binding protein 4, plasminogen activator inhibitor 1, interleukin 6 and monocyte chemoattractant protein 1 and lower levels of adiponectin. Moreover, patients with metabolic syndrome and high blood pressure had increased surrogate markers of sympathetic activity and decreased baroreflex sensitivity. Logistic regression analysis showed that high-density lipoprotein, retinol-binding protein 4 and plasminogen activator inhibitor-1 levels were independently associated with metabolic syndrome patients with high blood pressure. There is a strong trend for an independent association between metabolic syndrome patients with high blood pressure and glucose levels. CONCLUSIONS: High blood pressure, which may be related to the autonomic dysfunction, is associated with metabolic, inflammatory and prothrombotic dysregulation in patients with metabolic syndrome.

Whether sex influences the association of obstructive sleep apnea (OSA) with markers of cardiovascular risk in patients with hypertension is unknown. In this study, 95 hypertensive participants underwent carotid-femoral pulse wave velocity, 24-hour ambulatory blood pressure monitoring, echocardiogram, and polysomnography after a 30-day standardized treatment with hydrochlorothiazide plus enalapril or losartan. OSA was present in 52 patients. Compared with non-OSA patients, pulse wave velocity values were higher in the OSA group (men: 11.1±2.2 vs 12.7±2.4 m/s, P=.04; women: 11.8±2.4 vs 13.2±2.2 m/s, P=.03). The proportion of diastolic dysfunction was significant in men and women with OSA. Compared with non-OSA patients, nondipping systolic blood pressure in OSA was higher in men (14.3% vs 46.4%) and in women (41.4% vs 65.2%). OSA was independently associated with pulse wave velocity (β=1.050; P=.025) and nondipping systolic blood pressure (odds ratio, 3.03; 95% confidence interval, 1.08-8.55; P=.035) in the regression analysis. In conclusion, OSA is independently associated with arterial stiffness and nondipping blood pressure in patients with hypertension regardless of sex.

Arterial hypertension is frequently associated to glucose and lipid metabolism abnormalities. The purpose of this study was to determine if antioxidants (fruit extract) supplementation interfere with glucose and lipid metabolism in overweight hypertensive patients. A randomized clinical trial was conducted with 30 individuals, 23 hypertensive patients (group A) and 7 normotensive controls (group B). They were randomized to take 3 capsules of different fruits extract a day (blueberry, cranberry and pomegranate) or placebo for 4 weeks. This is a crossover study, which started with placebo changed to capsules and vice versa. Blood samples were collected after 12 hours fasting for biochemical tests (glucose, insulin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides), anthropometric assessment (weight, height, and body mass index), systolic BP, diastolic BP and heart rate were evaluated at baseline, after 4, and 8 weeks. The comparisons between groups were held with the GLM repeated measures. Twenty three hypertensive patients (age 47 years, 14 females) and 7 normotensive controls (age 40 years, 7 females) were evaluated. BMI, blood pressure, heart and lipid profile did not differ between groups. HOMAir decreased significantly in both groups. See results in table 1. Values are expressed as medians (±SD) In these preliminary results a 4-weeks supplementation of antioxidants (fruit extract) improved insulin resistance in overweight hypertensive and normotensive subjects. Financial support: FAPESP 2014/25808-3

Introduction: The approach known as ‘ embracement ’ adopts relational strategies or soft technologies which promote bonding and may impact therapy adherence Objectives: To assess the influence of the religiosity in the embracement approach on therapy adherence, quality of life, in hypertensive outpatients. This approach may be associated or not with the use of educational technology in a virtual learning environment(VLE) for distance learning (DL). Methods: This was a prospective randomized clinical study conducted with the following 3 groups of hypertensive patients: Group A (n=16, 12 women, mean age of 55.3±13 years, mean BMI of 32.3±6 kg/m 2 , receiving individual orientation required by an embracement strategy characterized by 7 nursing visits at 20-day intervals, for 4 months); Group VLE (n=10, 7 women, mean age of 51.5±7 years, mean BMI of 29.4±6 kg/m 2 ,using a technological education strategy for DL and making 7 nursing visits at 20-day intervals, for 4 months); Control group (n=10, 5 women, mean age of 57.6±9 years, mean BMI of 29.7±6 kg/m 2 , making 1 nursing visit at baseline and 1 after 120 days.) At baseline and after 120 days, the following tools were applied: the Morisky test, WHOQOL, Religion Index (DUREL), and ambulatory blood pressure monitoring (ABPM). The VLE group had remote access to the ‘ Hypertension E-Care ’ site (6 specific educational modules). Results: At baseline, there were no differences in clinical blood pressure, ABPM, and socio-demographic variables among the 3 groups. At the final assessment, the VLE group (44.4±0.4) showed significant improvement (p Conclusion: This study shows that religious belief can improve blood pressure control, specifically when associated with education technology.

Left ventricle remodeling is a common consequence of uncontrolled hypertension. Hypertension treatment including renin-angiotensin-aldosterone system inhibition and beta-blockers offers cardiac protection. Carvedilol uses in cardiomyopathy from different etiology have shown good results in left ventricle reverse remodeling. There is a lack of information regarding carvedilol use in hypertensive cardiomyopathy. The main objective in this study was to evaluate the use of carvedilol in hypertensive patients with reduced left ventricle ejection fraction. We evaluate 98 subjects with reduced left ventricle ejection fraction (55 years age, 59 males, 64 white, 34 nonwhite) before and after at least six months of carvedilol use. Clinical data, laboratory tests, and echocardiogram were evaluated at least 6 months before and after carvedilol was added to the treatment. Other causes of cardiomyopathy, including coronary artery disease, were excluded. A hundred percent of patients was taking diuretic and renin-angiotensin-aldosterone system inhibitors. Twenty eight percent were using statins, 19% were using antidiabetic drugs, and 29% were taking digoxin. Blood pressure and heart rate (144/92 mmHg, 84 bpm) decreased significantly after (130/82 mmHg, 70 bpm) carvedilol treatment. Ejection fraction improved in 68.5% patients. Let ventricle diastolic diameter decreased from 62 to 56 mm, left ventricle systolic diameter decreased from 53 to 42 mm, left ventricle mass index decreased from 145 to 129 g/m 2 , left ventricle relative posterior wall increased from 0.32 to 0.36. Carvedilol, in addition to antihypertensive drugs, showed improvement in hemodynamic parameters, and in echocardiographic structural and functional parameters in hypertensive cardiomyopathy patients.

The association of anthropometric (waist circumference) and hemodynamic (blood pressure) changes with abnormalities in glucose and lipid metabolism has been motivation for a lot of discussions in the last 30 years. Nowadays, blood pressure, body mass index/abdominal circumference, glycemia, triglyceridemia, and HDL-cholesterol concentrations are considered in the definition of Metabolic syndrome, referred as Visceral adiposity syndrome (VAS) in the present review. However, more than 250 years ago an association between visceral and mediastinal obesity with hypertension, gout, and obstructive apnea had already been recognized. Expansion of visceral adipose tissue secondary to chronic over-consumption of calories stimulates the recruitment of macrophages, which assume an inflammatory phenotype and produce cytokines that directly interfere with insulin signaling, resulting in insulin resistance. In turn, insulin resistance (IR) manifests itself in various tissues, contributing to the overall phenotype of VAS. For example, in white adipose tissue, IR results in lipolysis, increased free fatty acids release and worsening of inflammation, since fatty acids can bind to Toll-like receptors. In the liver, IR results in increased hepatic glucose production, contributing to hyperglycemia; in the vascular endothelium and kidney, IR results in vasoconstriction, sodium retention and, consequently, arterial hypertension. Other players have been recognized in the development of VAS, such as genetic predisposition, epigenetic factors associated with exposure to an unfavourable intrauterine environment and the gut microbiota. More recently, experimental and clinical studies have shown the autonomic nervous system participates in modulating visceral adipose tissue. The sympathetic nervous system is related to adipose tissue function and differentiation through beta1, beta2, beta3, alpha1, and alpha2 adrenergic receptors. The relation is bidirectional: sympathetic denervation of adipose tissue blocks lipolysis to a variety of lipolytic stimuli and adipose tissue send inputs to the brain. An imbalance of sympathetic/parasympathetic and alpha2 adrenergic/beta3 receptor is related to visceral adipose tissue storage and insulin sensitivity. Thus, in addition to the well-known factors classically associated with VAS, abnormal autonomic activity also emerges as an important factor regulating white adipose tissue, which highlights complex role of adipose tissue in the VAS.

FUNDAMENTO: Infusão de intralipid e heparina resulta em aumento da pressão arterial e também em anormalidades autonômicas em indivíduos normais e hipertensos. OBJETIVO: Avaliar a sensibilidade a insulina e o impacto da infusão de intralipid e de heparina (ILH) sobre a resposta hemodinâmica, metabólica e autonômica em pacientes com a forma indeterminada da doença de Chagas. MÉTODOS: Doze pacientes com a forma indeterminada da doença de Chagas e 12 voluntários saudáveis foram avaliados. RESULTADOS: A pressão arterial basal e a frequência cardíaca foram semelhantes nos dois grupos. Os níveis plasmáticos de noradrenalina encontravam-se ligeiramente aumentados no grupo de pacientes chagásicos. Após o Teste de Tolerância a Insulina (TTI), houve um declínio significativo na glicose dos dois grupos. A Infusão de ILH resultou em aumento da pressão arterial em ambos os grupos, mas não houve nenhuma mudança significativa na noradrenalina plasmática. O componente de Baixa Frequência (BF) mostrou-se semelhante e aumentou de forma semelhante em ambos os grupos. O componente de Alta Frequência (AF) apresentou-se menor no grupo chagásico. CONCLUSÃO: Pacientes com forma indeterminada da doença de Chagas apresentaram aumento da atividade simpática no momento basal e uma resposta inadequada à insulina. Eles também tiveram um menor componente de alta frequência e sensibilidade barorreflexa prejudicada no momento basal e durante a infusão de intralipid e heparina.

Sickle cell anemia (SCA) is associated to increased cardiac output, normal heart rate (HR), abnormal QT dispersion and lower diastolic blood pressure (DBP). The mechanisms are still unknown. The objective of this study was to test the hypothesis that there is cardiovascular autonomic dysfunction (CAD) in SCA. The secondary objectives were to distinguish the roles of chronic anemia and hemoglobinopathy and to evaluate the predominance of the sympathetic or parasympathetic systems in the pathogenesis of CAD. Sixteen subjects with SCA, 13 with sickle cell trait (SCT), 13 with iron deficiency anemia (IDA), and 13 healthy volunteers (HV) were evaluated. All subjects were submitted to 24h-electrocardiogram (24h-ECG), plasma norepinephrine (NE) measurement before and after isometric exercise (IE), and also Valsalva maneuver (VM), diving maneuver (DV), and tilt test (TT). Baroreflex sensitivity (BRS) was also evaluated. The minimum, average and maximum HR as well as the percentage of bradycardia and tachycardia at 24-h ECG were similar in all groups. NE at baseline and after IE did not differ between groups. The SCA group showed less bradycardia at phase IV of VM, less bradycardia during DV, and also less tachycardia and lower DBP during TT. BRS for bradycardia and tachycardia reflex was decreased in the SCA and SCT groups. In conclusion, 1) there is CAD in SCA, and it is characterized by the reduction of BRS and the limitation of HR modulation mediated by the parasympathetic system; 2) cardiovascular sympathetic activity is preserved in SCA; and 3) hemoglobinopathy is the preponderant ethiopathogenic factor.

Malignant hypertension seems to be the consequence of very high blood pressure. Furthermore, an increase in sympathetic andrenin-angiotensin system activity is considered to be the main mechanisms producing malignant hypertension. In the presentstudy, 10 offspring of malignant hypertensive (OMH) parents (age 28 ± 5 years, 7 males, 3 females, 2 white and 8 non-white) and10 offspring of normotensive (ONT) parents (age 28 ± 6 years, 2 males, 8 females, 3 white and 7 non-white) were evaluated. TheOMH group had significantly higher (P < 0.05) casual blood pressure (125 ± 10/81 ± 5 mmHg) compared with ONT (99 ± 13/67± 5 mmHg). The increase in blood pressure was greater in OMH (∆ SBP = 17 ± 2 vs ∆ SBP = 9 ± 1 mmHg in ONT) during coldpressor testing, but they had a lower increase in heart rate ( ∆ HR = 13 ± 2 vs ∆ HR = 20 ± 3 bpm in ONT) during isometric exercise(handgrip test). Sympathetic activity, measured by microneurography, was significantly higher (P < 0.05) before exercise inOMH (17 ± 6 vs 11 ± 4 burst/min in ONT) and exhibited a greater increase (∆ = 18 ± 10 vs ∆ = 8 ± 3 burst/min in ONT) duringisometric exercise. This study showed increased sympathetic activity in OMH before exercise and a greater response duringisometric exercise, suggesting an autonomic abnormality before exercise and a greater sympathetic response to physical stressin OMH compared to ONT.Key words: Malignant hypertension; Offspring of malignant hypertensive parents; Sympathetic activity; MicroneurographyPublication supported by FAPESP.Received September 17, 2007. Accepted August 19, 2008

Background: Previous studies have shown associations between vegetarian (VEG) diet and a healthy lifestyle and the maintenance of adequate body composition evaluated by anthropometric parameters. Objective: To analyze whether vegetarian men have higher rates of adequate nutritional status compared to omnivorous (OMN) men, evaluated by various methods. Methods: In this observational study, from 745 individuals from Sao Paulo, we enrolled 44 OMN and 44 VEG apparently healthy men participants in the CARVOS Study were evaluated by two 24-h dietary recalls, body mass index (BMI), circumference measurements, waist-hip ratio (WHR), skinfolds, and by BIA. Results: OMN men had the highest percentage of overweight/obesity based on BMI (70.4%, P=0.001), WHR (15.9%, P=0.026), waist circumference (50%, P=0.001), arm circumference (20.5%, P=0.001), tricipital skinfold (77.3%, P=0.008), % body fat by total of skinfolds (77.3%, P=0.001), and % body fat by BIA (47.7%, P=0.001). Multiple logistic regression showed that being OMN compared to being VEG significantly increased the risk of overweight/obesity (OR 12.12, CI 3.7 to 39.4); inadequate waist circumference (OR 8.39, CI 2.4 to 28.9); inadequate WHR (OR 9.85, CI 1.1 to 86.7); obesity by total of skinfolds (OR 6.2, CI 1.9 to 20.3), high % body fat by total of skinfolds (OR 8.93, CI 2.5 to 32.0) and by BIA (OR 5.7, IC 1.7-19.0). Conclusion: Vegetarian men have higher rates of adequate nutrition and a lower prevalence of overweight according to BMI, excess abdominal fat, and excess body fat estimated by circumferences, skinfold measurement, and by BIA.

Leptin is produced primarily by adipocytes. Although originally associated with the central regulation of satiety and energy metabolism, increasing evidence indicates that leptin may be an important mediator in cardiovascular pathophysiology. The aim of the present study was to investigate plasma leptin levels in patient with Chagas' heart disease and their relation to different forms of the disease. We studied 52 chagasic patients and 30 controls matched for age and body mass index. All subjects underwent anthropometric, leptin and N-terminal pro-brain natriuretic peptide (NT-proBNP) measurements and were evaluated by echocardiography, 12-lead electrocardiogram (ECG), and chest X-ray. All patients had fasting blood samples taken between 8:00 and 9:00 am. Chagasic patients were divided into 3 groups: group I (indeterminate form, IF group) consisted of 24 subjects with 2 positive serologic reactions for Chagas' disease and no cardiac involvement as evaluated by chest X-rays, ECG and two-dimensional echocardiography; group II (showing ECG abnormalities and normal left ventricular systolic function, ECG group) consisted of 14 patients; group III consisted of 14 patients with congestive heart failure (CHF group) and left ventricular dysfunction. Serum leptin levels were significantly lower (P0.001) in the CHF group (1.4 +/- 0.8 ng/mL) when compared to the IF group (5.3 +/- 5.3 ng/mL), ECG group (9.7 +/- 10.7 ng/mL), and control group (8.1 +/- 7.8 ng/mL). NT-proBNP levels were significantly higher (P0.001) in the CHF group (831.8 +/- 800.1 pg/mL) when compared to the IF group (53.2 +/- 33.3 pg/mL), ECG group (83.3 +/- 57.4 pg/mL), and control group (32 +/- 22.7 pg/mL). Patients with Chagas' disease and an advanced stage of CHF have high levels of NT-ProBNP andlow plasma levels of leptin. One or more leptin-suppressing mechanisms may operate in chagasic patients.

Introduction: In men with hypertension, obstructive sleep apnea (OSA) is associated with increased arterial stiffness. However, it is not clear if the impact of OSA on patients with hypertension is similar in women. Methods: We recruited consecutive patients with established diagnosis of hypertension under a standardized antihypertensive treatment (hydrochlorothiazide plus enalapril or losartan). All patients were submitted to full polysomnography and carotid-femoral pulse wave velocity (PWV). We performed analysis according to the presence of OSA (defined by an apnea-hypopnea index ≥15 events/hour of sleep) and by gender (male and females). Results: Ninety-five patients were studied (14males without OSA; 28 males with OSA, 29 females without OSA and 24 females with OSA). OSA frequency was 66% in males group versus 45% in females group (p=0.02). The age of female with OSA (59±10yrs) was significantly higher than female without OSA(52±10yrs), while the age did not differ between the male with(58±10yrs) or without OSA(56±8yrs). The BMI was also significantly greater in female with OSA (32.8±5 vs. 28.7±5kg/m2), while was similar in male with(30.5±4.5) or without OSA(29.5±2.5). The blood pressure was not different in the patients with or without OSA. PWV was significantly higher in both male(12.7m/s) and female(13.2m/s) with OSA than the couterparts without OSA(male-11 m/s, female-11.7 m/s) even after adjustments by age. The multivariate linear regression showed that OSA was independently associated with PWV(p=0.008). Conclusions: In patients with hypertension, the presence of OSA is associated with higher PWV regardless of gender.

Young adult offspring of hypertensive parents (pHTN⊕) are a good model for assessing abnormalities of anthropometric, cardiometabolic, and autonomic variables prior to clinical hypertension. The objectives of this study were to determine whether these variables and autonomic responses to oral carbohydrates were altered in offspring of pHTN⊕. Two hundred consecutive patients, including 100 pHTN⊕, were evaluated, with 29 patients, including 14 pHTN⊕, given a 70-gram carbohydrate load. The pHTN⊕ group had higher blood pressure, pulse pressure, abdominal circumference (AC), weight, body mass index, and basal metabolic rate than offspring of normotensive parents (pHTN∅). At baseline, the low-frequency (LF, sympathetic) to high-frequency (HF, parasympathetic) ratio, assessed by spectral analysis of heart rate variability, was similar in both groups. After the carbohydrate load, the LF/HF ratio was greater in offspring of pHTN⊕. pHTN⊕ individuals have abnormalities of anthropometric and hemodynamic variables at baseline and autonomic responses to oral carbohydrates before developing hypertension.

Arterial hypertension is a public health problem and patient adherence to treatment is challenging. This study tested whether frequent nurse visits provide additional benefits to antihypertensive treatment. Every 30 days, a pharmacist visited these patients to deliver antihypertensive drugs and perform a pill count. Nurses visited group A (48 patients) every 15 days and group B (52 patients) every 90 days. Ambulatory blood pressure (BP) monitoring was performed 15 and 180 days after randomization. At randomization, groups A and B had the same clinical systolic (191 +/- 5 v 186 +/- 3 mm Hg) and diastolic BP levels (122 +/- 3 v 117 +/- 4 mm Hg), respectively. After 90 days, BP declined more in group A than in group B (35 +/- 5/19 +/- 3 v 27 +/- 5/9 +/- 3 mm Hg). At 180 days, the difference increased because the reduction persisted in group A but decreased in group B (36 +/- 6/21 +/- 4 v 17 +/- 4/10 +/- 2 mm Hg). The mean ambulatory BP monitoring values were similar in both groups at 15 and 180 days. However, the attenuation of the clinic-daytime BP difference was larger in group A than in group B (systolic, -13 +/- 4 v -3 +/- 4 mm Hg; diastolic -11 +/- 3 v -4 +/- 3 mm Hg). The patients with clinic-daytime differences decreased more in group A (systolic, 16 to 10; diastolic, 20 to 14) than in group B (systolic, 19 and 20; diastolic, 22 and 22). These data indicate that frequent nurse visits significantly attenuate the white coat effect (clinic daytime BP difference).

Endothelium may be damaged, especially at the coronary microcirculation, in animal models of Chagas' disease by several mechanisms. Endothelial dysfunction has been reported in chronic Chagas' heart disease patients with heart failure. Nevertheless, peripheral endothelial function has never been studied in patients with Chagas' heart disease without heart failure and other conditions that could per se alter the endothelial function. Endothelial function was evaluated in 9 patients with Chagas' heart disease (44.8 +/- 1.5 years, 5 females, left ventricular ejection fraction > or = 60%) and 10 healthy matched controls (38.6 +/- 5.5 years, 5 females). Extreme caution was exercised to select patients with no other conditions that could per se alter the endothelial function. Forearm blood flow was measured at baseline and during intra-brachial artery infusion of crescent doses of acetylcholine (0.75, 5, and 15 microg/100 mL tissue/min) and nitroprusside (1, 2, and 4 microg/ 100 mL tissue/min), an endothelium-dependent and an endothelium-independent vasoactive drug, respectively. At baseline, blood pressure and heart rate (continuously recorded with Finapress) and the forearm blood flow were similar in both groups. Acetylcholine (ACh) and sodium nitroprusside (SNP) caused significant and similar dose-dependent increases in forearm blood flow of all subjects: maximum ACh response of 24.8 versus 23.7, and maximum SNP response 24.4 versus 23.7 mL/100 mL tissue/min, respectively, for control and chagasic Groups. No significant systemic hemodynamic changes were observed during the intra-arterial infusion of the drugs. The authors conclude that the peripheral endothelial function is preserved in Chagas' heart disease patients without heart failure.

Objective— During hypoxia, active substances released by the endothelium play a key role in the cardiovascular and respiratory responses elicited to optimize oxygen delivery. As hypercholesterolemia is a major cause of endothelial dysfunction, it may interfere with these responses. Methods and Results— We studied cardiovascular and ventilatory responses to acute systemic hypoxia in 14 patients with hypercholesterolemia (HC) and 13 control (CO) subjects. Oxygen saturation decreased similarly in both groups. Diastolic blood pressure increased only in the HC group ( P =0.0002) and, despite systolic blood pressure increases both in the HC group, 140±4 (95% confidence interval [CI],131 to 149 mm Hg) to 154±4 mm Hg (95% CI,145 to 164 mm Hg), and in the CO group, 133±3 (95% CI,126 to 140 mm Hg) to 140±4 mm Hg (95% CI,132 to 148 mm Hg), the HC group showed an enhanced pressor response ( P =0.03, group comparison). Both groups had increased forearm blood flow, but the decrease in forearm vascular resistance in the CO group, 40±5 (95% CI, 30 to 51 UR) to 31±4 UR (95% CI,23 to 39 UR) ( P =0.0001) was not seen in the HC group, 29±3 (95% CI, 22 to 37 UR) to 26±3 UR (95% CI, 20 to 33 UR), ( P =0.03, group comparison). Conclusions— Hypercholesterolemic patients demonstrate a hyperreactive pressor response and absence of forearm vasodilation during acute systemic hypoxia.

Oxidative stress emerges as a potential factor in the pathogenesis of hypertension and a common signal transduction mechanism by which various risk factors mediate cardiovascular and renal disease. A greater level of oxidative stress could contribute to higher rates of hypertension and related cardiovascular and renal complications in African Americans than in white Americans. The objective of this study was to compare oxidative stress induced by a standardized episode of acute hyperlipidemia in the two groups. Fifteen African Americans (37 +/- 1 years, 9 women/6 men, body mass index 30 +/- 2 kg/m(2)) and 15 whites (38 +/- 2 years, 9 women/6 men, body mass index 27 +/- 1 kg/m(2)) were evaluated. Acute hyperlipidemia was induced by a 4-h long infusion of Intralipid and heparin. Blood samples were drawn at baseline and after 2 and 4 h of acute hyperlipidemia for nonesterified fatty acids, triglycerides, and F2-isoprostanes, a biomarker of oxidative stress. Plasma nonesterified fatty acids and triglycerides increased significantly and similarly in African Americans and whites after 2 and 4 h of the Intralipid and heparin infusion. Although baseline plasma F2-isoprostanes did not differ between groups, F2-isoprostanes increased more in African Americans than in whites at 2 h (12.2 +/- 2.6 v 5.0 +/- 2.9 pg/mL, P

Evidence suggests that obesity may raise blood pressure (BP) through oxidative stress–sensitive mechanisms and that the Dietary Approaches to Stop Hypertension combination diet (DASH-CD) may decrease BP by enhancing antioxidant capacity. To address this question, 12 obese patients with high-normal–to–stage 1 hypertension (hypertensives) and 12 lean normotensives were studied on their usual diets and after following the DASH-CD and a low-antioxidant diet in random sequence for 4 weeks each. Acute oxidative stress was induced by a 4-hour infusion of intralipid and heparin. Ferric-reducing activity of plasma (FRAP) and plasma F 2 -isoprostanes were measured as biomarkers of antioxidant capacity and oxidative stress, respectively. BP was lower in obese hypertensives on the DASH-CD than on the usual and low-antioxidant diets (−8.1±1.5/−7.4±1.6 mm Hg, P 2 -isoprostanes increased from baseline during intralipid and heparin in both groups on the low-antioxidant diet but not in obese hypertensives on the DASH-CD. Among free-living obese hypertensives, the DASH-CD raises antioxidant capacity, lowers BP, and reduces oxidative stress induced by acute hyperlipidemia. The findings are consistent with evidence that elevated BP in obese subjects may reflect an imbalance between antioxidant capacity and oxidative stress that is improved by the DASH-CD.

Background Chagas disease (CD) induces autonomic dysfunction and inflammatory activity, which may promote metabolic abnormalities. We studied metabolism and his correlation with Autonomic Nervous System (ANS) and inflammation in CD. Methods and Results Sixty subjects were divided into 4 groups: control group (CG), IF (indeterminate form) group; ECG group (ECG abnormalities and normal left ventricular systolic function), and LVD group (left ventricular sistolic dysfunction). Levels of adiponectin, leptin, insulin, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) were assayed in serum samples by ELISA. ANS was assessed by heart rate variability in frequency domain in 24-hour Holter and postural tilt test (rest and orthostatic position). High frequency (HFr) component values were used to estimate parasympathetic activity and low frequency (LFr) component, sympathetic activity. Analyzes were made of the correlations of each of the metabolic parameters (leptin and adiponectin) with the inflammatory cytokines (interleukin-6 and TNF- alpha) and with the ANS assessment measurements. No significant differences were observed in leptin and insulin levels. Adiponectin was higher in ECG and LVD groups: [CG = 4766.5 (5529.5), IF = 4003.5 (2482.5), ECG = 8376.5 (8388.5), LVD = 8798 (4188.0) ng/mL, p