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Arterial blood pressure (BP) is a very useful variable in clinical practice. Its measurement is simple, inexpensive and easy; it is worth noting that BP should be accurately obtained, following the recommendations of the VI Brazilian Guidelines on Hypertension (DBH VI)1. Office BP measurement is the central parameter for the diagnosis, treatment and follow-up of systemic arterial hypertension (SAH), being directly, continuously and independently related to the risk of fatal and non-fatal cardiovascular (CV) events1-3. Thus, the consideration of BP values closer to the upper limits of normality, the so-called prehypertension (PH)2, and intervention on those values have been emphasized over the last decade, because PH represents an important opportunity to prevent established SAH, contributing to reduce the associated CV risk. Repeated BP measurement at the office allows the diagnosis of hypertension and normotension. To better assess BP behavior, there are methods that analyze BP by using a higher number of measurements, minimizing interferences of the environment, situation and observer. Those alternatives are as follows: 24-hour ambulatory BP monitoring (ABPM); and dwelling BP measurement [home BP monitoring (HBPM) and BP self-measurement (BPSM)]. Based on those methods, two other BP classifications were adopted: white coat hypertension (WCH) and masked hypertension (MH)1,3-5 (Figure 1). Figure 1 Classification of blood pressure behavior considering office BP, ABPM and home BP measurements1. ABPM: ambulatory blood pressure monitoring; BP: blood pressure. Epidemiological and clinical studies on those conditions are still limited; however, they deserve attention because of their higher CV risk as compared with normotension6,7. This document represents the position of the Brazilian Society of Cardiology Arterial Hypertension Department (DHA/SBC) on the diagnosis and non-drug and drug therapy for PH, WCH and MH, aiming at contributing to a better clinical practice.

Post-exercise hypotension (PEH) may follow a session of physical exercises. This effect has high clinical relevance for hypertensive individuals. Although there are several studies on the subject, an analysis is still lacking on a state-of-art approach considering different types of exercises. Using a review of literature, the aim of this paper was to verify the relationship between aerobic exercise and resistance exercise in PEH in hypertensive people. For the purpose of this study, Scielo and Medlinedatabases were surveyed, and the main inclusion criteria were studies on the subject in English language and a sample of hypertensive adults. One hundred and twenty-six studies were found. However, only 32 papers, 5 of which on resistance exercise and 27 on aerobic exercise were used for this study. Although the studies surveyed used different prescription models for resistance exercise, PEH was observed mainly in the laboratory setting. After aerobic exercise, it was noted that PEH occurred for longer periods. However, there are differences of opinion as to the best intensity and duration of the exercise to be prescribed. Therefore, in hypertensive individuals declines in arterial pressure following aerobic exercise are apparently greater than those observed with resistance exercise. Nevertheless, in order to achieve sounder conclusions, further studies on ambulatory blood pressure monitoring should be conducted.

The world changed in just a few months after the emergence of the novel coronavirus disease 2019 (COVID-19), caused by a beta coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. Brazil currently has the world's second-highest COVID-19 death toll, second only to the USA. The COVID-19 pandemic is spreading fast in the world with more than 181 countries affected. This editorial refers to the article published in Arquivos Brasileiros de Cardiologia: "Increase in home deaths due to cardiorespiratory arrest in times of COVID-19 pandemic."1 Their main results show a gradual increase in the rate of out-of-hospital cardiac arrest during the Coronavirus disease 2019 (COVID-19) pandemic in the city of Belo Horizonte, Minas Gerais, Brazil. Their data demonstrate a proportional increase of 33% of home deaths in March 2020 compared to previous periods. Their study is the first Brazilian paper to demonstrate the same trend observed in other countries.O mundo mudou em apenas alguns meses após o surgimento da doença do novo coronavírus 2019 (COVID-19), causada por um betacoronavírus denominado síndrome respiratória aguda grave por coronavírus 2 (SARS-CoV-2). A COVID-19 foi declarada uma pandemia pela Organização Mundial da Saúde (OMS) em 11 de março de 2020. O Brasil apresenta atualmente o segundo maior índice de mortalidade por COVID-19 do mundo, perdendo apenas para os EUA. A pandemia da COVID-19 está se espalhando rapidamente pelo mundo, com mais de 181 países afetados. O presente editorial se refere ao artigo publicado nos Arquivos Brasileiros de Cardiologia: “Aumento de óbitos domiciliares devido a parada cardiorrespiratória em tempos de pandemia de COVID-19”1 Seus principais resultados mostram um aumento gradual na taxa de paradas cardiorrespiratórias extra-hospitalares durante a pandemia da doença por coronavírus 2019 (COVID-19) na cidade de Belo Horizonte, Minas Gerais, Brasil. Seus dados demonstram um aumento proporcional de 33% dos óbitos domiciliares em março de 2020 em relação aos períodos anteriores. O estudo é o primeiro artigo brasileiro a demonstrar a mesma tendência observada em outros países.

Since the first description of Tetralogy of Fallot (ToF) in 1671 by Niels Stensen and in 1888 by Étienne-Louis Arthur Fallot, numerous papers have reported on this anomaly, along with its variants and concomitant cardiovascular anomalies. Aberrant right subclavian artery (ARSA) is the most common anomaly of the aortic arch. Different from the left aberrant subclavian artery, occurrence of ARSA in ToF-patients has only casuistically been reported so far. The present study reports on two ToF-patients with ARSA. It is important to note that knowledge of the coexistence of both anomalies has highly practical points during surgical or endovascular corrections of congenital heart defects (including ToF).Desde a primeira descrição da tetralogia de Fallot (ToF) em 1671 por Niels Stensen e em 1888 por Étienne-Louis Arthur Fallot, vários trabalhos relataram essa anomalia juntamente com suas variantes e anomalias cardiovasculares concomitantes. A artéria subclávia direita aberrante (ASDA) é a anomalia do arco aórtico mais comum. Diferentemente da artéria subclávia esquerda aberrante, a ocorrência de ASDA em pacientes com ToF só foi relatada casuisticamente. Apresentamos dois pacientes de ToF com ASDA. É importante notar que o conhecimento da coexistência das duas anomalias tem pontos muito práticos durante correções endovasculares ou cirúrgicas de defeitos cardíacos congênitos (inclusive ToF).

Only two papers have addressed the early outcomes of patients with hypoplastic left heart syndrome (HLHS) undergoing the Norwood operation, in Brazil.We evaluated patients with HLHS undergoing the first-stage Norwood operation in order to identify the predictive factors for early (within the first 30 days after surgery) and intermediate (from early survival up to the Glenn procedure) mortality.Patients with HLHS undergoing the stage I Norwood procedure from January 2016 through April 2019, in our service, were enrolled. Demographic, anatomical, and surgical data were analyzed. Endpoints were early mortality (within the first 30 days after surgery), intermediate mortality (from early survival up to the Glenn procedure) and the need for postoperative ECMO support. Univariate and multivariate analyses were performed, and odds ratios, with 95% confidence intervals, were calculated. A p-value0.05 was considered statistically significant.A total of 80 patients with HLHS underwent the stage I Norwood procedure. The 30-day survival rate was 91.3% and the intermediate survival rate 81.3%. Fourteen patients (17.5%) required ECMO support. Lower weight (p=0.033), aortic stenosis (vs aortic atresia; p=0.036), and the need for postoperative ECMO support (p=0.009) were independent predictive factors for 30-day mortality. Mitral valve stenosis (vs mitral valve atresia; p=0.041) was an independent predictive factor for intermediate mortality.The present study includes the largest Brazilian cohort of patients with HLHS undergoing the stage I Norwood procedure in the recent era. Our survival rates were comparable to the highest survival rates reported globally. Low body weight, aortic valve stenosis, and the need for postoperative ECMO support were independent predictors for 30-day mortality. Mitral valve stenosis was the only independent predictive factor for intermediate mortality.Apenas dois artigos abordam os resultados precoces de pacientes com síndrome do coração esquerdo hipoplásico (SHCE) submetidos à operação de Norwood, no Brasil.Avaliamos pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood para identificar os fatores preditivos de mortalidade precoce (nos primeiros 30 dias após a cirurgia) e intermediária (desde a sobrevida precoce até o procedimento de Glenn).Foram incluídos pacientes com SHCE submetidos em nosso serviço ao primeiro estágio da operação de Norwood de janeiro de 2016 a abril de 2019. Dados demográficos, anatômicos e cirúrgicos foram analisados. Os desfechos foram mortalidade precoce (nos primeiros 30 dias após a cirurgia), mortalidade intermediária (desde a sobrevida precoce até o procedimento de Glenn) e a necessidade de suporte pós-operatório com ECMO. Foram realizadas análises univariadas e multivariadas e calculados odds ratios, com intervalos de confiança de 95%. Um valor de p0,05 foi considerado estatisticamente significativo.Um total de 80 pacientes com SHCE foram submetidos ao primeiro estágio da operação de Norwood. A taxa de sobrevida em 30 dias foi de 91,3% e a taxa de sobrevida intermediária foi de 81,3%. Quatorze pacientes (17,5%) necessitaram de suporte com ECMO. Menor peso (p=0,033), estenose aórtica (vs atresia aórtica; p=0,036) e necessidade de suporte pós-operatório com ECMO (p=0,009) foram fatores preditivos independentes para mortalidade em 30 dias. A estenose da valva mitral ( vs atresia da valva mitral; p=0,041) foi um fator preditivo independente para mortalidade intermediária.O presente estudo inclui a maior coorte brasileira de pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood na era recente. Nossas taxas de sobrevida foram comparáveis às mais altas taxas de sobrevida relatadas globalmente. Baixo peso corporal, estenose valvar aórtica e necessidade de suporte pós-operatório com ECMO foram preditores independentes para mortalidade em 30 dias. A estenose da valva mitral foi o único fator preditivo independente para mortalidade intermediária.

In 2016, the European Society of Cardiology (ESC) recognized heart failure (HF) with ejection fraction between 40 and 49% as a new HF phenotype, HF with mid-range ejection fraction (HFmrEF), with the main purpose of encouraging studies on this new category. In 2018, the Brazilian Society of Cardiology adhered to this classification and introduced HFmrEF in Brazil. This paper presents a narrative review of what the literature has described about HFmrEF. The prevalence of patients with HFmrEF ranged from 13 to 24% of patients with HF. Analyzing the clinical characteristics, HFmrEF shows intermediate characteristics or is either similar to HF with preserved ejection fraction (HFpEF) or to HF with reduced fraction (HFrEF). Regarding the prognosis, HFmrEF’s all-cause mortality is similar to HFpEF’s and lower than HFrEF’s. Studies that analyzed cardiac mortality concluded that there was no significant difference between HFmrEF and HFrEF, both of which were lower than HFpEF. Despite the significant increase of publications on HFmrEF, there is a great scarcity of prospective studies and clinical trials that allow delineating specific therapies for this new phenotype. To better treat HFmrEF patients, it is fundamental that cardiologists and internists understand the differences and similarities of this new phenotype.

The cardiovascular effects of alcohol are well known. However, most research has focused on the beneficial effects (the "French paradox") of moderate consumption or the harmful consequences, such as dilated cardiomyopathy, associated with heavy consumption over an extended period. An association between the ingestion of acute alcohol and onset of cardiac arrhythmias was first reported in the early 70's. In 1978, Philip Ettinger described "Holiday heart syndrome" (HHS) for the first time, as the occurrence, in healthy people without heart disease known to cause arrhythmia, of an acute cardiac rhythm disturbance, most frequently atrial fibrillation, after binge drinking. The name is derived from the fact that episodes were initially observed more frequently after weekends or public holidays. Since the original description of HHS, 34 years have passed and new research in this field has increased the volume of knowledge related to this syndrome. Throughout this paper the authors will comprehensively review most of the available data concerning HHS and highlight the questions that remain unresolved.

Submitral left ventricular aneurysm is a cardiac pathology widely recognized, but relatively unknown, occurred almost exclusively in African black patients. Although still this idea of racial prevalence exists, cases have been described in patients of all the races. Ten Brazilian cases were reported. One of them was presented inside an Italian paper that refers the surgical treatment of a Brazilian patient of black race. We reported one more submitral left ventricular aneurysm case in a brown female patient, with antecedents of peripheral thromboembolism initially not identified as consequence of the cardiac pathology.

Natural myocardial markers, or speckles, originated from constructive and destructive interference of ultrasound in the tissues may provide early diagnosis of myocardial changes and be used in the prediction of some cardiac events. Due to its relatively temporal stability, speckles can be tracked by dedicated software along the cardiac cycle, enabling the analysis of the systolic and diastolic function. They are identified by either conventional 2D grey scale and by 3D echo, conferring independence of the insonation angle, thus allowing assessment of cardiac mechanics in the three spatial planes: longitudinal, circumferential, and radial. The purposes of the present paper are: to discuss the role and the meaning of cardiac strain obtained by speckle tracking during the evaluation of cardiac physiology and to discuss clinical applications of this novel echocardiographic technology.

5. Anselm DD, Baranchuk A. Brugada Phenocopy Emerging as a New Concept. Rev Esp Cardiol. 2013;66(9):755. References DOI: 10.5935/abc.20130249 Dear Editor, We read with great interest the case report by Gazzoni et al1 regarding a Brugada ECG pattern induced by hypokalemia. This paper is important because it contributes to the growing body of literature describing Brugada Phenocopies (BrP)2-5. Briefly, BrP are characterized by ECG patterns that are identical to type-1 or type-2 Brugada ECG patterns despite the absence of true congenital Brugada Syndrome (BrS). BrP are induced by various clinical circumstances including: hypokalemia, hyperkalemia, hypothermia, myocardial ischemia, and pulmonary embolism. We have established six etiological categories of BrP2-4 along with a systematic approach to diagnose BrP3 by excluding sodium channel dysfunction in the myocardium. The presented case by Gazzoni et al1 would possibly qualify under category (i) metabolic conditions; however, further analysis of this case report is required. Specifically, this is the first report of a possible BrP induced by hypokalemia in association with hypokalemic periodic paralysis (HPP). Patients with HPP are known to have gene mutations resulting in abnormalities of either dihydropyridine-sensitive calcium channels or sodium channels (SCN4A) in skeletal muscles. Patients with true congenital BrS have mutations in the myocardial sodium channels (SCN5A) and the association in this patient is most intriguing and remains speculative. The type-1 “coved” Brugada ECG pattern observed in this patient could have been induced by the transient serum hypokalemia (which would qualify this as a BrP) or there may be a congenital dysfunction in this patient’s sodium channels in both his skeletal muscles (HPP) and myocardium resulting in the ECG abnormalities. Therefore, we recommend to the authors that a myocardial provocative challenge with a sodium channel blocker such as procainamide, ajmaline, or flecainide be performed to rule out myocardial sodium channel dysfunction. In addition, we also suggest that future reports use the established term Brugada Phenocopy to provide consistency in the literature and facilitate future research.

Dear Editor, Nowadays, the invasive approach plays a crucial role in the management of acute coronary syndromes, according to the recommendations in clinical practice guidelines. This tendency was reflected in some papers published in Revista Espanola de Cardiologia in 2011 and 2012. Regarding ST-segment elevation acute coronary syndromes, regional programs on primary coronary angioplasty have been developed across Spain. Time delay until reperfusion, however, remains the main drawback of these programs. For instance, Badalona's experience shows that in only 27% of the patients transferred from other hospitals for primary angioplasty the coronary artery was opened within the time limits recommended in the guidelines, i.e. in less than 2 hours from the first medical contact1. Therefore, fibrinolysis should not be ruled out as an alternative treatment in some cases. Furthermore, data from cardiac magnetic resonance imaging did not evidence significant differences in left ventricular volumes and function between patients treated with primary angioplasty or pharmaco-invasive strategy (initial fibrinolysis followed by routine coronary angioplasty 24 hours later) in a single hospital registry2. Prediction of prognosis is a matter of concern. The 4 most known prognostic scores (TIMI, PAMI, CADILLAC and GRACE) were compared in patients managed with either primary or rescue coronary angioplasty3. All 4 scores (particularly TIMI, CADILLAC and GRACE) had an excellent accuracy to predict mortality at 30 days and 1 year; prediction of reinfarction or new revascularization, however, was very poor with any score. The invasive management has been extended to populations previously excluded from this treatment, such as elderly patients. In a retrospective study on very old patients (≥ 85 years) with non-ST-segment elevation acute coronary syndrome, the invasive approach reduced mortality and any ischemic event at 3 years compared with a matched population managed with a conservative strategy4. Despite the favorable results of the invasive strategy in any type of acute coronary syndrome, secondary prevention should not be overlooked. In this sense, the opening of a cardiac catheterization laboratory and the subsequent increase of coronary intervention procedures for myocardial infarction, improved mortality at 30 days but not between 30 days and 2 years after adjusting for ACE inhibitor, beta blocker and statin treatment5.

BACKGROUND: Cardiac Anxiety (CA) is the fear of cardiac sensations, characterized by recurrent anxiety symptoms, in patients with or without cardiovascular disease. The Cardiac Anxiety Questionnaire (CAQ) is a tool to assess CA, already adapted but not validated to Portuguese. OBJECTIVE: This paper presents the three phases of the validation studies of the Brazilian CAQ. METHODS: To extract the factor structure and assess the reliability of the CAQ (phase 1), 98 patients with coronary artery disease were recruited. The aim of phase 2 was to explore the convergent and divergent validity. Fifty-six patients completed the CAQ, along with the Body Sensations Questionnaire (BSQ) and the Social Phobia Inventory (SPIN). To determine the discriminative validity (phase 3), we compared the CAQ scores of two subgroups formed with patients from phase 1 (n = 98), according to the diagnoses of panic disorder and agoraphobia, obtained with the MINI - Mini International Neuropsychiatric Interview. RESULTS: A 2-factor solution was the most interpretable (46.4% of the variance). Subscales were named "Fear and Hypervigilance" (n=9; alpha = 0.88), and "Avoidance", (n = 5; alpha = 0.82). Significant correlation was found between factor 1 and the BSQ total score (p

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)? After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up). Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients. The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.

The expression "Cardiovascular Epidemiology" has been widely used in observational studies that assess risk factors for cardiovascular disease. However, it includes research in biology, behavior, treatment and prevention of cardiovascular disease. In addition to exploring the relationship between risks of health conditions and states of diseases that can be hardly tested in experimental studies, epidemiology provides methodological arsenal to launch cause-effect connections, establishing the basis for cardiovascular prevention. Large cohort studies have provided information on the etiology and prevention of cardiovascular disease that built a great part of the current medical knowledge. The well-known Framingham Heart Study is among the pioneer cohort studies1. This study was conducted in Framingham, a 28,000 inhabitant's town located 21 miles west of Boston. The study enrolled 6,000 medium class Americans, 30 to 59 years old, mostly white, who were followed for 20 years. The study focused on risk factors for coronary heart and cardiovascular disease. It was exemplary planned, conducted and analyzed, establishing the basis of much that we know about causation of cardiovascular disease. Countless studies were inspired by the Framingham experience, expanding the epidemiological framework of several risk factors and diseases. The Atherosclerosis Risk in Communities (ARIC) study investigated the etiology of atherosclerosis and its clinical outcomes, and variation in cardiovascular risk factors, medical care, and disease by race, sex, place, and time. In a different way of the Framingham study, this cohort was conducted in three ethnically mixed communities - Forsyth County, North Carolina, and suburbs of Minneapolis, Minnesota, and Washington County, Maryland - and in one black community - in Jackson, Mississippi - enrolling 4,000 adults, aged 45 64 years, from each community, who were examined twice, three years apart2. An extensive laboratory with biochemistry assessment and ultrasound scanning of carotid and popliteal arteries were innovative methods investigated in this study3. The Nurses' Health Study (NHS)4 and the Health Professionals Follow-up Study (HPFS), led by Harvard University, Boston, Massachusetts, started addressing restricted questions among professional groups of women and men. The NHS was planned to investigate the long-term consequences of the use of oral contraceptives among a highly cooperative motivated group of women, the American registered nurses, aged 30 to 55, in 1976, who lived in the 11 most populous states of the US - California, Connecticut, Florida, Maryland, Massachusetts, Michigan, New Jersey, New York, Ohio, Pennsylvania, and Texas. Approximately 122,000 nurses, out of the 170,000 mailed, responded the baseline questionnaire, and every two years members received a follow-up questionnaire with questions about diseases and health-related conditions including smoking, hormone use and menopausal status. In subsequent follow-up inquiries, diet and nutrition data were collected. The subsequent Nurses' Health Study II and III investigated younger nurses and expanded the investigation to other research questions5. The Health Professionals Follow-up Study enrolled 51,529 men - mostly dentists and veterinarians, but also pharmacists, optometrists, osteopath physicians, and podiatrists, including a small sample of African- and Asian-Americans. The aim was to investigate men's health associated to nutritional factors over the incidence of cancer, heart disease, and other vascular diseases. The data collection was carried out using self-answered questionnaires with questions about diseases and alcohol consumption, health-related topics like smoking, physical activity, and medications taken every two years, and dietary information each four-year intervals6. The studies commented above gave origin to more than 7,700 papers and countless citations, which are the foundation for the current cardiovascular disease knowledge. These large cohort studies are a few examples of very expensive studies, which demanded long follow-up periods, supported by the American government agencies. In Brazil, pioneer studies were fully funded by international agencies, as the Pelotas birth cohort study, which enrolled more than 5,000 newborns and their families at about 30 years ago. It has shown the development of cardiovascular risk factors linked to perinatal outcomes7,8. The Brazilian government has recently started to fund large epidemiologic and clinical studies. Beside to answering relevant questions to the Brazilian population, these studies will contribute for the universal knowledge of cardiovascular disease causation, prevention and treatment. The ELSA study (Estudo Longitudinal da Saude do Adulto) is an example of a large cohort study being conducted in the adult Brazilian population9. It is investigating the risks and prognosis of diabetes and cardiovascular disease in a cohort of more 15,000 employees of universities and affiliated hospitals. Large clinical trials have been sponsored as well by Brazilian agencies, such as the PREVER Prevention10 and Treatment11 trials, and the Stem Cell Therapy Trials for the management of cardiac conditions12,13. Other clinical studies as the ReHot, which is investigating the prevalence and treatment of resistant hypertension, are on the way currently. These studies are evidences of the experience of Brazilian investigators, who could plan and conduct such kind of studies. The complementary strengths of observational studies and randomized clinical trials expands the knowledge of cardiovascular disease determinants, prevention, and treatment. Besides the scientific benefits, we are breaking down barriers, improving skills in coordination and conduction of large national studies, fomenting junior investigators, and mentoring clinical and research fellows. The legacy of these sound studies will certainly change the way we understand and practice cardiology. In the I Symposium of Cardiovascular Epidemiology, recently carried out in Porto Alegre, Professors, physicians, post-doctoral fellows, graduate and medical students experienced integration between the Brazilian and the international cardiovascular epidemiology research. Brazilian and international speakers, including Paul K. Whelton (ALLHAT PI)14, Peter Libby (Inflammation investigator, Chief of Cardiology Division of Brigham Women' Hospital, Harvard University)15, Thomas Lee (Health Policy and Management investigator, Harvard University)16, and Lu Chi (Harvard University)17, presented their main ongoing projects and several sessions of state of art updating the knowledge on cardiovascular epidemiology. This issue of the Arquivos Brasileiros de Cardiologia has a supplement with 72 abstracts presented at the Symposium, examples of the products of clinical and epidemiological research in our country. Three of them were awarded: two randomized clinical trials and a cost-effectiveness analysis study (see the stars in the abstracts). The Symposium was also conducted in honor of Professor Jorge Pinto Ribeiro legacy. Professor Jorge left an enormous contribution to science and a legion of academic orphans, as can be seen by some of his last articles published18-28. His sound work and competence helped to improve research and cardiology practice, not only locally, but nationwide. Hospital de Clinicas de Porto Alegre (HCPA) will honor him naming the Clinical Research Building on Professor Jorge Pinto Ribeiro behalf. In addition, three prizes were instituted on his name: for leading scientists, who made major academic contributions, an outstanding young investigator, and a policy maker, who helped the HCPA to achieve its aims in excellence of health assistance and quality of care. We hope that the Arquivo's readers enjoy the high quality of the abstracts presented at the Symposium.

Accurate recognition of individuals at higher immediate risk of sudden cardiac death (SCD) is still an open question. The fortuitous nature of acute cardiovascular events just does not seem to fit the well-known model of ventricular tachycardia/fibrillation induction in a static arrhythmogenic substrate by a synchronous trigger. On the mechanism of SCD, a dynamical electrical instability would better explain the rarity of the simultaneous association of a correct trigger and an appropriate cardiac substrate. Several studies have been conducted trying to measure this cardiac electrical instability (or any valid surrogate) in an ECG beat stream. Among the current possible candidates we can number QT prolongation, QT dispersion, late potentials, T-wave alternans (TWA), and heart rate turbulence. This article reviews the particular role of TWA in the current cardiac risk stratification scenario. TWA findings are still heterogeneous, ranging from very good to nearly null prognostic performance depending on the clinical population observed and clinical protocol in use. To fill the current gaps in the TWA base of knowledge, practitioners, and researchers should better explore the technical features of the several technologies available for TWA evaluation and pay greater attention to the fact that TWA values are responsive to several factors other than medications. Information about the cellular and subcellular mechanisms of TWA is outside the scope of this article, but the reader is referred to some of the good papers available on this topic whenever this extra information could help the understanding of the concepts and facts covered herein.

Along the past few years the number of papers on heterotopic cardiac transplant has been very scarce in the medical literature, including at the international level; this is particularly true in reference to the long term follow-up of these patients and the reason which led to the presentation of our report.To report the initial clinical experience and late evolution of 4 patients undergoing heterotopic heart transplantation, indications for this procedure and its major complications.The surgeries were performed between 1992 and 2001, and all had as indication for heterotopic transplantation the PVR, which ranged from 4.8 WU to 6.5 WU, with a transpulmonary gradient above 15 mmHg. In the 3rd patient, a direct anastomosis between the pulmonary arteries was performed without the use of a prostetic tube, and a mitral valvuloplasty and a LV aneurysmectomy were performed in the native heart. The immediate immunosuppressive regimens were double, with cyclosporine and azathioprine in the first 3 patients, and cyclosporine and mycophenolate mofetil in the 4th patient.One immediate death occurred from graft failure, one death occurred after 2 (1/2) years, from endocarditis in an intraventricular thrombus in the native heart, and a third death occurred 6 years after transplantation, from post-operative complications of the aortic valve surgery in the native heart. The remaining patient is well, 15 years after the transplantation. This patient is in functional class II (NYHA), 6 years after a surgical occlusion of the native heart aortic valve.Heterotopic heart transplantation results are inferior to those of orthotopic heart transplantation because they present higher RVP. The intraventricular thrombi, in the native heart, which require prolonged anticoagulation, and aortic valve complications, also in the native heart, may require surgical treatment. However, a patient's 15-year survival has demonstrated a long-term effectiveness of this option for selected patients.

A study evaluated the relationship between the defense of dissertations and their publication within the realm of the entire Medical School of the University of São Paulo (FM-USP). The existence of differences among different areas of knowledge and the time between defense of dissertations and their publication is questioned.To characterize publications related to dissertations defended in graduate courses of the Heart Institute (InCor) of the University of São Paulo Medical School (FM-USP).A retrospective survey was carried out featuring graduate work at FM/USP for the 1994-2004 period. Initially, data were collected on students who defended dissertations during this period, on their advisors, and on the dissertations defended in the course of the period. Then, by crossing these data with data from Medline and Web of Science, publications by these authors and data were located that referred to the respective publications.During that period, 268 dissertations were defended, resulting in 195 publications within a period of up to 10 years after their defense. The median time for publication after defense was one year and nine months, with a median impact factor of 2.1, and a median of 4 citations per paper. There was no statistically significant correlation among any of the data studied.A significant percentage of the dissertations were published, and in the group studied, publication took place within increasingly short times after their defense. This fact may be related to the success of the graduate commissions' policies and to the importance currently lent to debates on this theme, all of which contribute to improvement in the quality of graduate studies.

Arritmogenic right ventricular dysplasia (ARVD) is characterized by the gradual replacement of myocytes by adipose and fibrous tissue. Described in 1977, is considered a potentially lethal cause of cardiac disease poorly understood. This disorder usually involves the right ventricle and has been associated with arrthymia, heart failure, and sudden death. In this paper, we report a case of a 25-year-old patient with syncope associated with ventricular extrasystoles. A magnetic resonance imaging was performed and showed findings that support ARVD diagnose.

Apelin is a recently discovered peptide, identified as an endogenous ligand of receptor APJ. Apelin and receptor APJ are expressed in a wide variety of tissues including heart, brain, kidneys and lungs. Their interaction may have relevant pathophysiologic effects in those tissues. In fact, the last decade has been rich in illustrating the possible roles played by apelin in human physiology, namely as a regulating peptide of cardiovascular, hypothalamus-hypophysis, gastrointestinal, and immune systems. The possible involvement of apelin in the pathogenesis of high prevalence conditions and comorbidities - such as hypertension, heart failure, and Diabetes Mellitus Type 2 (T2DM) - rank it as a likely therapeutic target to be investigated in the future. The present paper is an overview of apelin physiologic effects and presents the possible role played by this peptide in the pathogenesis of a number of conditions as well as the therapeutic implications that might, therefore, be investigated.

Giant cell arteritis (GCA) is a systemic immune-mediated granulomatous vasculitis of large- and medium-sized arteries mainly affecting elderly people. Death from GCA alone is rare and usually results of ruptured aorta. In this paper is reported a case of a 83-year-old woman who unexpectedly died during treatment of GCA. Necropsy revealed inflammatory involvement of the coronary arteries with left descendent anterior artery thrombosis, myocardial infarct and rupture of the anterior wall of the left ventricle, as well as hemopericardium and cardiac tamponade. Myocardial infarction leading to sudden death is an exceptional complication of GCA.

This paper aims at comparing cardiorespiratory functional capacity during exercise--represented by indicators of functional limitation, maximal oxygen uptake (VO2max), and anaerobic threshold--plus cardiopulmonary responses to maximal exercise in congestive heart failure (CHF) patients belonging to different age groups.Fifty-four CHF patients, stratified by age group, were evaluated as follows: group I--30 to 39 years (n = 12); group II--40 to 49 years (n = 18); group III--50 to 59 years (n = 17); and group IV--60 years and above (n = 7). All patients underwent maximal cardiopulmonary exercise testing (CPET) on treadmills. A single-factor analysis of variance (ANOVA) was performed to compare different age groups.No significant differences were found in maximal oxygen uptake and anaerobic threshold among the age groups, nor in maximal values for carbon dioxide production, oxygen pulse, respiratory exchange ratio, pulmonary ventilation, and ventilatory equivalents for oxygen and carbon dioxide.These findings suggest that cardiorespiratory functional capacity during exercise in patients with CHF, as well as cardiopulmonary variables at maximal exercise, may be similarly affected by the heart disease in all studied age groups.

To evaluate the results of combined surgery (carotid endarterectomy and coronary artery bypass grafting) in patients with concomitant carotid and coronary artery disease.The authors reviewed 49 different reports describing several aspects of the combined surgery in 4788 patients to analyze early events in the perioperative period.Overall stroke, acute myocardial infarction (AMI), and mortality rates were 4.3%, 2.2%, and 4.2%, respectively. Most recent papers (1990 to 2000) show significant lower incidence of strokes compared to those published earlier (1972 to 1989) (4.1% x 10.2%; p0.05). In this same survey, the incidence of postoperative stroke was higher in the series with a small sample (n50) than in those with a larger population (n100) (7.2% x 3.9%; p0.05), denoting the impact of surgeons' experience on postoperative results.In sum, we believe that combined carotid endarterectomy and coronary artery bypass grafting is a safe and effective procedure when performed by experienced and qualified surgeons.

The authors review percutaneous coronary intervention (PCI) evolution and its growing application in myocardial revascularization for patients with coronary heart disease in Brazil and worldwide. PCI was introduced in 1977 using only the catheter balloon. Limitations of this method (acute occlusion and coronary restenosis) led to the adoption of coronary stents and more recently the advent of drug-eluting stents2, which were developed to drastically reduce restenosis rates. These developments allowed the exponential growth of percutaneous coronary intervention (PCI) procedures in Brazil which have replaced many bypass surgery procedures and have become the gold standard for the majority of symptomatic patients suffering from coronary artery disease. The preference for this procedure gained new dimensions in 2000 when the Brazilian Public Healthcare System (SUS) began reimbursing for stent procedures. This measure exemplified the importance of the Public Healthcare System's participation in incorporating medical advances and offering a high standard of cardiovascular treatment to a large portion of the Brazilian population. It is emphasized that prevention of in-stent restenosis is complex due to its unpredictable and ubiquitous occurrence. Control of this condition improves quality of life and reduces the recurrence of angina pectoris, the need to perform new revascularization procedures and hospital readmissions. The overall success of the drug-eluting stents has proven to be reliable and consistent in overcoming restenosis and has some beneficial impact for all clinical and angiographic conditions. This paper discusses the adoption and criteria for the use of drug-eluting stents in other countries as well as the recommendations established by the Brazilian Society of Interventional Cardiology for their reimbursement by SUS. The incorporation of new healthcare technology involves two distinct stages. During the first stage, the product is registered with the National Health Surveillance Agency (ANVISA). During this stage the interested company submits to the regulatory agency, results from clinical studies that demonstrate the efficacy and safety of the new device or pharmaceutical product. Frequently, in addition to clinical studies, approval records for clinical use from the regulatory agencies of other countries, mainly the United States of America and the European Community are also submitted. The successful completion of this stage means that the medication or device may be prescribed or used by the physicians in Brazil. The second stage in the incorporation of new healthcare technology involves the reimbursement or financing of the treatment that was approved in the previous stage based on its efficacy and safety. This stage can be more complex than the first one since the new technology, whether a substitution for established treatment methods or the introduction of a new treatment concept, are usually more expensive. The incorporation of new technology requires a cost-effectiveness analysis so that fund administrators can make decisions based on the universal scenario of limited resources to finance healthcare with treatments that are more and more burdensome. The difficulties of funding management are aggravated by medical and social ethical implications that arise when a treatment is approved based on its efficacy and safety but is not made available to patients who could benefit greatly from it. In Brazil, assessment methods for the incorporation of new technology based on reimbursement or financing have not been fully developed for either the private healthcare plans or the Brazilian Public Healthcare System (SUS). The implementation of new technology in both healthcare systems is a slow process and frequently the implementation is a result of the requirements of patients or the organizations that represent them and at times is the result of legal proceedings or political pressure imposed by physicians and their respective scientific societies. Our objective is to review the evolution of percutaneous coronary intervention (PCI) in Brazil and its current status in view of the advent of drug-eluting stents, the growing participation of drug-eluting stents in myocardial revascularization to treat patients with coronary heart disease, as well as, to compare the regulatory standards from Brazil and other countries regarding the incorporation and recommendations for the use of this new technology.

Although Wegener's granulomatosis is known for almost 65 years, the disease is still a dilemma for physicians. This is probably due to its different clinical presentations or to the lack of diagnostic methods. The laboratorial diagnosis is supported on the presence of antineutrophil cytoplasmic antibodies (ANCA-c) and on histological analysis of tissues from affected organs. This paper describes a case report of a patient whose clinical history presented all protean aspects of the disease, including cardiac involvement such as myocarditis, pericarditis and, surprisingly, intracardiac mass.

To evaluate the "normal" or low-voltage P wave of the 12-leads conventional electrocardiogram (ECG), in patients with serious electric ventricular disturbances in hypertrophic (HC) and dilated (DC) cardiomyopathies.Twenty cases of cardiomyopathies, 11 HC and 9 DC, ages ranging from 23 to 73 (x = 41) years have been studied. The analysis of the P wave was performed with ECG, amplified ECG at 1 mv = 20 mm and speed-paper at 50 mm/sec (ECG2), and the Frank-system vector-cardiogram (VCG). Voltage, delays and shapes of the P wave were evaluated by ECG2 and amplified VCG with gain at 1 mv = 160 mm. All electrical data were correlated with dimension of the left atrium (LA), dimension of left ventricular diastolic diameter (LVDD), dimension of left ventricular systolic diameter (LVSD), interventricular septal thickness (IST), posterior wall thickness ((PWT) and ejection fraction (EF) of the left ventricle of bidimensional echocardiogram (ECHO).Changes in morphologies and delays on the the P wave were best observed only on ECG2 and VCG. The mean voltage of P wave on ECG was 0.1 mv and the mean duration of the P loop on VCG was 133.7 msec in HC and 145.2 msec in DC, with mean terminal delay of 49.2 msec and 46.8 msec, respectively, due to slow atrial depolarization.In HC and DC with severe electric ventricular changes, the low-voltage and increased duration of P wave, are attributed to intraatrial-block due to structural changes of the atrial myocardium.

The association of tetralogy of Fallot with atrial isomerism has been rarely reported. Eight cases (five with left isomerism and three with right isomerism) are known. This paper reports two other cases of tetralogy of Fallot with left atrial isomerism. The syndrome's defects were disguised and without clinical expression because of the presence of the right ventricular outlet obstruction of tetralogy of Fallot. These diagnostic elements, not recognized in one of the patients previous to surgical correction of tetralogy of Fallot, were present: junctional rhythm, bronchial isomerism, partial anomalous pulmonary vein connection, agenesy of inferior vena cava and abdominal heterotaxy; their identification previous to surgical correction of tetralogy of Fallot, is necessary for an adequate surgical management.

To study the trends of mortality rates from cardiovascular diseases (CVD) and coronary heart disease (CHD) in eight capitals of Brazil.Death rates for these cities were studied in men (M) and female (F), standardized using the population of São Paulo, SP, 1980. Rates were calculated for CVD (ICD-9: 390-459) and CHD (ICD-9:410-414). The cities were Belém, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo, Curitiba and Porto Alegre. Using simple linear regression, we obtained the annual difference in rates with a confidence interval of 95%.For CVD a decline was detected of -2.6% (M) and -2.69% (F) in Belém; in Salvador, -1.53% (M) and -1.70% (F) and in São Paulo, -1.27% (M) and -1% (F) and for F in Belo Horizonte (-0.82%) and in Curitiba (-1.52%). Recife, Porto Alegre and Curitiba (M) showed stability during the period. There was a rise of the rates in Rio de Janeiro +1.37% (M) and +0.84% (F) and for M in Belo Hozironte (1%). The rates for CHD showed a decline in Belém-2.64% (M) and -2.74% (F); São Paulo, -1.4% (M) and -1.06% (F) and for F in Belo Horizonte. A stable trend was detected in Salvador, Curitiba, Porto Alegre and for M in Belo Horizonte. There was a rise in the rates of Recife +3.5% (M) and +4.4% (F) and in Rio de Janeiro +2.34% (M) and +2.53% (F).The magnitude of death rates and of the time trends showed in this paper reveal important regional differences. Questions related to the different assignment of diagnosis in the chapter of CVD could explain some of the observed trends. However, the rise of mortality rates in Rio de Janeiro could hardly be explained by classificatory matters. Tobacco, diet and medical care could explain the rise of mortality from CVD and CHD in Rio de Janeiro.

Pheochromocytoma is a cause of hypertension that frequently can be cured by surgery. The aim of this paper, based on 5 cases of pheochromocytoma, is to relate our experience in diagnosis and treatment in this pathology. In four of 5 patients with pheochromocytoma we observed unusual characteristics of the disease. Association with neurofibromatosis in one case, with rheumatic mitral regurgitation in another; and in a third case the tumor was malignant. One patient had catecholamine-mediated electrocardiographic changes which disappeared with treatment. Since symptoms of adrenergic hyperactivity were present in all cases, the rise in the levels of vanilmandelic acid and urinary metanephrines were useful in confirming the diagnosis. Computed tomography and I-131 meta-benzylguanidine for radioisotopic imaging, displayed not only all tumoral masses but also bone metastases in the malignant case. During the follow-up period, from the sixth month to the fourth year after surgery, four patients were asymptomatic, and have normal urinary catecholamine metabolite levels. The patient with a malignant form of pheochromocytoma continued to show elevated catecholamines release and remained hypertensive in spite of adrenal mass resection.

Utilization of fibrinolytic drugs in non-coronary diseases has been described since 1949, but despite of that, works about that subject are very rare in the literature. In this paper we discuss the cases of three patients that were treated with such compounds for pulmonary embolism, peripheral arterial embolism, and thrombosis in mechanical aortic prosthesis. All patients had excellent in-hospital outcome, and were totally asymptomatic at the discharge time. It is emphasized the clinical symptoms, sometimes unexpected, and the importance of the complementary tests not only in the disease's diagnosis, but also in some decisions that must be taken during the patient's evolution, where they can help us to decide, for example, about the correct moment to stop the thrombolytic infusion. In conclusion, fibrinolytic drugs can be utilized in the management of many affections that otherwise would be treated by emergency surgery.

The description of hemolytic anemia after mitral valve repair has been infrequent. The present paper presents this complication, discussing its diagnosis and surgical aspects, such as the association with the use of teflon felt for posterior annuloplasty. This complication happened in two children at our institution, one treated medically with supplementation of folic acid and ferrous sulfate and another requiring surgery for replacement of the teflon felt using a piece of heterologous pericardium for a new annuloplasty and leaflet advancement.

Many studies have demonstrated fairly high incidence of supraventricular arrhythmias after coronary artery bypass surgery, and have tried to identify preoperative, operative and postoperative factors related to their appearance. The present paper analysed 186 patients submitted to coronary artery bypass and reported a incidence of atrial fibrillation of 6.04% (11 cases). The male sex was dominant (81.2%) with ages varying from 49 to 73 (mean 54.58) years. The preoperative incidence of diabetes, smoking and systemic hypertension were, respectively, 18.2%, 54.51% and 36.4%. The mean number of vessels bypassed was 2.42 +/- 1.19 and the left circumflex artery was involved in 81.20% of these cases. Cardiopulmonary bypass time was 100 +/- 39.6 min and ischemic arrest time of 79.6 +/- 37.7 min. Single double stage cannulae for venous drainage were used in 45.5% of the patients and ventricular fibrillation and cardiac overdistention occurred in 63.60% immediately after CPB. Atrial fibrillation presented around 1.66 +/- 2.17 days in the postoperative period and 45.5% of the patients had more than one distinct episode of the arrhythmia. Treatment constituted of cardioversion in 25%, atenolol oral in 18.75% and digitalis associated to quinidine in 56.25%. These numbers permit us to suggest that some of the above factors may contribute to the genesis of arrhythmias, such as single double stage cannulation for venous drainage, inadequate myocardial protection, overdistention and cardiac fibrillation and, mainly, the presence of proximal circumflex artery obstructions responsible for atrial ischemia before and during surgery.

The paper presents five cases of the Syndrome described by Goldenhar, which consists in oculo-auriculo-vertebral alterations. Classic descriptions relate the presence of epibulbar dermoid, pre-auricular appendixes, mandible hypoplasia and vertebral anomalies. Excepting by some vertebral alterations, all the other anomalies were common to the five cases. This syndrome may be accompanied by congenital cardiopathy in a percentage varying from 15 to 50%, depending on the publications. The reason of hospitalization was the real presence of congenital cardiopathy of important clinical repercussion. Three patients had Tetrad of Fallot, one transposition of the great arteries, and the last one total annomalous pulmonary venous connection, which died due to clinical complications. The four patients were submitted to surgical correction of their cardiac defects, being the face defects programmed to the corrected later on.

The aim of this paper is to review clinical and laboratory features of this unusual pathology and its complications, indicating transcatheter embolization as a first choice for its management. Our case report is of a seven year-old child, with complex pulmonary arteriovenous fistula of the anterior segment of right superior lobe, which was diagnosed mainly by cintilography and pulmonary angiogram. Clinically she had cyanosis, fatigue with exertion, clubbing of the fingers and polycythemia with low partial pressure of oxygen (PAO2: 68.1 mmHg; Sat O2: 92.4%; Hct: 47.5%; Hb: 16 gr%). She did not have Rendu-Osler-Weber disease. The anatomic structure and localization of the complex fistula was showed by cineangiographic study. We preferred to manage this fistula with transcatheter embolization with a 02 gauge stainless steel coil occluding device (Gianturco-Wallace), as it was single and the patient was too young for sustain surgical trauma and the outcome would be positively satisfactory. After the embolization cyanosis was relieved and we could see normal pulmonary circulation following the point of the pre-existing fistula. We concluded that a judicious assessment by cineangiography could help select the transcatheter embolization procedure as an attractive therapeutic approach instead of surgery.