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1. Neurological and Psychiatric Disorders in Patients with Rheumatic Heart Disease: Unveiling what is Beyond Cardiac Manifestations

Author

Luiz Paulo Bastos Vasconcelos, Marcelle Cristina da Silva Bastos Vascon, Francisco Biagio Murta E. Di Flora, Flávio Augusto Paes de Oliveira, Pedro Drummond Lima, Lucas Campos Barbosa E. Silva, Breno Camargos Mucelli- Spolaor, José Luiz Padilha da Silva, William Antônio de Magalhães Esteves, Maria Carmo P. Nunes, and Antônio Lúcio Teixeira

Subjects
rheumatic heart disease, basal ganglia motor dysfunction, obsessive-compulsive symptoms, mood disorders, migraine, Diseases of the circulatory (Cardiovascular) system, RC666-701, Public aspects of medicine, RA1-1270
Abstract

Background: Rheumatic heart disease (RHD) is the most serious manifestation of rheumatic fever, which may also affect the brain. The current study assessed the prevalence of neuropsychiatric manifestations in patients with RHD, including clinical features associated with basal ganglia motor dysfunction (BGMD). Methods: We conducted neurologic and psychiatric assessments in consecutive patients with RHD referred to a tertiary center for heart valve diseases. Echocardiography was performed to assess the pattern of valvular involvement and RHD severity. Validated questionnaires for the evaluation of cognition, depression, anxiety, and obsessive-compulsive symptoms (OCS) were applied. BGMD was clinically defined by the presence of hyperkinetic movement disorders. Results: Fifty patients with age of 43.2 ± 10.8 years, 84% female, were included. Mitral valve was affected in 47 patients (94%), and 21 of them (42%) also had aortic valve involvement. Chorea (22%), chronic tics (18%), OCS (48%), major depression (34%), generalized anxiety disorder (54%), cognitive complaints (66%), migraine (52%) and seizures (18%) were frequently reported. The factors associated with BGMD were age (p = 0.018), major depression (p = 0.013), and Yale-Brown Obsessive Compulsive (Y-BOCS) score (p = 0.011). The severity of heart disease was not associated with BGMD. Conclusions: Neuropsychiatric manifestations are frequent in RHD patients, which may persist up to three decades after acute rheumatic fever. Age, major depression and severity of OCS were independently associated with BGMD. These manifestations deserve a close attention of clinicians and researchers dealing with adult patients with RHD.

Published
2022
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2. Pulmonary Artery Systolic Pressure Response to Exercise in Patients with Rheumatic Mitral Stenosis: Determinants and Prognostic Value

Author

Henrique Silveira Costa, Sanny Cristina Castro Faria, Maria do Carmo Pereira Nunes, Judy Hung, José Luiz Padilha da Silva, Robert A. Levine, Timothy C. Tan, William A. M. Esteves, André Gorle de Miranda Chaves, and Flávio Augusto Paes de Oliveira

Subjects
Male, medicine.medical_specialty, Population, Hemodynamics, Blood Pressure, 030204 cardiovascular system & hematology, Pulmonary Artery, Article, 030218 nuclear medicine & medical imaging, 03 medical and health sciences, 0302 clinical medicine, medicine.artery, Mitral valve, Internal medicine, Heart rate, Medicine, Humans, Mitral Valve Stenosis, Radiology, Nuclear Medicine and imaging, education, education.field_of_study, business.industry, Hazard ratio, Middle Aged, medicine.disease, Prognosis, Pulmonary hypertension, Blood pressure, medicine.anatomical_structure, Pulmonary artery, Cardiology, Exercise Test, Mitral Valve, Female, Cardiology and Cardiovascular Medicine, business
Abstract

BACKGROUND: Pulmonary hypertension in response to exercise is a marker of the hemodynamic severity of mitral stenosis (MS). However, the factors related to elevated pulmonary pressure with exercise are not well defined. The aim of this study was to assess the parameters associated with the pulmonary pressure response to exercise in patients with pure rheumatic MS. An additional aim was to determine the impact of exercise-induced pulmonary hypertension on clinical outcome. METHODS: One hundred thirty patients with MS (94% women; mean age, 45 ± 11 years) underwent exercise echocardiography. A range of echocardiographic parameters were obtained at rest and at peak exercise. Symptom-limited graded ramp bicycle exercise was performed in the supine position. The primary end point was mitral valve intervention, either percutaneous or surgical. RESULTS: In the overall population, systolic pulmonary artery pressure (SPAP) increased from 38.3 ± 13.4 mm Hg at rest to 65.8 ± 20.7 mm Hg during exercise. Increases in mean mitral gradient, right ventricular function, left atrial volume, and net atrioventricular compliance were independently associated with SPAP at peak exercise, after adjusting for changes in heart rate. During the follow-up period (median, 17 months; range, 1–45 months), 46 adverse clinical events were observed. By multivariate Cox proportional-hazards analysis adjusted for age and sex, SPAP achieved at peak exercise was an important predictor of adverse outcome (adjusted hazard ratio, 1.025; 95% CI, 1.010–1.040; P = .001). New York Heart Association functional class (adjusted hazard ratio, 2.459; 95% CI, 1.509–4.006; P < .001) and the interaction between valve area and net atrioventricular compliance (P = .001) were also significant predictors of adverse events. Time-dependent areas under the receiver operating characteristic curve for the model with SPAP during exercise were better than for the model with SPAP at rest, with a significant improvement from 3 years onward. CONCLUSIONS: In patients with MS, the pulmonary artery pressure response to exercise is determined by a combination of factors, including transmitral mean gradient at exercise, net atrioventricular compliance, left atrial volume, and right ventricular function. Pulmonary artery pressure at peak exercise is a predictor of clinical outcomes and adds incremental prognostic value beyond that provided by standard resting measurements, including valve area. (J Am Soc Echocardiogr 2020;33:550–8.)

Published
2019

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