[Show abstract][Hide abstract] ABSTRACT: Insights from the “-omics” science have recently emphasized the need to implement an overall strategy in medical research. Here, the development of Systems Medicine has been indicated as a potential tool for clinical translation of basic research discoveries. Systems Medicine also gives the opportunity of improving different steps in medical practice, from diagnosis to healthcare management, including clinical research. The development of Systems Medicine is still hampered however by several challenges, the main one being the development of computational tools adequate to record, analyze and share a large amount of disparate data. In addition, available informatics tools appear not yet fully suitable for the challenge because they are not standardized, not universally available, or with ethical/legal concerns. Cardiovascular diseases (CVD) are a very promising area for translating Systems Medicine into clinical practice. By developing clinically applied technologies, the collection and analysis of data may improve CV risk stratification and prediction. Standardized models for data recording and analysis can also greatly broaden data exchange, thus promoting a uniform management of CVD patients also useful for clinical research. This advance however requires a great organizational effort by both physicians and health institutions, as well as the overcoming of ethical problems. This narrative review aims at providing an update on the state-of-art knowledge in the area of Systems Medicine as applied to CVD, focusing on current critical issues, providing a road map for its practical implementation.
European Journal of Internal Medicine 10/2014; · 2.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objetivo
Caracterizar a distribuição dos níveis de colesterol total (CT), colesterol LDL (C-LDL), colesterol HDL (C-HDL) e triglicéridos nos utentes dos cuidados de saúde primários em Portugal.
Estudo transversal envolvendo 719 médicos de família, segundo distribuição estratificada e proporcional à densidade populacional de cada região. Os primeiros dois utentes adultos de cada dia de consulta foram convidados a participar independentemente do motivo de consulta. Foi utilizado um inquérito para recolha de dados sociodemográficos, clínicos e laboratoriais, incluindo o perfil lipídico avaliado nos 12 meses precedentes.
Foram avaliados 16.856 indivíduos (61,6% do sexo feminino, 58 ± 15 anos), dispondo-se da determinação de CT, C-LDL, C-HDL e triglicéridos em 95,9% (N = 16.159), 59,1% (N = 9.956), 95,4% (N = 16.074) e 97,9% (N = 16.494), respetivamente. Detetou-se hipercolesterolemia (≥ 200 mg/dl) em 47% e níveis aumentados de C-LDL (≥ 130 mg/dl) em 38,4%. A hipertrigliceridemia (≥ 200 mg/dl) e o C-HDL diminuído (< 40 mg/dl) foram menos prevalentes, afetando 13% da população. A dislipidemia foi mais frequente nos homens entre os 30-60 anos e nas mulheres pós-menopausa. Considerando a população com idade ≥ 40 anos, 54,1% dos indivíduos cumpriam critérios de elegibilidade para terapêutica hipolipidemiante e 44,7% estavam medicados com estatinas (mas apenas 16,0% desses apresentavam CT ≤ 175 mg/dl).
Conclusões A prevalência de dislipidemia é elevada entre os utentes adultos dos cuidados de saúde primários em Portugal. Além disso, é particularmente frequente nos homens entre os 30-60 anos e nas mulheres após a menopausa, que deverão constituir grupos-alvo nas estratégias preventivas de saúde pública.
Revista Portuguesa de Cardiologia (English Edition). 01/2014;
[Show abstract][Hide abstract] ABSTRACT: To evaluate the influence of metabolic syndrome in the effectiveness of antihypertensive treatment and to compare it using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) (2001 and 2004), International Diabetes Federation (IDF) and American Heart Association/National Heart, Lung and Blood Institute (AHA-NHLBI) definitions.
The VALSIM (Estudo de Prevalência da Síndrome Metabólica) survey was designed as an observational cross-sectional study performed in a primary healthcare setting in Portugal. The first two adult patients scheduled for an appointment on a given day were invited to participate. The treatment effectiveness was evaluated by the occurrence of uncontrolled hypertension (≥140/90 mmHg) in patients taking antihypertensive drugs. Logistic regression analysis was used to determine the association between uncontrolled hypertension and metabolic risk factors, with adjustments for age, sex, and pattern of antihypertensive treatment.
Among the 16 856 individuals evaluated, 8925-treated hypertensive patients were identified. Only 35.8% of them had controlled hypertension. The risk of poor blood pressure control increased with age, waist circumference, serum levels of triglycerides and HDL-cholesterol. Among treatable risk factors, metabolic syndrome as defined by NCEP-ATP III 2001 diagnostic criteria was the strongest independent predictor of uncontrolled hypertension (odds ratio: 1.23; 95% CI: 1.08-1.41; P = 0.002). In opposition, the IDF or AHA-NHLBI definitions of metabolic syndrome failed to identify patients at risk of poor blood pressure control.
Metabolic syndrome is associated with lower effectiveness of antihypertensive therapy and the NCEP-ATP III 2001 definition of metabolic syndrome is the one that better identifies patients at risk of poor blood pressure control.
Journal of Hypertension 06/2013; · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aim
To characterize the distribution of total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C) and triglycerides in primary health care users.
We performed a cross-sectional study in a primary care setting, involving 719 general practitioners based on stratified distribution proportional to the population density of each region of Portugal.
The first two adult patients scheduled for an appointment on a given day were invited to participate. A questionnaire was applied to assess sociodemographic, clinical and laboratory data including lipid profile.
The study included 16 856 individuals (mean age 58.1±15.1 years; 61.6% women). Data on TC, LDL-C, HDL-C and triglycerides were available for 95.9% (n=16 159), 59.1% (n=9956), 95.4% (n=16 074) and 97.9% (n=16 494) of the population, respectively. Hypercholesterolemia (TC ≥200 mg/dl) was detected in 47%, and 38.4% had high levels of LDL-C (≥130 mg/dl). Hypertriglyceridemia (≥200 mg/dl) and low HDL-C (<40 mg/dl) were less prevalent, affecting roughly 13% of the population. Dyslipidemia was more common in middle-aged men and in post-menopausal women. Of the population aged over 40, 54.1% met eligibility criteria for lipid-lowering therapy and 44.7% were medicated with statins, but only 16.0% of these had TC ≤175 mg/dl.
Dyslipidemia is highly prevalent in primary health care users in Portugal. It is particularly common in middle-aged men and post-menopausal women, who should be considered target groups for preventive public health measures.
Revista Portuguesa de Cardiologia. 01/2013; 32(12):987–996.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 11/2012; · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cystatin C is a marker of renal dysfunction, and preliminary studies have suggested it might have a role as a prognostic marker in patients with coronary artery disease. The aim of the present study was to evaluate the usefulness of cystatin C for risk stratification of patients with ST-segment elevation myocardial infarction, regarding in-hospital and long-term outcomes. We included 153 consecutive patients with ST-segment elevation myocardial infarction treated by primary angioplasty. The baseline cystatin C level was measured at coronary angiography. The in-hospital outcome was determined as progression to cardiogenic shock or in-hospital death, and the long-term outcome was assessed, considering the following end points: (1) death and (2) death or reinfarction. Of the 153 patients evaluated (age 61 ± 12 years; 75.6% men), 15 (14.4%) progressed to cardiogenic shock and 4 (2.7%) died during hospitalization. The patients who progressed to cardiogenic shock or died during hospitalization had significantly greater cystatin C levels (1.02 ± 0.44 vs 0.69 ± 0.24 mg/L; p = 0.001). Long-term follow-up was available for 130 patients (583 ± 163 days). Among them, 11 patients died and 7 had reinfarction. A high baseline cystatin C level was associated with an increased risk of death (hazard ratio 8.5; p = 0.009) and death or reinfarction (hazard ratio 3.89; p = 0.021). Furthermore, only high baseline cystatin C levels and left ventricular ejection fraction ≤40% were independent predictors of the long-term risk of death, with synergistic interaction between the 2. In conclusion, cystatin C is a new biomarker with significant added prognostic value for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, predicting both short- and long-term outcomes.
The American journal of cardiology 02/2012; 109(10):1431-8. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare definitions of metabolic syndrome (MS) in relation to their association with coronary artery disease (CAD) and stroke.
We performed a cross-sectional study in a primary care setting, involving 719 general practitioners and based on stratified distribution proportional to the population density. The first two adult patients scheduled for an appointment on a given day were invited to participate, irrespective of the reason for the consultation. A questionnaire was applied to record sociodemographic, clinical and laboratory data. A diagnosis of MS was defined according to NCEP-ATP III 2001, NCEP-ATP III 2004, IDF and AHA/NHLBI criteria. Multivariate logistic regression analysis was used to assess the risk of CAD and stroke according to gender, age, body mass index, waist circumference, HDL cholesterol, triglycerides, hypertension, diabetes and MS according to each definition.
The study included 16,856 individuals (age 58.1 +/- 15.1 years). The prevalence of MS adjusted for gender, age and region size according to the 2001 and 2004 NCEP-ATP III, IDF and AHA/NHLBI definitions was 28.4%, 32.8%, 65.5% and 69.4%, respectively. The degree of agreement according to k statistics was modest and only 60.3% simultaneously fulfilled the criteria of all definitions. Hypertension was the treatable risk factor most strongly associated with CAD and stroke. Only the IDF and AHA/NHLBI definitions of MS were independently associated with CAD (OR: 1.74 and 2.26, respectively). Regarding stroke, only the AHA/NHLBI criteria showed a statistically significant association (OR: 1.85).
MS as defined according to the AHA/NHLBI criteria appears to be the best predictor of CAD and stroke in the Portuguese population, and remains an independent risk factor for CAD and stroke after adjustment for its individual components.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 02/2011; 30(2):139-69. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the prevalence, treatment and control of diabetes mellitus (DM) in primary health care users, to characterize associated cardiovascular (CV) risk factors and effectiveness of their treatment, and to estimate the clinical impact of DM on the occurrence of coronary artery disease (CAD) and stroke.
The VALSIM Study was performed in a primary care setting and involved 719 general practitioners (GPs), based on stratified distribution and proportional to the population density of each region of mainland Portugal and the islands of Madeira and the Azores. A questionnaire on sociodemographic and clinical data (previous diagnosis of DM, CAD or stroke, antidiabetic and antihypertensive medication and statins) and laboratory tests (lipids and HbA1C) was applied by participating GPs to the first two adult patients scheduled for an appointment on a given day, and blood pressure (BP) was measured. DM was defined as fasting glucose of > or = 126 mg/dl or use of antidiabetic agents.
The study included 16,856 individuals (mean age 58.1 +/- 15.1 years; 61.6% women), of whom 3215 were identified as diabetic. The prevalence of DM adjusted for gender and age in primary health care users was 14.9%, higher in men (M: 16.8%; F: 13.2%), and increased with age. Among the diabetic population, 90.2% were being treated with antidiabetic drugs and 51.7% had HbA1C lower than 7%. Around 91% had high BP (> or = 130/80 mmHg or were taking antihypertensive medication), 39.5% were overweight, 45.1% were obese, 69.3% had abdominal obesity, 71.8% had metabolic syndrome (ATP III criteria), 12% presented CAD and 5% had past history of stroke. The association between these CV risk factors and DM was stronger in women, and the impact of DM on occurrence of CAD and stroke was also higher in women. Among diabetic hypertensives, 78.4% were being treated with antihypertensive drugs, but only 9.3% had BP < 130/80 mmHg (M: 9.5%; F: 9.1%). Of diabetic patients with CAD, 94.2% were taking antihypertensive medication, but only 9.8% had controlled BP (M: 13.7%; F: 6.1%). Although 59% of the diabetic population were being treated with statins, only 6.7% had total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl and HDL-cholesterol > 60 mg/dl. Of diabetic patients with CAD, 76.5% were being treated with statins, but only 29.4% had total cholesterol < 175 mg/dl (M: 34.2%; F: 24.1%).
The management of DM in a primary care setting in Portugal can and should be improved, since 9.8% of patients are not treated and 48.3% are not controlled. DM has a considerable clinical impact due to its strong association with CAD and stroke. The risk of stroke and CAD is much higher in diabetic women, due firstly to a stronger association of DM with other risk factors in women, and secondly to less aggressive treatment.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/2010; 29(4):509-37. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although having high clinical efficacy in the treatment of human epidermal growth factor receptor-2 (HER2+) metastatic breast cancer, trastuzumab has been associated with cardiotoxicity, and the etiology and pathogenesis of this condition is currently under investigation.
This paper reviews the cardiotoxicity, associated with trastuzumab use and discusses the risk assessment and management of cardiac dysfunction.
The increased risk of cardiotoxicity is lower when trastuzumab is given as monotherapy (3%-7%) compared with anthracyclines + trastuzumab therapy (27%). Type II cardiac changes occur in trastuzumab-treated patients, which do not appear to be dose-related, are not associated with histological changes, and are generally reversible. Several risk factors for cardiac events have been identified and assessing levels of troponin I and N-terminal pro-brain B-type natriuretic peptide before and after treatment with trastuzumab may allow early detection of cardiotoxicity. A symptomatic and functional evaluation scheme for patients indicated for treatment with trastuzumab has also been proposed to work alongside therapeutic options for the treatment of heart failure.
The risk of cardiac dysfunction associated with trastuzumab can be justified given the increase in overall survival. This risk is lower when trastuzumab is given as monotherapy. The paradigm for cardiologists remains the same: treat the cancer effectively whilst preventing cardiotoxicity.
[Show abstract][Hide abstract] ABSTRACT: Hypertension (HT) is the most common modifiable risk factor for cardiovascular disease, and HT management and control is of major importance in preventive strategies. However, patterns of antihypertensive (AHT) treatment have never been evaluated in Portugal.
To estimate the prevalence of HT and to characterize its management in a primary care setting, identifying the most frequently used drugs and evaluating regional variations in treatment patterns.
The VALSIM study is a descriptive cross-sectional study performed in a primary care setting, involving 719 general practitioners (GPs) and representative of all regions of Portugal. The first two patients aged > or = 18 years consulting their GP on each day were asked to participate, irrespective of the reason for the consultation. After informed consent was obtained, a questionnaire was used to collect sociodemographic, clinical and laboratory data. Two blood pressure (BP) measurements were taken after a 5-minute rest period in a seated position. HT was defined as BP higher than 140/90 mmHg or use of antihypertensive medication.
A total of 16,856 subjects were evaluated (mean age 58.1 +/- 15.1 years; 61.3% women). The prevalence of HT adjusted for age and gender was 42.62% (males: 43.09%, females: 42.19%). Of the 9,189 hypertensive patients under treatment, the proportion receiving one, two or three or more drug classes was 47.62%, 36.16% and 16.22% respectively. The classes most frequently used in monotherapy were angiotensin receptor blockers (ARBs, 16.9%), angiotensin-converting enzyme inhibitors (ACEIs, 14.41%) and diuretics (5.85%). The most common associations of two classes were ARB-diuretic (11.82%), ACEI-diuretic (11.79%), ACEI-calcium channel blpcker (CCB, 2%), CCB-diuretic (1.81%) and ARB-CCB (1.53%). The most frequently used AHT drugs were diuretics (47.4%), ARBs (43%) and ACEIs (39.2%). CCBs were used in 18.9% and beta-blockers in 16.2% only. Different patterns of treatment were identified according to gender, age and region of residence. Diuretics were used more in the elderly, women, and in the Azores (61.9%) and the Alentejo (58.3%). ARBs were used preferentially in middle-aged patients, men and in the Northern region (48.6%).
There is considerable regional variation in treatment patterns. The proportion of hypertensive patients under monotherapy is still very high. Increasing the use of combination antihypertensive therapy would probably improve HT control in the population. Furthermore, increased use of CCBs would probably also be useful, as they are used less than would be expected, compared to other European countries.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 06/2009; 28(5):499-523. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The metabolic syndrome (MS) is a constellation of risk factors of metabolic origin that is associated with increased risk of type 2 diabetes mellitus (DM) and cardiovascular disease (CVD). Several regional studies have been conducted to determine its prevalence, but they are insufficient to determine the situation nationally or to characterize overall cardiovascular risk in Portugal.
To determine the prevalence of MS and each of its components in adult primary health care users in Portugal.
The VALSIM Study, involving 719 general practitioners (GPs), was performed in a primary care setting, based on stratified distribution and proportional to the population density of each region of mainland Portugal and the islands of Madeira and the Azores. The first two adult patients scheduled for an appointment on a given day were invited to participate, irrespective of the reason for the consultation. After informed consent was obtained, a questionnaire on sociodemographic, clinical and laboratory data was completed by the GP. A previous diagnosis of coronary artery disease (CAD), stroke or DM was identified by the GP based on medical records. A diagnosis of MS was defined according to the NCEP ATP III criteria. Logistic regression multivariate analysis was used to assess the risk of MS according to age, body mass index (BMI), waist circumference (WC) and region of residence for each gender, and to determine the association of CAD, stroke and DM with gender, age, BMI, WC, blood pressure and previous diagnosis of hypertension (HT), fasting glucose and previous diagnosis of DM.
The study included 16,856 individuals (mean age 58.1+/-15.1 years, 18-96 years; 61.62% women). The prevalence of MS adjusted for gender, age and size of region was 27.5% and showed regional variations, being highest in the Alentejo (30.99%) and lowest in the Algarve (24.42%). MS was more common among women and increased with age, BMI and WC. Independent protective factors were residence in the Algarve (odds ratio [OR]: 0.78; 95% confidence interval [CI] 0.66-0.92 p=0.002) or in Lisbon and Tagus Valley (OR: 0.83, 95% CI 0.77-0.91, p<0.001), while residence in the Northern (OR: 1.11; 95% CI 1.01-1.21, p=0.03) or Central regions (OR: 1.08; 95% CI 1.002-1.16, p=0.045) was an independent risk factor after correction for gender and age. MS was linked to increased prevalence of HT (OR: 3.88; 95% CI 3.61-4.18, p<0.001), and high blood pressure was the most frequent MS component, particularly in men (93.7%). MS was the most powerful factor associated with a diagnosis of DM, particularly in women (OR 7.23; 95% CI 6.22-8.40, p<0.001). Although there was a strong association between MS and CAD (OR: 1.16; 95% CI 1.01-1.34, p=0.043), the most potent risk factor associated with CVD was HT.
The prevalence of MS in Portugal is high (27.5%) and is strongly linked to the occurrence of CVD, and in particular to DM. These results highlight the need to implement preventive strategies for reducing overall cardiovascular risk in the Portuguese population.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 12/2008; 27(12):1495-529. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Metabolic syndrome is a cluster of interrelated cardiometabolic risk factors that are associated with an increased risk for both type 2 diabetes and atherosclerotic cardiovascular disease. These risk factors include visceral obesity, atherogenic dyslipidemia (elevated triglycerides and low HDL cholesterol), elevated blood pressure, dysglycemia (pre-diabetes or diabetes) and a prothrombotic and proinflammatory state. The condition is progressive, beginning with borderline risk factors, and worsens over time. Primary treatment is lifestyle therapy--weight loss, increased physical activity and antiatherogenic diet. But, as the metabolic syndrome progresses, drug therapy directed at individual risk factors may be needed.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 01/2008; 26(12):1409-21. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fabry disease is a rare X-linked lysosomal storage disorder caused by a deficiency of alpha-galactosidase, which results in progressive intracellular accumulation of glycosphingolipids in various tissues. Cardiac involvement is frequent, with left ventricular (LV) hypertrophy (concentric, apical or asymmetric septal) as the most common finding. Evaluating LV systolic dysfunction with conventional echocardiography is not sufficiently sensitive to detect impaired myocardial function early in the course of the disease. Doppler myocardial imaging can quantify changes in global and regional longitudinal myocardial function with great precision.
To identify parameters of cardiac dysfunction in patients with Fabry disease with no cardiac symptoms using conventional or Doppler echocardiography and tissue Doppler (including tissue tracking, strain and strain rate).
Four patients with Fabry disease (3 female; mean age 47 +/- 17 years) and 29 healthy controls (19 female and 10 male; mean age 38 +/- 14 years) were studied with conventional echocardiography and tissue Doppler imaging using a Vivid 7 scanner. The following parameters were measured: LV dimensions, ejection fraction (using Simpson's rule), systolic and diastolic velocities and tissue tracking of the mitral annulus at six sites (apical views). LV peak systolic strain and strain rate were obtained in 12 segments from apical views.
Two patients had LV hypertrophy (one concentric and one apical). Diastolic impairment was detected in three patients by reduced flow propagation velocity of early transmitral flow (Vp) and E/Vp ratio. Mitral annulus systolic velocities were lower in Fabry disease than in the controls. Peak systolic strain and strain rate were diminished in all segments in three patients, showing impaired myocardial systolic function. The results are presented for each of the four patients.
In patients with Fabry disease, with no cardiac symptoms and normal LV systolic function on conventional echocardiography, diastolic dysfunction was detected by Vp and E/Vp ratio regardless of LV hypertrophy. However, tissue Doppler imaging was able to detect impaired myocardial systolic function, particularly in patients with LV hypertrophy.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 07/2006; 25(6):613-37. · 0.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The current steps for diagnosing heart disease are very time consuming, delaying the correct identification of the problem, therefore, delaying the right treatment. In this study we have developed an experimental method using e-mail in order to identify patients with "rule out myocardial" condition and reduce the time lag for thrombolysis or coronary angioplasty in this clinical setting. Three different locations linked to the Internet by ISDN lines were used. Each line was connected with a computer. A pager and a dedicated phone line were also used. The following steps were performed for each situation: filling out of a questionnaire, ECG recording, questionnaire mailing and ECG by e-mail as attachment, pager warning that an urgent cardiology consultation was requested, including the doctor and patient's phone number, time to open the message and reply by e-mail, phone call for additional comments. A total of 24 attempts of interactive communication were performed. In 22 of those, an answer was obtained in less than 30 minutes. Two failures were recorded. One was due to a delay in the pager message, which did not arrive within the first hour; the second was due to a computer break down. This report shows that it is possible to establish a fast communication between the out patient clinic and the hospital (less than 30 minutes in most cases) at a very low cost and in a simple manner.
Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology 04/1999; 18(3):247-52. · 0.59 Impact Factor