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1.  Physical activity: practice this idea 
Sedentary habits or insufficient activities to promote health benefits can influence the occurrence of chronic diseases. The cardiovascular risk factors arise, at least partially, from the individual-environment interaction during life, and worsen with aging and lack of physical exercise. Health promotion and prevention are among the greatest challenges of public health policies. However, physical activity turns out to be rarely recommended and, thus have a very poor adhesion. In spite of consensus about the benefits of physical activity in both primary and secondary prevention, only 32% of adults and 66% of children and adolescents, according to Healthy People 2010 guideline, practice leisure-time physical activity. Thus, the regular practice of physical activity and healthy habits require changes in basic concepts in government and social policies. The higher involvement of public and private sectors related to health and education, the more expressive would be the reduction in socioeconomic costs and the improvement in quality of life.
PMCID: PMC3925885  PMID: 24551484
Exercise; physical activity; barrier
2.  Mode of Death on Chagas Heart Disease: Comparison with Other Etiologies. A Subanalysis of the REMADHE Prospective Trial 
Background
Sudden death has been considered the main cause of death in patients with Chagas heart disease. Nevertheless, this information comes from a period before the introduction of drugs that changed the natural history of heart failure. We sought to study the mode of death of patients with heart failure caused by Chagas heart disease, comparing with non-Chagas cardiomyopathy.
Methods and results
We examined the REMADHE trial and grouped patients according to etiology (Chagas vs non-Chagas) and mode of death. The primary end-point was all-cause, heart failure and sudden death mortality; 342 patients were analyzed and 185 (54.1%) died. Death occurred in 56.4% Chagas patients and 53.7% non-Chagas patients. The cumulative incidence of all-cause mortality and heart failure mortality was significantly higher in Chagas patients compared to non-Chagas. There was no difference in the cumulative incidence of sudden death mortality between the two groups. In the Cox regression model, Chagas etiology (HR 2.76; CI 1.34–5.69; p = 0.006), LVEDD (left ventricular end diastolic diameter) (HR 1.07; CI 1.04–1.10; p<0.001), creatinine clearance (HR 0.98; CI 0.97–0.99; p = 0.006) and use of amiodarone (HR 3.05; CI 1.47–6.34; p = 0.003) were independently associated with heart failure mortality. LVEDD (HR 1.04; CI 1.01–1.07; p = 0.005) and use of beta-blocker (HR 0.52; CI 0.34–0.94; p = 0.014) were independently associated with sudden death mortality.
Conclusions
In severe Chagas heart disease, progressive heart failure is the most important mode of death. These data challenge the current understanding of Chagas heart disease and may have implications in the selection of treatment choices, considering the mode of death.
Trial Registration
ClinicalTrails.gov NCT00505050 (REMADHE)
Author Summary
Chagas disease remains a burden for public health systems in Latin American countries. Several authors believe that sudden death is the main cause of death in this population. So many efforts have been made to prevent sudden death in Chagas disease. In order to verify if sudden death is the leading cause of death in Chagasic heart failure, we performed a subanalysis of the REMADHE prospective trial, which included a population of outpatients in a tertiary referral center for heart failure. We grouped patients according to etiology (Chagas vs non-Chagas) and modes of death that were classified as progressive heart failure death, sudden death, other cardiovascular death, noncardiovascular death or unknown death. Our study showed that in this end of the spectrum of presentation of Chagas disease, with systolic heart dysfunction, progressive heart failure is the main mode of death. These data have implications for the development of new strategies for prevention of chagasic heart failure.
doi:10.1371/journal.pntd.0002176
PMCID: PMC3636047  PMID: 23638197
3.  Endothelial function in pre-pubertal children at risk of developing cardiomyopathy: a new frontier 
Clinics  2012;67(3):273-278.
Although it is known that obesity, diabetes, and Kawasaki's disease play important roles in systemic inflammation and in the development of both endothelial dysfunction and cardiomyopathy, there is a lack of data regarding the endothelial function of pre-pubertal children suffering from cardiomyopathy. In this study, we performed a systematic review of the literature on pre-pubertal children at risk of developing cardiomyopathy to assess the endothelial function of pre-pubertal children at risk of developing cardiomyopathy. We searched the published literature indexed in PubMed, Bireme and SciELO using the keywords ‘endothelial', ‘children', ‘pediatric' and ‘infant' and then compiled a systematic review. The end points were age, the pubertal stage, sex differences, the method used for the endothelial evaluation and the endothelial values themselves. No studies on children with cardiomyopathy were found. Only 11 papers were selected for our complete analysis, where these included reports on the flow-mediated percentage dilatation, the values of which were 9.80±1.80, 5.90±1.29, 4.50±0.70, and 7.10±1.27 for healthy, obese, diabetic and pre-pubertal children with Kawasaki's disease, respectively. There was no significant difference in the dilatation, independent of the endothelium, either among the groups or between the genders for both of the measurements in children; similar results have been found in adolescents and adults. The endothelial function in cardiomyopathic children remains unclear because of the lack of data; nevertheless, the known dysfunctions in children with obesity, type 1 diabetes and Kawasaki's disease may influence the severity of the cardiovascular symptoms, the prognosis, and the mortality rate. The results of this study encourage future research into the consequences of endothelial dysfunction in pre-pubertal children.
doi:10.6061/clinics/2012(03)12
PMCID: PMC3297038  PMID: 22473410
Endothelial Function; Infant; Healthy; Cardiomyopathy; Heart Failure
4.  Cytogenetic characterization and genome size of the medicinal plant Catharanthus roseus (L.) G. Don 
AoB Plants  2012;2012:pls002.
The genome size and organization of the important medicinal plant Catharanthus roseus is shown to correspond to 1C = 0.76 pg (~738 Mbps) and 2n = 16 chromosomes. The data provide a sound basis for future studies including cytogenetic mapping, genomics and breeding.
Background and aims
Catharanthus roseus is a highly valuable medicinal plant producing several terpenoid indole alkaloids (TIAs) with pharmaceutical applications, including the anticancer agents vinblastine and vincristine. Due to the interest in its TIAs, C. roseus is one of the most extensively studied medicinal plants and has become a model species for the study of plant secondary metabolism. However, very little is known about the cytogenetics and genome size of this species, in spite of their importance for breeding programmes, TIA genetics and emerging genomic research. Therefore, the present paper provides a karyotype description and fluorescence in situ hybridization (FISH) data for C. roseus, as well as a rigorous characterization of its genome size.
Methodology
The organization of C. roseus chromosomes was characterized using several DNA/chromatin staining techniques and FISH of rDNA. Genome size was investigated by flow cytometry using an optimized methodology.
Principal results
The C. roseus full chromosome complement of 2n = 16 includes two metacentric, four subtelocentric and two telocentric chromosome pairs, with the presence of a single nucleolus organizer region in chromosome 6. An easy and reliable flow cytometry protocol for nuclear genome analysis of C. roseus was optimized, and the C-value of this species was estimated to be 1C = 0.76 pg, corresponding to 738 Mbp.
Conclusions
The organization and size of the C. roseus genome were characterized, providing an important basis for future studies of this important medicinal species, including further cytogenetic mapping, genomics, TIA genetics and breeding programmes.
doi:10.1093/aobpla/pls002
PMCID: PMC3292738  PMID: 22479673
5.  Norepinephrine Remains Increased in the Six-Minute Walking Test after Heart Transplantation 
Clinics  2010;65(6):587-591.
OBJECTIVE:
We sought to evaluate the neurohormonal activity in heart transplant recipients and compare it with that in heart failure patients and healthy subjects during rest and just after a 6-minute walking test.
INTRODUCTION:
Despite the improvements in quality of life and survival provided by heart transplantation, the neurohormonal profile is poorly described.
METHODS:
Twenty heart transplantation (18 men, 49±11 years and 8.5±3.3 years after transplantation), 11 heart failure (8 men, 43±10 years), and 7 healthy subjects (5 men 39±8 years) were included in this study. Blood samples were collected immediately before and during the last minute of the exercise.
RESULTS:
During rest, patients’ norepinephrine plasma level (659±225 pg/mL) was higher in heart transplant recipients (463±167 pg/mL) and heathy subjects (512±132), p<0.05. Heart transplant recipient’s norepinephrine plasma level was not different than that of healthy subjects. Just after the 6-minute walking test, the heart transplant recipient’s norepinephrine plasma level (1248±692 pg/mL) was not different from that of heart failure patients (1174±653 pg/mL). Both these groups had a higher level than healthy subjects had (545±95 pg/mL), p<0.05.
CONCLUSION:
Neurohormonal activity remains increased after the 6-minute walking test after heart transplantation.
doi:10.1590/S1807-59322010000600005
PMCID: PMC2898555  PMID: 20613934
Heart transplantation; Heart failure; Exercise; Norepinephrine; Cardiac rehabilitation; 6-minute walking test
6.  Hydrotherapy in Heart Failure: A Case Report 
Clinics (Sao Paulo, Brazil)  2009;64(8):824-826.
doi:10.1590/S1807-59322009000800020
PMCID: PMC2728200  PMID: 19690671
7.  Acute Aerobic Exercise Reduces 24-H Ambulatory Blood Pressure Levels in Long-Term-Treated Hypertensive Patients 
Clinics (Sao Paulo, Brazil)  2008;63(6):753-758.
BACKGROUND
Even with anti-hypertensive therapy, it is difficult to maintain optimal systemic blood pressure values in hypertensive patients. Exercise may reduce blood pressure in untreated hypertensive, but its effect when combined with long-term anti-hypertensive therapy remains unclear. Our purpose was to evaluate the acute effects of a single session of aerobic exercise on the blood pressure of long-term-treated hypertensive patients.
METHODS
Fifty treated hypertensive patients (18/32 male/female; 46.5±8.2 years; Body mass index: 27.8±4.7 kg/m2) were monitored for 24 h with respect to ambulatory (A) blood pressure after an aerobic exercise session (post-exercise) and a control period (control) in random order. Aerobic exercise consisted of 40 minutes on a cycle-ergometer, with the mean exercise intensity at 60% of the patient’s reserve heart rate.
RESULTS
Post-exercise ambulatory blood pressure was reduced for 24 h systolic (126±8.6 vs. 123.1±8.7 mmHg, p=0.004) and diastolic blood pressure (81.9±8 vs. 79.8±8.5 mmHg, p=0.004), daytime diastolic blood pressure (85.5±8.5 vs. 83.9±8.8 mmHg, p=0.04), and nighttime S (116.8±9.9 vs. 112.5±9.2 mmHg, p<0.001) and diastolic blood pressure (73.5±8.8 vs. 70.1±8.4 mmHg, p<0.001). Post-exercise daytime systolic blood pressure also tended to be reduced (129.8±9.3 vs. 127.8±9.4 mmHg, p=0.06). These post-exercise decreases in ambulatory blood pressure increased the percentage of patients displaying normal 24h systolic blood pressure (58% vs. 76%, p=0.007), daytime systolic blood pressure (68% vs. 82%, p=0.02), and nighttime diastolic blood pressure (56% vs. 72%, p=0.02). Nighttime systolic blood pressure also tended to increase (58% vs. 80%, p=0.058).
CONCLUSION
A single bout of aerobic exercise reduced 24h ambulatory blood pressure levels in long-term-treated hypertensive patients and increased the percentage of patients reaching normal ambulatory blood pressure values. These effects suggest that aerobic exercise may have a potential role in blood pressure management of long-term-treated hypertensive.
doi:10.1590/S1807-59322008000600008
PMCID: PMC2664274  PMID: 19060996
Hypertension; Exercise; Blood Pressure; Treated Hypertension
8.  The Relationship Between Heart Rate Reserve and Oxygen Uptake Reserve in Heart Failure Patients on Optimized and Non-Optimized Beta-Blocker Therapy 
Clinics (Sao Paulo, Brazil)  2008;63(6):725-730.
BACKGROUND
The relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in heart failure patients either on non-optimized or off beta-blocker therapy is known to be unreliable. The aim of this study was to evaluate the relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in heart failure patients receiving optimized and non-optimized beta-blocker treatment during a treadmill cardiopulmonary exercise test.
METHODS
A total of 27 sedentary heart failure patients (86% male, 50±12 years) on optimized beta-blocker therapy with a left ventricle ejection fraction of 33±8% and 35 sedentary non-optimized heart failure patients (75% male, 47±10 years) with a left ventricle ejection fraction of 30±10% underwent the treadmill cardiopulmonary exercise test (Naughton protocol). Resting and peak effort values of both the percentage of oxygen consumption reserve and percentage of heart rate reserve were, by definition, 0 and 100, respectively.
RESULTS
The heart rate slope for the non-optimized group was derived from the points 0.949±0.088 (0 intercept) and 1.055±0.128 (1 intercept), p<0.0001. The heart rate slope for the optimized group was derived from the points 1.026±0.108 (0 intercept) and 1.012±0.108 (1 intercept), p=0.47. Regression linear plots for the heart rate slope for each patient in the non-optimized and optimized groups revealed a slope of 0.986 (almost perfect) for the optimized group, but the regression analysis for the non-optimized group was 0.030 (far from perfect, which occurs at 1).
CONCLUSION
The relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in patients on optimized beta-blocker therapy was reliable, but this relationship was unreliable in non-optimized heart failure patients.
doi:10.1590/S1807-59322008000600003
PMCID: PMC2664269  PMID: 19060991
Heart rate; Beta-blockers; Oxygen consumption; Heart failure; Exercise
9.  Heart Rate Dynamics During A Treadmill Cardiopulmonary Exercise Test in Optimized Beta-Blocked Heart Failure Patients 
Clinics (Sao Paulo, Brazil)  2008;63(4):479-482.
BACKGROUND
Calculating the maximum heart rate for age is one method to characterize the maximum effort of an individual. Although this method is commonly used, little is known about heart rate dynamics in optimized beta-blocked heart failure patients.
AIM
The aim of this study was to evaluate heart rate dynamics (basal, peak and % heart rate increase) in optimized beta-blocked heart failure patients compared to sedentary, normal individuals (controls) during a treadmill cardiopulmonary exercise test.
METHODS
Twenty-five heart failure patients (49±11 years, 76% male), with an average LVEF of 30±7%, and fourteen controls were included in the study. Patients with atrial fibrillation, a pacemaker or noncardiovascular functional limitations or whose drug therapy was not optimized were excluded. Optimization was considered to be 50 mg/day or more of carvedilol, with a basal heart rate between 50 to 60 bpm that was maintained for 3 months.
RESULTS
Basal heart rate was lower in heart failure patients (57±3 bpm) compared to controls (89±14 bpm; p<0.0001). Similarly, the peak heart rate (% maximum predicted for age) was lower in HF patients (65.4±11.1%) compared to controls (98.6±2.2; p<0.0001). Maximum respiratory exchange ratio did not differ between the groups (1.2±0.5 for controls and 1.15±1 for heart failure patients; p=0.42). All controls reached the maximum heart rate for their age, while no patients in the heart failure group reached the maximum. Moreover, the % increase of heart rate from rest to peak exercise between heart failure (48±9%) and control (53±8%) was not different (p=0.157).
CONCLUSION
No patient in the heart failure group reached the maximum heart rate for their age during a treadmill cardiopulmonary exercise test, despite the fact that the percentage increase of heart rate was similar to sedentary normal subjects. A heart rate increase in optimized beta-blocked heart failure patients during cardiopulmonary exercise test over 65% of the maximum age-adjusted value should be considered an effort near the maximum. This information may be useful in rehabilitation programs and ischemic tests, although further studies are required.
doi:10.1590/S1807-59322008000400011
PMCID: PMC2664123  PMID: 18719758
Heart failure; Heart rate; Carvedilol; Exercise; Optimization
10.  Reproducibility of the Self-Controlled Six-Minute Walking Test in Heart Failure Patients 
Clinics (Sao Paulo, Brazil)  2008;63(2):201-206.
INTRODUCTION
The six-minute walk test (6WT) has been proposed to be a submaximal test, but could actually demand a high level of exercise intensity from the patient, expressed by a respiratory quotient >1.0, following the guideline recommendations. Standardizing the 6WT using the Borg scale was proposed to make sure that all patients undergo a submaximal walking test.
PURPOSE
To test the reproducibility of the six-minute treadmill cardiopulmonary walk test (6CWT) using the Borg scale and to make sure that all patients undergo a submaximal test.
METHODS
Twenty-three male heart failure patients (50±9 years) were included; these patients had both ischemic (5) and non-ischemic (18) heart failure with a left ventricle ejection fraction of 23±7%, were diagnosed as functional class NYHA II-III and were undergoing optimized drug therapy. Patients were guided to walk at a pace between “relatively easy and slightly tiring” (11 and 13 on Borg scale). The 6CWT using the Borg scale was performed two times on a treadmill with zero inclination and patient control of speed with an interval of 24 hours. During the sixth minute, we analyzed ventilation (VE, L/min), respiratory quotient, Oxygen consumption (VO2, ml/kg/min), VE/VCO2 slope, heart rate (HR, bpm), systolic blood pressure (SBP, mmHg), diastolic (DBP, mmHg) blood pressure and distance.
RESULTS
The intraclass correlation coefficients at the sixth minute were: HR (ri=0.96, p<0.0001), VE (ri=0.84, p<0.0001), SBP (ri=0.72, p=0.001), distance (ri=0.88, p<0.0001), VO2 (ri=0.92, p<0.0001), SlopeVE/VCO2 (ri=0.86, p<0.0001) and RQ<1 (ri=0.6, p=0.004).
CONCLUSION
Using the 6CWT with the Borg scale was reproducible, and it seems to be an appropriate method to evaluate the functional capacity of heart failure patients while making sure that they undergo a submaximal walking test.
PMCID: PMC2664221  PMID: 18438574
Walking test; Heart failure; Reproducibility; Borg scale; Exercise

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