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The scientific novelty of the study A large number of reports have demonstrated that depressed heart rate variability after myocardial infarction (MI), left ventricular dysfunction and arrhythmias are powerful predictors of mortality. Nevertheless there is a lack of detailed assessment of heart rate variability in the acute period of MI, especially during the first 24 hours, from long-term (24-h) recordings, and the value of different parameters of heart rate variability in predicting dangerous complications of MI was not fully evaluated. The indications of complex and constant monitoring of heart rate variability, left ventricular function, arrhythmias in acute MI are not based on scientific studies as well as their value in predicting the effect of different methods of management, course and outcomes of critical cardiac conditions. Thus, the current study differs from all the earlier studies in that we assessed heart rate variability in the very early period of myocardial infarction (the first and the third day) using long time recordings (24 h), both – time-domain and frequency-domain –methods, and evaluated its changes in relation to arrhythmias and left ventricular function, using not only conventional 2D-echocardiography but also left ventricular long axis function assessment by M-mode and tissue Doppler imaging. The aim of the study The aim of the study was to determine the association between heart rate variability, cardiac arrhythmias and left ventricular... [to full text]

L’objectif de la présente thèse était de caractériser le sommeil d’un groupe clinique d’enfants et d’adolescents ayant un trouble d’anxiété comme diagnostic primaire et le comparer à un groupe témoin. Dans un premier temps, nous avons vérifié si le profil de la fréquence cardiaque nocturne des enfants et des adolescents pouvait être regroupé selon le diagnostic. Pour ce faire, la fréquence cardiaque nocturne de 67 adolescents anxieux et 19 sujets non anxieux a été enregistrée à l’aide d’un équipement ambulatoire. Les résultats de cette étude montrent que le profil de la fréquence cardiaque nocturne chez les enfants anxieux varie selon le diagnostic. Alors que les adolescents non anxieux montrent un profil de la fréquence cardiaque nocturne plat, on retrouve les associations suivantes chez les adolescents ayant un trouble anxieux : a) un profil croissant de la fréquence cardiaque chez les adolescents ayant un trouble d’anxiété de séparation; b) un profil décroissant de la fréquence cardiaque chez les adolescents ayant un trouble d’anxiété généralisé; c) un profil en forme de U chez les adolescents ayant un trouble d’anxiété sociale. De plus, une association significative a été observée entre le diagnostic et la présence de fatigue matinale. L’association d’un profil de la fréquence cardiaque nocturne avec un diagnostic d’anxiété suggère la présence d’une dysrégulation de la modulation chronobiologique du système nerveux autonome. Étant donné que le profil de la fréquence cardiaque nocturne s’exprime différemment selon le diagnostic, qu’en est-il de l’architecture du sommeil? Dans un deuxième temps, nous avons enregistré le sommeil en laboratoire d’un groupe clinique de 19 jeunes ayant un trouble d’anxiété comme diagnostic primaire, avec comorbidités et médication et comparé à 19 jeunes non anxieux. Les résultats de cette étude ont montré que les participants du groupe anxieux ont une latence au sommeil plus longue, une latence au sommeil paradoxal plus longue et une durée d’éveil plus longue lorsque comparé au groupe témoin. L’évaluation subjective de la qualité du sommeil chez le groupe d’adolescents anxieux montre que leur auto-évaluation reflète les valeurs enregistrées en laboratoire. Nous avons également observé chez le groupe anxieux une fréquence cardiaque moyenne plus élevée et un index plus élevé d’apnée-hypopnée, bien que non pathologique. Nous avons également observé une association positive entre l’anxiété de trait et l’indice d’apnée-hypopnée et la latence au sommeil, ainsi qu’une association positive entre l’anxiété manifeste et la latence au sommeil paradoxal. Ces résultats suggèrent que le sommeil chez cette population est altéré, que des signes d’hypervigilance physiologique sont présents et qu'une association existe entre ces deux paramètres. Finalement, dans la troisième étude de cette thèse, nous avons analysé l’activité cardiaque pendant le sommeil en utilisant les paramètres temporels et fréquentiels de la variabilité cardiaque chez un groupe clinique de dix-sept enfants et adolescents ayant un trouble d’anxiété comme diagnostic primaire avec comorbidité et médication, et comparé à un groupe non anxieux. Les résultats ont montré que les participants du groupe anxieux, lorsque comparés au groupe non anxieux, présentent des intervalles interbattements plus courts, un indice temporel de la variabilité cardiaque représentant la branche parasympathique moindre, une activité des hautes fréquences normalisées moindre et un ratio basse fréquence sur haute fréquence augmenté. Plusieurs corrélations ont été observées entre les mesures cliniques de l’anxiété et les mesures de la variabilité cardiaque. Ces résultats viennent ajouter à la littérature actuelle un volet descriptif clinique à ce jour non documenté, soit l’impact de l’anxiété pathologique chez un groupe clinique d’enfants et d’adolescents sur le processus normal du sommeil et sur la régulation de la fréquence cardiaque. En résumé, les résultats de ces trois études ont permis de documenter chez un groupe clinique d’enfants et d’adolescents ayant de l’anxiété pathologique, la présence d’une altération circadienne du profil de la fréquence cardiaque, d’une architecture altérée du sommeil ainsi qu’une dysrégulation du système nerveux contrôlant l’activité cardiaque. / The aim of this thesis was to characterize, in a clinical group of children and adolescents with anxiety disorder as a primary diagnostic, the sleep period and to compare it to a control group. Firstly, we have verified if the nocturnal sleep pattern of children and adolescents could be grouped by psychiatric disorders. Sixty-seven children and adolescents with anxiety disorders and nineteen non anxious match controls were monitored using ambulatory recording equipment. Results showed that nocturnal heart rate pattern of anxious adolescents would vary accordingly with the diagnosis. While non anxious adolescents exhibit a flat nocturnal heart rate pattern through the night, anxious participants showed the following associations: a) increased nocturnal heart rate pattern associated with separation anxiety disorder; b) decreased nocturnal heart rate pattern associated with generalized anxiety disorder; and c) U shape nocturnal heart rate pattern associated with social phobia. Moreover, a significant association was found between anxiety diagnosis and presence of morning fatigue. The association between nocturnal heart rate patterns with anxiety suggests that the circadian modulation of heart rate is dysregulated, but what about the sleep macrostructure? Secondly, we have monitored in a sleep laboratory a clinical sample of nineteen adolescents with pathological anxiety, comorbidity and medication, and compared it to nineteen non anxious match controls. Results showed that anxious participants had longer sleep latency, longer REM sleep latency and longer awake period during sleep when compared to control participants. Compared to control participants, anxious patients subjectively reported sleep disturbances, manifested objective sleep disorders and presented no adaptation to the laboratory environment. Moreover, higher nocturnal heart rate and higher apnea-hypopnea index were observed in anxious group when compared to non anxious group. Significant positive associations were observed between Trait anxiety and apnea-hypopnea index as well as for sleep latency while manifest anxiety was associated to REM sleep latency. Results suggest that sleep of children and adolescents with pathological anxiety is altered, that signs of physiological hypervigilance are observed and that both are associated. Following previous results, we have analyzed in a third study heart rate variability during nocturnal sleep using both, times and frequency domains in a clinical sample group of seventeen children and adolescents with anxiety disorder as primary diagnostic with comorbidity and medication. Results showed that anxious when compared to non anxious, had a shorter interbeat interval, and had lower rMSSD values, less high frequency in normalized units and higher low frequency/high frequency ratio. Correlations were observed between clinical anxiety scores and time and frequency domains of heart rate variability. These results add to the growing body of literature that pathological anxiety in a clinical group of children and adolescents impact on sleep process and heart rate regulation during sleep. Overall findings add to the growing body of recent clinical literature, a sleep alteration description of a clinical sample of children and adolescents. From the three studies of this thesis, results showed that circadian heart rate pattern is altered, that sleep architecture is altered, and that the time and frequency domain of nocturnal heart rate variability is altered in a clinical group of children and adolescents with pathological anxiety.

Disertacijoje iškelta sergančiųjų ūminiu miokardo infarktu ir cukriniu diabetu asmenų nepalankios ligos eigos problema bei apžvelgos galimybės prognozuoti tokių asmenų ligos baigtis.Darbo uždaviniais buvo: 1) įvertinti širdies ritmo variabilumo ir hemodinamikos žymenis sergantiesiems ūminiu miokardo infarktu bei cukriniu diabetu priklausomai nuo ligos eigos ir baigčių, palyginti juos su nesergančiųjų cukrininu diabetu atitinkamais žymenimis; 2) nustatyti sergančiųjų miokardo infarktu prognozinę širdies ritmo variabilumo ir hemodinamikos žymenų vertę mirties, skilvelinės aritmijos, grįžtamosios išemijos išsivystymui ar jungtinei vertinamajai baigčiai stacionare; 3) nustatyti prognozinę širdies ritmo variabilumo ir hemodinamikos žymenų vertę per 1 metus ir per 5 metus po persirgto miokardo infarkto įvykusiems: mirčiai dėl bet kokios ir dėl širdinės priežasties, pakartotino miokardo infarkto išsivystymui, neplanuotos širdies revaskuliarizacijos procedūros atlikimui, nekomplikuotos išeminės širdies ligos eigos buvimui; 4) nustatyti ar prognozinė širdies ritmo variabilumo ir hemodinamikos žymenų vertė analizuojamoms baigtims skiriasi tiriamųjų grupėse: a) cukriniu diabetu sergančiųjų asmenų, b) cukriniu diabetu nesergančiųjų asmenų; 5) gautų prognozinių modelių diskriminuojančias savybes palyginti tarpusavyje ir su pripažintais ūminio miokardo infarkto rizikos vertinimo kriterijais (kairiojo skilvelio išstūmio frakcija, GRACE ir TIMI rizikos vertinimo skalėmis). / Unfavourable outcomes of the diabetic patients with acute myocardial infarction were analysed in the dissertation and possibilities to predict the course of the disease was reviewed. The objectives of the study were: 1) to evaluate the measures of heart rate variability and impedance cardiography for the patients with acute myocardial infarction, and their alterations in reliance on the different outcomes, according to the patients’ status of diabetes mellitus; 2) to determine prognostic value of combined assessment of heart rate variability and impedance cardiographymeasures for in-hospital outcomes of myocardial infarction: in-hospital mortality, ventricular arrhythmia, recurrent ischemia and complicated in-hospital course; 3) to determine prognostic value of combined assessment of heart rate variability and impedance cardiography measures for long-term (1 and 5 years) outcomes after myocardial infarction: mortality (both all-cause death and cardiac death), ischemic complications (recurrent non-fatal myocardial infarction and need for revascularization procedures) and uncomplicated long-term course; 4) to assess whether prognostic value of combined heart rate variability and hemodynamic measures differs in separate patient groups: diabetic or non-diabetic; 5) to compare the discriminative power of the obtained prognostic models and widely recognized risk markers, such as ejection fraction of the left ventricle, GRACE and TIMI scores.

Emotions are an integral part of the human experience and their interpretation can provide valuable but also misleading clues about oneself and other people’s state of mind. Negative emotional states can be perceived as uncomfortable and – when experienced chronically – can develop into anxiety and mood disorders. The more pervasive these disorders the more severely they affect and disable a person’s everyday functioning and often their sleep as well. According to Lang and colleagues (1998), emotions may be expressed verbally, behaviorally, and physiologically, i.e., emotions can be reported, observed, and objectively measured. Each measurement approach provides important, unique, and often conflicting information that can be used in the assessment and treatment evaluation of psychological disorders affecting the emotions. Autonomic measures have been used to indicate the physiological components of emotions, such as those along the worry-anxiety-fear-panic spectrum. Worry has been shown to suppress cardiac responses to imaginal feared material (see Borkovec, Alcaine, & Behar, 2004) and reduce autonomic variability (Hoehn-Saric, McLeod, Funderburk, & Kowalski, 2004; Hoehn-Saric, McLeod, & Zimmerli, 1989). Results for panic and anticipatory anxiety are less conclusive but theoretically these states should go along with increased autonomic arousal. Abnormal autonomic arousal might also be present during sleep as both panic disorder and worrying have been associated with sleeping difficulties. However, most empirical research has been confined to the laboratory where high internal validity is achieved at the cost of poor ecological validity. Thus, the purpose of this doctoral dissertation is to extend and validate laboratory findings on worry, anticipatory anxiety, and panic using ambulatory monitoring. Twenty-four hour monitoring not only can give valuable insights into a person’s daytime emotional experience but also allows observing how these emotions might affect their sleep in their natural environment. In the following chapter, the reader will be introduced to a conceptual framework that ties together worry, anxiety, fear, and panic, and related anxiety disorders (section 2.1), to autonomic arousal and electrodermal and cardiac arousal in particular (section 2.2), to sleep and its relation to autonomic arousal and anxiety disorders (section 2.3), and to ambulatory monitoring (section 2.4). After illustrating the aims of this thesis (chapter 3), chapters 4 to 6 present the results of three empirical studies conducted as part of this doctoral research. The first study deals solely with electrodermal monitoring and how it is affected by confounding variables in an ambulatory context (chapter 4). The next study then seeks to investigate the relationship between electrodermal arousal and anticipatory anxiety and panic in a sample of panic disorder patients and healthy controls. The last study focuses primarily on the effect of trait and state worry on subjective and objective sleep and electrodermal and cardiac arousal in a group of high and low worriers. Chapters 7 to 9 summarize and integrate the findings from these three empirical studies, discuss methodological limitations, and provide an outlook into future research.

A síndrome dos ovários policísticos (PCOS) é o distúrbio endócrino mais comum em mulheres em idade reprodutiva, sendo caracterizado por anovulação crônica e manifestações de hiperandrogenismo. O sobrepeso e a obesidade afetam a maioria das mulheres com PCOS e, quando presentes, podem acentuar as alterações reprodutivas e metabólicas associadas à síndrome. Dessa forma, a redução de peso através da restrição calórica é de suma importância nas mulheres com PCOS e excesso de peso. Entretanto, ainda não está estabelecido se a composição da dieta por si só pode ter efeitos significativos sobre as alterações metabólicas e hormonais da PCOS. Poucos ensaios clínicos randomizados avaliando o efeito de diferentes intervenções dietéticas foram realizados em mulheres com PCOS, sendo que os estudos existentes apresentam, em sua maioria, curta duração e pequeno tamanho amostral. Dietas com redução de carboidratos, assim como dietas com baixo índice glicêmico e carga glicêmica têm sido o principal foco de estudo em mulheres com PCOS e, embora os resultados sejam controversos, estudos demonstram superioridade desses tipos de dieta em relação a uma dieta convencional na melhora do perfil antropométrico e da sensibilidade insulínica. Por outro lado, mudanças de estilo de vida podem não ser suficientes para promover uma redução de peso significativa e intervenções farmacêuticas podem ser necessárias. O orlistat é um fármaco usado no tratamento da obesidade que age através da inibição das lipases gástricas e pancreáticas e não tem efeitos adversos sistêmicos, sendo o único fármaco antiobesidade disponível em muitos países. Dessa forma, com o objetivo de avaliar os efeitos do orlistat nas variáveis clínicas relacionadas à perda de peso, assim como comparar esses efeitos com aqueles obtidos com o uso da metformina, em mulheres com PCOS, realizou-se uma revisão sistemática e meta-análise. Os resultados dessa revisão sistemática sugerem que o orlistat leva a uma redução significativa do peso/índice de massa corporal (IMC) em mulheres com PCOS. Além disso, os resultados da meta-análise evidenciaram que o orlistat e a metformina têm efeitos similares na redução de IMC, testosterona, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) e insulina em mulheres com PCOS com sobrepeso e obesidade. Outro fator a ser considerado é o aumento do risco cardiovascular associado à PCOS. Estudos demonstram que as alterações cardiovasculares pré-clínicas são mais frequentes nesta população do que em mulheres sem a síndrome de mesma idade. A variabilidade da frequência cardíaca (VFC) é a medida das variações cíclicas dos intervalos entre as batidas cardíacas (intervalo R-R), e reflete a função cardíaca autonômica. Alterações na VFC podem refletir doença cardiovascular subclínica. A redução do consumo de gordura saturada tem um importante papel na prevenção primária e secundária de doenças cardiovasculares. Dessa forma, realizou-se um estudo com objetivo de avaliar se o consumo de ácidos graxos saturados (SFA) está associado com VFC em mulheres com PCOS. Oitenta e quatro mulheres com PCOS foram incluídas no estudo. A análise da VFC foi realizada no repouso e após teste de stress mental. As participantes foram estratificadas de acordo com a mediana do consumo de SFA (8,5% do consumo energético total), avaliado por questionário de frequência alimentar. Os resultados desse estudo indicam que o menor consumo de SFA combinado com menor consumo de carne vermelha e maior consumo de frutas, vegetais e feijões está associado com melhor VFC em resposta ao stress e níveis circulantes mais baixos de testosterona em mulheres com PCOS. / Polycystic ovary syndrome (PCOS), the most common endocrinological disorder in women of reproductive age, is characterized by hyperandrogenism and chronic anovulation. Obesity or overweight affect most of patients with PCOS and may accentuate reproductive and metabolic issues. Thus, weight reduction through calorie restriction is extremely important in overweight/obese PCOS women. However, it remains unclear whether the diet composition per se may have significant effects on metabolic and hormonal issues of PCOS. A few randomized controlled trials (RCTs) evaluating the effect of different dietary interventions have been performed in PCOS women, and most studies have short-term and small sample size. Low-carbohydrate diets as well as diets with low glycemic index and glycemic load have been the main focus of studies in PCOS women, and although the results are controversial, studies demonstrated superiority of these diets in relation to a conventional diet in improving anthropometric profile and insulin sensitivity. On the other hand, lifestyle changes may not be sufficient to promote significant weight loss, and pharmaceutical interventions may be required. Orlistat is a drug for the treatment of obesity that acts by inhibiting gastric and pancreatic lipases. Orlistat does not have systemic adverse effects and it is currently the sole anti-obesity agent available in many countries. In this way, a systematic review and meta-analysis was performed. The aim was to assess the effects of orlistat on weight loss-associated clinical variables and to compare these effects to those obtained with metformin treatment in overweight/obese women with PCOS. The results of this systematic review indicate that orlistat leads to significant reduction in weight/body mass index (BMI) in PCOS. In addition, the results of meta-analysis indicate that orlistat and metformin have similar effects in reducing BMI, HOMA, testosterone and insulin in overweight/obese PCOS women. Another point to consider is the increased cardiovascular risk associated with PCOS. Studies have demonstrated that preclinical cardiovascular disorders are more frequent in PCOS than in women without the syndrome of same age. The heart rate variability (HRV) is a measure of the time variation between heart beats (R-R interval), and reflects autonomic cardiac function. Alterations in HRV may reflect subclinical cardiovascular disease. Reduction in saturated fat intake has an important role in primary and secondary of cardiovascular disease. Thus, we performed a study assessing whether dietary saturated fatty acids (SFA) intake is associated with stress-induced HRV in patients with PCOS. Eighty-four PCOS women were included in the study. The HRV analysis was performed at rest and after mental stress test. Participants were stratified by median SFA intake (8.5% of daily energy intake), assessed by food frequency questionnaire. The results indicate that lower SFA intake is associated with more favorable stress-related HRV and lower testosterone in women with PCOS.

INTRODUÇÃO. Mulheres pós-menopáusicas apresentam maior risco de desenvolvimento de doença arterial coronariana. Estudos observacionais demonstraram que a terapia de reposição hormonal produz efeitos benéficos no perfil lipídico e na modulação autonômica cardíaca. O aumento da variabilidade da freqüência cardíaca (VFC), até então atribuído à reposição hormonal, não foi testado em estudos randomizados, placebo-controlados, delineados para permitir a comparação entre as duas formas mais utilizadas de reposição hormonal. A VFC de 24 horas calculada pelo método não linear Mapa de Retorno Tridimensional permite avaliar tanto a modulação vagal como a simpática. OBJETIVOS Avaliar a modulação autonômica cardíaca de mulheres pósmenopáusicas através da análise da VFC no domínio do tempo e dos índices do Mapa de Retorno Tridimensional no ECG de 24 horas. Testar a hipótese de que a reposição hormonal contínua, seja com estradiol isolado (TRE), seja com estradiol associado à noretisterona (TRH), por um período de três meses, aumenta a VFC nessas mulheres. MÉTODOS Quarenta mulheres pós-menopáusicas (46 a 63 anos; média = 54,6 ± 4,2) foram randomizadas para um dos três tratamentos, de forma contínua: TRH, estrogenioterapia (TRE) ou placebo, por três meses consecutivos. Previamente, todas as mulheres foram submetidas a exames clínico, ginecológico e laboratorial (glicose, estradiol, HDL, LDL, triglicerídios; mamografia e ultrassonografia transvaginal). O ECG de 24 horas foi gravado em cada paciente, antes e após o tratamento, para calcular os índices da VFC. RESULTADOS Não houve diferença estatisticamente significativa entre os três grupos, após 3 meses de tratamento, nos índices da VFC e do Mapa de Retorno Tridimensional. A TRH diferiu da TRE apenas quanto ao perfil lipídico. A associação com a noretisterona provocou uma redução de 12,4 % no HDL (p = 0,008). CONCLUSÃO Em mulheres pós-menopáusicas, a terapia de reposição hormonal contínua com estradiol, ou com estradiol associado à noretisterona, por um período de 3 meses, não altera a modulação autonômica cardíaca avaliada pela VFC. / Background: Postmenopausal women are at greater risk of coronary heart disease. Observational studies have demonstrated that hormone replacement therapy (HRT) improves lipid profile and cardiac autonomic modulation. The cardioprotective effect attributed to HRT has not been tested in randomized, placebo-controlled trials to compare the two most frequently used regimens. This study evaluates cardiac autonomic modulation in postmenopausal women using time domain indices of heart rate variability (HRV) and indices derived from the three-dimensional return map, and investigates whether continuous HRT for three months, either with estradiol alone (ERT) or with estradiol and norethisterone (HRT), increases HRV in postmenopausal women. Methods: Forty postmenopausal women aged 46 to 63 years were consecutively and randomly assigned to one of three treatment groups: HRT, ERT, or placebo. For all women, clinical, gynecological and laboratory data (glucose, estradiol, HDL, LDL, triglycerides, mammography and transvaginal sonography) were collected. Patients underwent 24-h ECG before and after the treatment to evaluate HRV indices. Results: Time domain indices of HRV as well as indices derived from the threedimensional return map presented no significant changes after interventions. The only significant difference between HRT and ERT groups was in lipid profile. HDL cholesterol levels decreased 12.4% (p = 0.008) for women who used HRT. Conclusion: In postmenopausal women, continuous hormone replacement therapy with estradiol or estradiol with norethisterone for 3 months does not affect cardiac autonomic modulation evaluated by HRV.

Dépression et maladies cardiovasculaires sont liées mais la physiopathologie de cette association est mal connue. Les mécanismes de la variabilité de la fréquence cardiaque (VFC) et de la dysfonction endothéliale (DE) pourraient rendre compte de cette association mais leur implication demeure controversée et seuls certains symptômes de la dépression, l’anhédonie et l’hyporéactivité émotionnelle (HE), semblent leur être associés. En outre, certains obstacles méthodologiques ont, jusqu’à présent, limité l’étude de la réactivité cardiaque et cérébrovasculaire dans l’anhédonie et l’HE. Dans ce travail, nous établissons par deux protocoles expérimentaux distincts 1) qu’une nouvelle technique d'échographie cérébrale (Tissue Pulsatility Imaging - TPI) permet de mettre en évidence des modifications de la réactivité cérébrovasculaire dans la dépression et 2) qu’il est possible d’associer la VFC et l’anticipation émotionnelle, processus clef dans l’HE. Nos résultats suggèrent que l’anhédonie et l’HE de la dépression peuvent être caractérisées par un trouble de l’anticipation émotionnelle, lui-même associé à une VFC diminuée et une DE cérébrale. / Depression and cardiovascular diseases are related but the physiopathology of this association is unclear. Heart rate variability (HRV) and endothelial dysfunction (ED) could account for this association but their involvement remains controversial and only some symptoms of depression, anhedonia and emotional hyporeactivity (EH), seem to be involved. In addition, some methodological obstacles have so far limited the assessment of cardiac and cerebrovascular reactivity in anhedonia and EH. In this work, we establish using two distinct protocols 1) that cerebrovascular changes in depression can be assessed using a new ultrasound technique (Tissue Pulsatility Imaging - TPI) and 2) that HRV and emotional anticipation, as a key process in EH, are associated. Our results suggest that anhedonia and EH in depression can be characterized by a blunted emotional anticipation which is associated with a decreased HRV and a cerebral ED.

pós-infarto agudo do miocárdio (IAM) têm mostrado baixo valor preditivo positivo quando estudados isoladamente. A possibilidade da Eletrocardiografia Dinâmica de 24 horas (ECGD) fornecer dados referentes a isquemia silenciosa (IS), arritmias ventriculares e modulação autonômica do coração pelo estudo da variabilidade da freqüência cardíaca (VFC), levou o autor a empregar este método em pacientes acometidos de IAM com o objetivo de avaliar se estas três variáveis estariam relacionadas a presença de eventos desfavoráveis em evolução a médio prazo. Material e Métodos – Foram selecionados 91 pacientes acometidos de um primeiro IAM não-complicado e realizados exames de ECGD de 24 h por dois dias consecutivos, antes da alta hospitalar. Os parâmetros pesquisados nos exames foram: isquemia silenciosa, identificação e quantificação de arritmias ventriculares e determinação dos índices de VFC pelos métodos do domínio do tempo e do mapa de retorno tridimensional. Foram considerados como desfechos: re-infarto, angina instável, taquicardia ventricular sustentada e morte. Resultados – No seguimento médio de 27,7 meses (DP=15,45), 23 (25%) dos pacientes apresentaram eventos, sendo nove fatais. Os eventos foram mais freqüentes entre os pacientes que apresentaram extra-sístoles ventriculares ≥10/hora (p=0,01) e também naqueles com IS (p=0,02). Em modelo de análise multifatorial, a presença de dislipidemia elevou o valor preditivo positivo dessas variáveis. Nenhum dos índices de VFC esteve significativamente relacionado ao surgimento de eventos. Conclusões – Em pacientes pós-IAM de baixo risco, a presença de arritmias ventriculares freqüentes ou de isquemia silenciosa está relacionada a um prognóstico desfavorável. O estudo da VFC não mostrou utilidade na estratificação de risco destes pacientes. / Introduction and objective – The noninvasive methods used in post-acute myocardial infarction (AMI) risk stratification have been shown to have a low predictive value when studied in isolation. The possibility that ambulatory electrocardiographic monitoring (AEM) may provide data on silent ischemia (SI), ventricular arrhythmias (VA) and autonomic modulation of the heart through the study of heart rate variability (HRV) led the present author to use this method in AMI patients with the aim of assessing whether these three variables could be related to the presence of unfavorable events in the medium term follow-up. Methods – Ninety-one patients with a first, uncomplicated AMI were selected and submitted to AEM for two consecutive days prior to discharge from the hospital. The parameters studied in the examination were as follows: presence of SI, identification and quantification of VA and determination of the HRV indices by the time domain and three-dimensional return map methods. The following were regarded as outcomes: new AMI, unstable angina, sustained ventricular tachycardia and death. Results – In the mean follow-up of 27.7 months (SD=15.45), 23 (25%) of the patients presented events, nine of which were fatal. Events occurred most frequently in the patients who presented ventricular premature contractions >= (p=0.01) and also in those with SI (p=0.04). In the multifactorial analysis the presence of dislipidemia raised the positive predictive value of these variables. None of the HRV indices was significantly correlated with the occurrence of events. Conclusions – In low-risk post-AMI patients the presence of frequent ventricular arrhythmias or silent ischemia is associated with an unfavorable prognosis. The study of HRV was not shown to be useful in the risk stratification of these patients.

Principais causas de morbi-mortalidade mundial, as doenças cardiovasculares têm o inicio de sua fisiopatologia em idade precoce e, maior predisposição para seu desenvolvimento na vigência das manifestações clinicas da síndrome metabólica como intolerância à glicose, resistência à insulina, obesidade, dislipidemia e hipertensão. Este trabalho foi conduzido com o objetivo de avaliar o efeito da dieta de cafeteria em ratos, sobre variáveis morfométricas, metabólicas e hemodinâmicas associadas às alterações no controle autonômico. Foram utilizados 32 animais, distribuídos em 2 grupos, com delineamento experimental que compreendeu o tratamento com a dieta (24 semanas) e a coleta dos dados. O modelo experimental usado permitiu observar presença de maior adiposidade abdominal, triacilglicerídeos aumentados caracterizando dislipidemia, aumento da glicemia de jejum e redução da resposta de decaimento da glicose, mostrando aumento da resistência à ação periférica da insulina. Observaram-se também HDL-c mais baixo, similaridade nos valores de pressão arterial e frequência cardíaca e alterações importantes no controle autonômico como, redução da variabilidade da frequência cardíaca, modificação no balanço simpato-vagal em favor da modulação simpática sobre a vagal, e correlação direta com os níveis de triacilglicerídeos. Em conjunto, esses achados demonstraram que a dieta de cafeteria induziu alterações de peso corporal e dos depósitos de gordura visceral (TAB) e muscular (TAM) em ratos normotensos acompanhadas de alterações precoces do sistema nervoso autônomo, identificando-se um papel relevante e precoce desse sistema na fisiopatologia da doença cardiovascular associada à alterações metabólicas. / Cardiovascular disease that has been the leading causes of morbidity and mortality in the global world has the beginning of its pathophysiology in precocious age and, greater predisposition for its development in the validity of the clinical manifestations of the metabolic syndrome as to the glucose intolerance, insulin resistance, dyslipidemia, obesity and hypertension. This study was lead with the objective to evaluate the effect of the cafeteria diet in rats, on morphometric, metabolic and hemodynamic parameters associated with the alterations of autonomic control. Rats (n=32) were distributed in 2 groups, one under cafeteria diet and the other on standard food (24 weeks). At the end of the experimental period data were collected. The treated animals presented bigger abdominal adiposity, increased tryacilglicerides characterizing dyslipidemia and increased of the fasting glycemia. The rate of glucose decay was also reduced showing increased peripheral insulin resistance. It was also observed lower HDL-c levels while values of arterial pressure and heart rate did not change. However significant changes in autonomic control of circulation as reduction of heart rate variability as well as increased sympathovagal balance were also observed. These changes were positively correlated with tryacilglicerides levels indicating that cafeteria diet induced not only alterations of body weight but also of the adipose deposits characterizing visceral (WAT) and muscular fat (BAT). Finally the results suggest that autonomic changes may be the early marker of cardiovascular impairment associated with metabolic illness.