Brasilia Heart Study
Brasilia Heart Study
BHS is a cohort study of consecutive myocardial infarction (MI) patients admitted within the
 first 24 hours of symptoms and has been ongoing since May of 2006. The purpose of this study
 is to assess for possible markers for increased risk after MI.
In-hospital assessment Patients admitted into the study are being submitted to in-hospital
 evaluation and blood samples collection upon admission (D1) and at the fifth day (D5) of MI.
 Patients are treated according to current US guidelines for STEMI and assistant physicians
 are responsible for all medical decisions without any influence of the investigators. Plasma
 and DNA samples are aliquoted for storage at -80 °C. DNA is extracted using QIAamp DNA Blood
 Mini Kit (Quiagen, GmBH Hilden).

 Follow-up After hospital discharge, patients are referred for a guideline-driven medical
 therapy at the study outpatient clinic and were reevaluated during visits every three months.
 Lifestyle counseling for diet, smoking cessation, regular physical activity and weight loss
 was oriented for all patients. Follow-up prescriptions include simvastatin with the addition
 of ezetimibe when necessary (LDL-C goal of 70 mg/dL), captopril or losartan for hypertension
 or reduced ejection fraction (<40%); hypoglycemic treatment to achieve a HbA1c goal ≤7% or 8%
 for individuals aged of 60 years or older; aspirin 100 mg/day and clopidogrel 75 mg/day; and
 anti-ischemic therapy as required (propranolol and isosorbide dinitrate, alone or in
 combination).The physicians involved in the clinical follow-up were blind to all the analysis
 performed in the study.

 Biochemical analysis Blood plasma samples are assessed for the following: blood glucose
 (Glucose GOD-PAP, Roche Diagnostics, Mannheim, Germany), total cholesterol (CHOD-PAP, Roche
 Diagnostics, Mannheim, Germany), triglycerides (TG) (GPO-PAP, Roche Diagnostics, Mannheim,
 Germany), high-density lipoprotein cholesterol (HDL-C) (HDL cholesterol without sample
 pre-treatment, Roche Diagnostics, Mannheim, Germany), C-reactive protein (CRP)
 (high-sensitivity CRP, Cardiophase, Dade Behring, Marburg, Germany), 8-isoprostane (EIA kit,
 Cayman Chemical Company, Ann Arbor, MI, USA), interleukin-2 (IL-2) (Fluorokine® MAP Human
 IL-2 Kit, R&D Systems, Minneapolis, MN, USA), tumor necrosis factor type α (TNF-α)
 (Fluorokine MAP Human TNF-α Kit, R&D Systems), and HbA1c (Variant II, Bio-Rad Laboratories,
 Hercules, CA, USA). Low-density lipoprotein cholesterol (LDL-C) is calculated by the
 Friedewald formula. Plasma insulin and C-peptide concentrations were determined by
 electrochemiluminescence (Roche Diagnostics, Mannheim, USA) and by imunoquimioluminescence
 (Immulite 2000, Diagnostic Products Corporation, Los Angeles, CA, USA), respectively. The
 Homeostasis Model Assessment version 2 (HOMA2) is used to estimate β-cell function (HOMA2%β)
 and insulin sensitivity (HOMA2%S). We use fasting plasma insulin levels to compute HOMA2%S,
 and plasma C-peptide to compute HOMA2%β. To evaluate nitric oxide (NO) production, the plasma
 levels of nitrite and nitrate (NOx) are measured by an NO chemiluminescence analyzer (model
 NOA, Sievers Instruments, Boulder, CO) after reduction with acidic vanadium (III) chloride.

 Brachial Artery Reactivity Brachial artery reactivity is assessed systematically 30 days
 (D30) after STEMI to estimate the decline in endothelial function that persists after the
 acute phase stress. At the time of the measurement, all patients are on the abovementioned
 secondary prevention protocol for at least 3 weeks, including simvastatin at the starting
 dose of 20 mg/day. Brachial artery measurements are performed after over-night fasting and
 any vasoactive medications were withdrawn 24 hours before assessment. After 10 minutes of
 rest in a quiet room with the temperature controlled around 22°C, the brachial artery is
 located above the elbow, and a longitudinal image of 6 to 8 cm was taken as the resting scan.
 A blood pressure cuff is placed on the forearm and inflated to 50 mm Hg above the systolic
 blood pressure for 5 min. The cuff is deflated, and the flow-mediated dilation (FMD) scan is
 obtained for two minutes. Ten minutes later, baseline measurements were repeated before and
 after five mg of isosorbide dinitrate. The percentage change in diameter for FMD and
 nitrate-mediated dilation was calculated in relation to the respective baseline scans.
 Brachial artery reactivity is analyzed by the same experienced physician who is blinded to
 the patients' data. The intra-observer reproducibility has been 95%.

 Echocardiography All echocardiographic measurements are performed according to American
 Society of Echocardiography and European Association of Echocardiography recommendations. All
 subjects undergo complete 2D ECHO using standard ultrasound equipment (iE 33 system, 2-5MHz
 sector transducer; Philips Medical Systems, Andover, MA), at D30. Images are acquired with
 simultaneous electrocardiographic (ECG) monitoring. Images are stored in DICOM (Digital
 Imaging and Communication in Medicine) for further measurements "offline". Quantifications
 are performed by averaging of three measurements. For ventricular remodeling evaluation the
 following measures are performed: LV end-diastolic diameter (LVEDD), LV end-systolic diameter
 (LVESD), LV septum diastolic thickness (SD) and posterior wall diastolic thickness (PD). Left
 ventricular mass (LVM) is calculated formula Devereux formula and indexed to body surface
 area (LVMI). LV wall relative thickness (ER) is calculated using the formula (2 x PPD) /
 LVEDD). Left ventricle end diastolic volume (LVEDV) and systolic volume (LVESV) and LE
 ejection fraction (LVEF) are calculated using Simpson's method.

 Carotid ultrasound The intima-media thickness (IMT) and the presence of carotid plaques are
 assessed using high-resolution ultrasound (Philips, Model IE 33, 3-9 MHz linear transducer,
 Philips Medical Systems, Andover, Massachusetts, USA) according to the protocols of the
 American Society of Echocardiography. The measurements are performed bilaterally in the
 posterior wall of the common carotid bulb and the internal carotid artery through an
 automatic edge detection program (QLAB version 6.0 software). The carotid plaque is defined
 as the presence of focal thickening of at least 50% higher than the adjacent areas or as a
 focal region with IMT ≥ 1.5 mm.

 Coronary angiography Coronary angiography is systematically performed in all enrolled
 patients according to standard techniques. Lumen narrowing >70% is considered as a
 significant stenosis. All coronary angiographies are classified by the Gensini score method.
 Efficacy of reperfusion is estimated by TIMI flow grade and myocardial blush grade (MBG) in
 the first angiogram after thrombolysis or percutaneous coronary intervention. All
 angiographic data are obtained by consensus of two experienced interventional cardiologists
 who are blinded to the investigation data.

 Cardiac Magnetic Resonance Imaging (CMRI) CMRI are performed at D30 and all patients are
 studied in supine position in a 1.5T scanner (Signa CV/i, General Electric Healthcare,
 Milwaukee, Wisconsin) with an 8-element cardiac phased-array surface receiver coil. All CMRI
 are acquired during breath-holds with ECG gating. LV size and function imaged by cine
 steady-state free-precession (typical TR 3.4 ms; TE 1.2 ms; temporal resolution 40-50 ms;
 in-plane spatial resolution 1.5-1.8 mm and 1.8-2.1 mm, depending on the field of view) are
 performed in multiple parallel short-axis planes (8 mm thick without spacing) and three
 radial long-axis planes. Using a previously described sequence[9] (repetition time, 4.8 ms;
 echo time, 1.3ms; in-plane spatial resolution between 1.5 X 2.0 mm and 1.9 X 2.0 mm), late
 gadolinium enhancement images (LGE) at matching cine-image slice locations are acquired 10 to
 15 minutes after intravenous gadolinium-DTPA administration (0.15 to 0.20 mmol/kg; Magnevist,
 Berlex Pharmaceuticals, Wayne, NJ).

 Statistical methods Categorical variables are compared by use of the chi-square test.
 Analysis of covariance (ANCOVA) is used to assess the association between the potential
 markers. Adjustments for baseline levels, age and gender are performed in all comparisons.
 Assumptions of the ANCOVA models (linearity, normality of distribution and equal variance)
 are checked using histograms, normal probability plots and residual scatter plots. Estimates
 of the cumulative event rate are calculated by the Kaplan-Meier method and the comparison
 between curves is made by Log rank test. For Cox multivariable regression models, the
 proportional hazard assumption is tested by adding time-dependent interaction variables that
 are confirmed to be valid in each of the models. A two-sided p-value of 0.05 was considered
 statistically significant.
Inclusion Criteria:

 -  less than 24 hours after the onset of MI symptoms

 -  ST-segment elevation of a least 1 mm (frontal plane) or 2 mm (horizontal plane) in two
 contiguous leads

 -  myocardial necrosis, as evidenced by increase to at least one value above the 99th
 percentile above the reference limit of CK-MB (25 U/L) and troponin I (0·04 ng/mL)
 followed by a decline of both

 Exclusion Criteria:

 -  Cognitive impairment

 -  Patients unable to attend follow-up

 -  Concomitant diseases with short-term survival expectancy, i.e. cancer, severe COPD