International Journal of Cardiology 179 (2015) 9–10

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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Letter to the Editor

Congenital heart disease in Southern Brazil: Potential impact and prevention Juliane Nascimento da Silva a, Patrícia Trevisan a, Victória Bernardes Guimarães b, Tatiana Diehl Zen a, Ernani Bohrer da Rosa c, Daniélle Bernardi Silveira a, Marileila Varella-Garcia d, Giorgio Adriano Paskulin a,e, Rafael Fabiano Machado Rosa a,e,f, Paulo Ricardo Gazzola Zen a,e,⁎ a

Graduate Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), RS, Brazil Graduation in Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), RS, Brazil c Graduation in Nursing, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), RS, Brazil d School of Medicine, Division of Medical Oncology, University of Colorado Denver, CO, USA e Clinical Genetics, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) and Complexo Hospitalar Santa Casa de Porto Alegre (CHSCPA), RS, Brazil f Clinical Genetics, Hospital Materno Infantil Presidente Vargas (HMIPV), RS, Brazil b

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Article history: Received 18 October 2014 Accepted 20 October 2014 Available online xxxx Keywords: Congenital heart defects Karyotype Pregnancy Drugs Teratogens Prevention

Congenital heart defects (CHDs) represent the most frequently observed malformation at birth and are the leading causes of death from congenital defects [1]. This condition represents an important cause of admissions and mortality of patients treated in pediatric intensive care units [2]. CHDs are the main cause of death in the first year of life, and the more severe forms correspond to about 20% of neonatal deaths [1, 3]. Thus, CHDs still represent a greater public health problem not only in Brazil but also worldwide. Despite the frequency and relevance of CHDs, its etiology is still poorly understood [4]. However, gestational expositions to teratogenic substances that affect the development of fetal heart represent a significant known cause [5]. Thus, the aim of this study was to evaluate the potential impact of the use of medicines and abuse substances during gestation of women with children with CHDs in Southern Brazil. This study was approved by the Ethics Committees in Research of the Hospital and the University. ⁎ Corresponding author at: Clinical Genetics — UFCSPA/CHSCPA, Rua Sarmento Leite, 245/403, CEP: 90050-170 Porto Alegre, RS, Brazil. E-mail address: [email protected] (P.R.G. Zen).

http://dx.doi.org/10.1016/j.ijcard.2014.10.052 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

For our analysis, we evaluated the same patients of the study developed by Zen et al. [6], which analyzed the gestational and family risk factors for CHDs in a sample of 302 patients hospitalized for the first time in a cardiac pediatric intensive care unit from Southern Brazil. They compare the data with 303 controls (patients without clinical evidence of CHDs hospitalized in the same intensive care unit). Patients with chromosomal abnormalities detected through high-resolution karyotyping were excluded. Thus, the final sample consisted of 250 patients with CHDs. They verified after analysis using logistic regression that the use of anti-hypertensive medication (n = 18), antibiotics (n = 32) and alcohol (n = 20) in the first trimester of pregnancy were statically associated to CHD [6]. Seven patients presented more than one exposition. Thus, we would verify that in 63 cases from the total sample (20.9%) of the CHDs would be related to the usage of these medicines and substances, and thus could be potentially prevented if the exposure had not occurred. Interestingly, this ratio is much higher than that described in the literature of etiological association between teratogen exposition during pregnancy and occurrence of CHDs (this correspond to around 2%) [7]. We believe that this high frequency may be related to certain factors, such as self-medication and the easy obtainment of nonprescription drugs, which are common in Brazil. This result also helps to highlight the impact of the use of teratogenic agents during pregnancy over the etiology of CHDs. The frequency described in literature of CHDs considered severe such as those of our sample is 3–4 cases per 1000 live births [6,8]. If we applied this frequency to Rio Grande do Sul in 2005, when according to the Information Service of Live Births (SINASC) there were 147,199 births in the state, we would estimate that it may have occurred at the birth of about 515 patients with CHDs of this type. If the values found in our study reflect this state's population, we would see that, if the usage of medicines and abuse substances were avoided, this action could potentially prevent the birth of 108 children with CHDs. We believe that this value would present important implications, not only on the costs and demands involved with public health but also on emotional exhaustion of the involved health teams and families. In our state, the majority of pediatric intensive care units is overloaded and has no professionals and equipment for the differential diagnosis of CHDs or

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J.N. da Silva et al. / International Journal of Cardiology 179 (2015) 9–10

even conditions for the surgical treatment of patients with CHD [7]. Furthermore, according to the data of 2002, the deficit of heart surgery for CHDs in Brazil is around 65% [9]. The frequency and potential impact associated to alcohol usage is noteworthy. Several studies have described a wide range of teratogenic effects associated to alcohol consumption during pregnancy, including the occurrence of CHDs [1]. Some authors have also emphasized the impact of prevention of alcohol consumption during pregnancy in the occurrence of mental retardation [10]. We believe, based on these data, that this could also be potentially extended to CHDs. We believe that education programs for both patients and healthcare professionals (including physicians) would be important in order to optimize the usage of medicines during pregnancy and raise awareness about the potential risks associated to the exposure to them and to different abuse substances. All these different actions could help in the prevention of CHDs, a condition considered a true public health problem not only in our country but also worldwide. Financial supports None. Conflict of interests None.

References [1] K.J. Jenkins, A. Correa, J.A. Feinstein, et al., Noninherited risk factors and congenital cardiovascular defects: current knowledge, Circulation 115 (2007) 2995–3014. [2] D. Kapil, A. Bagga, The profile and outcome of patients admitted to a pediatric intensive care unit, Indian J. Pediatr. 60 (1993) 5–10. [3] G. Acharya, V. Sitras, J.M. Maltau, et al., Major congenital heart disease in Northern Norway: shortcomings of pre-and postnatal diagnosis, Acta Obstet. Gynecol. Scand. 83 (2004) 1124–1129. [4] J.A. Harris, C. Francannet, P. Pradat, et al., The epidemiology of cardiovascular defects, part 2: a study based on data from three large registries of congenital malformations, Pediatr. Cardiol. 24 (2003) 222–235. [5] R. Kučienė, V. Dulskienė, Selected environmental risk factors and congenital heart defects, Medicina (Kaunas) 44 (2008) 827–832. [6] T.D. Zen, R.F. Rosa, P.R. Zen, et al., Gestational and family risk factors for carriers of congenital heart defects in Southern Brazil, Pediatr. Int. 53 (2011) 551–557. [7] L.L. Hagemann, P. Zielinsky, Rastreamento populacional de anormalidades cardíacas fetais por ecocardiografia pré-natal em gestações de baixo risco no município de Porto Alegre, Arq. Bras. Cardiol. 82 (2004) 313–319. [8] A.C. Pereira, R.F.R. Corrêa, G.F. Mota, et al., High specificity PCR screening for 22q11.2 microdeletion in three different ethnic groups, Braz. J. Med. Biol. Res. 36 (2003) 1359–1365. [9] V.C. Pinto Jr., C.V. Daher, F.S. Sallum, et al., Situação das cirurgias cardíacas congênitas no Brasil, Braz. J. Cardiovasc. Surg. 19 (2004) 3–6. [10] C. Lupton, L. Burd, R. Harwood, Cost of fetal alcohol spectrum disorders, Am. J. Med. Genet. C 127C (2004) 42–50.

Congenital heart disease in Southern Brazil: potential impact and prevention.

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