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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The concept of atherosclerosis began as a local issue with the involvement of vessels of the heart&#44; causing myocardial necrosis&#47;ischemia&#59; vessels of the brain&#44; causing cerebrovascular accidents and peripheral vessels&#44; causing intermittent claudication and other vascular limb issues&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">According to this concept&#44; the significance of atherosclerotic disease would depend on the importance of the affected vessel&#40;s&#41;&#46; In the case of coronary disease&#44; greater importance would be attributed to the left main or left anterior descending artery &#40;depending&#44; of course&#44; on the degree of obstruction&#41; and disease of the right coronary artery would be considered less serious&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Atherosclerosis is now identified as a systemic disease with conventional and emerging new risk factors&#44; some of which are still unknown and may potentially affect all vascular regions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The local concept maintains its importance for vascular intervention&#44; but in terms of prevention&#44; as well as the understanding of the disease&#44; the &#8220;systemic&#8221; approach to atherosclerosis seems to be the most consensual&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">LDL cholesterol is the cornerstone of atherosclerosis&#46; Today we have highly effective tools for lowering LDL and for reducing lipid atherosclerotic complications&#44; however&#44; even with a significant lowering of LDL&#44; events still occur&#46; Inflammation can explain some of this residual risk&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inflammation and inflammatory markers have long been associated with atherosclerosis and its complications&#46; The more consensual inflammatory markers are C-reactive protein&#44; interleukins&#44; blood sedimentation rate and leucocyte cell count&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; several inflammatory diseases&#44; especially periodontitis&#44; have been associated with atherosclerosis in multiple epidemiological studies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Experimental studies in rats confirm that periodontitis induces systemic inflammation and exacerbates atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In these circumstances&#44; periodontitis represents a cause and may be a consequence of systemic inflammation&#44; which has been linked to atherosclerosis in epidemiological and experimental studies&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Epicardial fat tissue &#40;EFT&#41; is the visceral fat depot of the heart&#46; It can be assessed either by standard echocardiography&#44; with a single thickness location&#44; or by computed tomography&#44; resulting in an assessment of total EFT volume&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">EFT is correlated with waist circumference and abdominal fat and is a marker of visceral fat&#46; It has been associated with several clinical conditions&#44; especially obesity&#44; metabolic syndrome&#44; diabetes&#44; atherosclerosis and inflammation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The extent of the role of EFT remains unclear&#44; however it has mechanical&#44; thermogenic&#44; metabolic and endocrine functions&#46; EFT can be a therapeutic target as it can be reduced with drugs&#44; in particular with metformin&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">With the increasing prevalence of obesity and diabetes in developed countries&#44; EFT emerges as an easy way to assess visceral adiposity and may also be a target for its treatment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">EFT has been associated with inflammation and atherosclerosis in several inflammatory diseases&#44; such as lichen planus and psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In the current edition of the Journal&#44; Erdal et al&#46; present a paper on the assessment by echocardiography of EFT in patients with severe periodontitis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> They studied EFT assessed by echocardiography in 33 patients with grade 3 periodontitis and compared the results with those of 33 periodontally healthy controls&#46; The groups were similar in age&#44; gender and conventional echocardiographic measurements and presented no significant differences in terms of diabetes&#44; hypertension&#44; smoking habits and dyslipidemia&#46; However&#44; EFF was significantly higher in patients with periodontitis&#46; They found a significant correlation between EFT and clinical parameters of periodontitis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">This study presents some points of interest&#44; as well as some limitations&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As points of interest&#44; the authors focused on two important and frequently forgotten markers of atherosclerosis&#58; periodontitis and EFT&#46; They proved EFT can be different in patients with the same cardiovascular risk profile&#44; when assessed according to conventional risk factors&#44; and&#44; in these circumstances&#44; periodontitis&#47;inflammation can be a differentiating factor&#46; This difference may weigh in on the decision over whether or not to begin therapy in patients with intermediate risk level&#44; assessed according to conventional risk factor scores&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The main limitations of the study are the small population size and the use of echocardiography&#44; which provides a limited assessment of EFT&#46; Moreover&#44; they assume that patients with high EFT will have a higher risk of developing atherosclerosis and its complications&#44; such as coronary artery disease&#44; but this concept is not supported&#44; and could not be proven in the present case-control study&#46; A case-control study can evidence an association of factors&#44; but not causality&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; this interesting paper highlights the importance of periodontitis and EFT in cardiovascular risk&#46; They conclude that both markers are linked and assume they represent a high atherosclerotic risk&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">More importantly&#44; we need to define whether we are facing risk markers or risk factors&#44; meaning whether these clinical markers can be reversed not only as parameters&#44; but especially in terms of reducing the cardiovascular risk in primary and secondary prevention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A long term randomized prospective study&#44; with an adequate sample size&#44; can provide answers to important question&#46; Until we have these results&#44; periodontitis and EFT are important markers of atherosclerosis&#46; In addition&#44; in terms of periodontitis&#44; oral health must be maintained&#44; not only for general health and but also possibly for vascular health&#46; EFT associated with obesity and other metabolic diseases must be treated according to current guidelines&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Periodontitis is more than a local disease. Epicardial fat tissue amounts to more than an occasional finding
A periodontite é mais do que uma doença localizada. O tecido adiposo epicárdico representa mais do que um achado ocasional
Roberto Palma Reisa,b
a Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Portugal
b Unidade de Cardiologia do Hospital Pulido Valente, Serviço de Cardiologia do CHLN, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The concept of atherosclerosis began as a local issue with the involvement of vessels of the heart&#44; causing myocardial necrosis&#47;ischemia&#59; vessels of the brain&#44; causing cerebrovascular accidents and peripheral vessels&#44; causing intermittent claudication and other vascular limb issues&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">According to this concept&#44; the significance of atherosclerotic disease would depend on the importance of the affected vessel&#40;s&#41;&#46; In the case of coronary disease&#44; greater importance would be attributed to the left main or left anterior descending artery &#40;depending&#44; of course&#44; on the degree of obstruction&#41; and disease of the right coronary artery would be considered less serious&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Atherosclerosis is now identified as a systemic disease with conventional and emerging new risk factors&#44; some of which are still unknown and may potentially affect all vascular regions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The local concept maintains its importance for vascular intervention&#44; but in terms of prevention&#44; as well as the understanding of the disease&#44; the &#8220;systemic&#8221; approach to atherosclerosis seems to be the most consensual&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">LDL cholesterol is the cornerstone of atherosclerosis&#46; Today we have highly effective tools for lowering LDL and for reducing lipid atherosclerotic complications&#44; however&#44; even with a significant lowering of LDL&#44; events still occur&#46; Inflammation can explain some of this residual risk&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inflammation and inflammatory markers have long been associated with atherosclerosis and its complications&#46; The more consensual inflammatory markers are C-reactive protein&#44; interleukins&#44; blood sedimentation rate and leucocyte cell count&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; several inflammatory diseases&#44; especially periodontitis&#44; have been associated with atherosclerosis in multiple epidemiological studies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Experimental studies in rats confirm that periodontitis induces systemic inflammation and exacerbates atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In these circumstances&#44; periodontitis represents a cause and may be a consequence of systemic inflammation&#44; which has been linked to atherosclerosis in epidemiological and experimental studies&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Epicardial fat tissue &#40;EFT&#41; is the visceral fat depot of the heart&#46; It can be assessed either by standard echocardiography&#44; with a single thickness location&#44; or by computed tomography&#44; resulting in an assessment of total EFT volume&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">EFT is correlated with waist circumference and abdominal fat and is a marker of visceral fat&#46; It has been associated with several clinical conditions&#44; especially obesity&#44; metabolic syndrome&#44; diabetes&#44; atherosclerosis and inflammation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The extent of the role of EFT remains unclear&#44; however it has mechanical&#44; thermogenic&#44; metabolic and endocrine functions&#46; EFT can be a therapeutic target as it can be reduced with drugs&#44; in particular with metformin&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">With the increasing prevalence of obesity and diabetes in developed countries&#44; EFT emerges as an easy way to assess visceral adiposity and may also be a target for its treatment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">EFT has been associated with inflammation and atherosclerosis in several inflammatory diseases&#44; such as lichen planus and psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In the current edition of the Journal&#44; Erdal et al&#46; present a paper on the assessment by echocardiography of EFT in patients with severe periodontitis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> They studied EFT assessed by echocardiography in 33 patients with grade 3 periodontitis and compared the results with those of 33 periodontally healthy controls&#46; The groups were similar in age&#44; gender and conventional echocardiographic measurements and presented no significant differences in terms of diabetes&#44; hypertension&#44; smoking habits and dyslipidemia&#46; However&#44; EFF was significantly higher in patients with periodontitis&#46; They found a significant correlation between EFT and clinical parameters of periodontitis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">This study presents some points of interest&#44; as well as some limitations&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As points of interest&#44; the authors focused on two important and frequently forgotten markers of atherosclerosis&#58; periodontitis and EFT&#46; They proved EFT can be different in patients with the same cardiovascular risk profile&#44; when assessed according to conventional risk factors&#44; and&#44; in these circumstances&#44; periodontitis&#47;inflammation can be a differentiating factor&#46; This difference may weigh in on the decision over whether or not to begin therapy in patients with intermediate risk level&#44; assessed according to conventional risk factor scores&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The main limitations of the study are the small population size and the use of echocardiography&#44; which provides a limited assessment of EFT&#46; Moreover&#44; they assume that patients with high EFT will have a higher risk of developing atherosclerosis and its complications&#44; such as coronary artery disease&#44; but this concept is not supported&#44; and could not be proven in the present case-control study&#46; A case-control study can evidence an association of factors&#44; but not causality&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; this interesting paper highlights the importance of periodontitis and EFT in cardiovascular risk&#46; They conclude that both markers are linked and assume they represent a high atherosclerotic risk&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">More importantly&#44; we need to define whether we are facing risk markers or risk factors&#44; meaning whether these clinical markers can be reversed not only as parameters&#44; but especially in terms of reducing the cardiovascular risk in primary and secondary prevention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A long term randomized prospective study&#44; with an adequate sample size&#44; can provide answers to important question&#46; Until we have these results&#44; periodontitis and EFT are important markers of atherosclerosis&#46; In addition&#44; in terms of periodontitis&#44; oral health must be maintained&#44; not only for general health and but also possibly for vascular health&#46; EFT associated with obesity and other metabolic diseases must be treated according to current guidelines&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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