2002;78(4)

Correlação Anatomoclínica

Caso 2/2002 – Homem de 60 anos, normotenso, apresentando confusão mental, dor torácica e alargamento de mediastino

Otavio Martucci et al. Gustavo Loureiro Carlos Osvaldo Teixeira Maria Aparecida Barone Teixeira

Correlação Anatomoclínica

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Original Article

Acute Myocardial Infarction: The First Manifestation of Ischemic Heart Disease and Relation to Risk Factors

Waldomiro Carlos Manfroi et al. Carolina Peukert Clarissa Bacha Berti Clarissa Noer … Danielle de Ávila Gutierres Felipe Theodoro Bezerra Gaspar Carvalho da Silva

OBJECTIVE: To assess the association between cardiovascular risk factors and acute myocardial infarction as the first manifestation of ischemic heart disease, correlating them with coronary angiographic findings. METHODS: We carried out a cross-sectional study of 104 patients with previous acute myocardial infarction, who were divided into 2 groups according to the presence or absence of angina prior to acute myocardial infarction. We assessed the presence of angina preceding acute myocardial infarction and risk factors, such as age >55 years, male sex, smoking, systemic arterial hypertension, lipid profile, diabetes mellitus, obesity, sedentary lifestyle, and familial history of ischemic heart disease. On coronary angiography, the severity of coronary heart disease and presence of left ventricular hypertrophy were assessed. RESULTS: Of the 104 patients studied, 72.1% were males, 90.4% were white, 73.1% were older than 55 years, and 53.8% were hypertensive. Acute myocardial infarction was the first manifestation of ischemic heart disease in 49% of the patients. The associated risk factors were systemic arterial hypertension (RR=0.19; 95% CI=0.06-0.59; P=0.04) and left ventricular hypertrophy (RR=0.27; 95% CI=0,.8-0.88; P=0.03). The remaining risk factors were not statistically significant. CONCLUSION: Prevalence of acute myocardial infarction as the first manifestation of ischemic heart disease is high, approximately 50%. Hypertensive individuals more frequently have symptoms preceding acute myocardial infarction, probably due to ventricular hypertrophy associated with high blood pressure levels.

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Original Article

Pharmacological Therapy for Myocardial Infarction in the Elderly: An 8-year Analysis

Márcia Regina Pinho Makdisse et al. Andrea de M. Matsushita Iran Gonçalves Júnior Odete Miranda … Ana Cristina Gomes Monica M. Cartocci Silvia Covre Antonio Carlos de Camargo Carvalho

OBJECTIVE:To assess the changes in the medicamentous treatment of elderly patients hospitalized with acute myocardial infarction occurring over an 8-year period. METHODS:We retrospectively analyzed 379 patients above the age of 65 years with acute myocardial infarction who were admitted to the coronary unit of a university-affiliated hospital from 1990 to 1997. The patients were divided into 2 groups, according to the period of time of hospital admission as follows: group 1 – from 1990 to 1993; and group 2 – from 1994 to 1997. RESULTS:The use of beta-blockers (40.8%chi 75.2%, p<0.0001) and angiotensin-converting enzyme inhibitors (42% chi59.5%, p=0.001) was significantly greater in group 2, while the use of calcium antagonists (42% chi 18.5%, p<0.0001) and general antiarrhythmic drugs (19.1% chi 10.8%, p=0.03) was significantly lower. No significant difference was observed in regard to the use of acetylsalicylic acid, thrombolytic agents, nitrate, and digitalis in the period studied. The length of hospitalization was shorter in group 2 (13.4±8.9 days chi 10.5±7.5 days, p<0.001). The in-hospital mortality was 35.7% in group 1 and 26.6% in group 2 (p=0.07). CONCLUSION: Significant changes were observed in the treatment of elderly patients with acute myocardial infarction, with a greater use of beta-blockers and angiotensin-converting enzyme inhibitors and a lower use of calcium antagonists and antiarrhythmic drugs in group 2. The length of hospitalization and the mortality rate were also lower in group 2, even though the reduction in mortality was not statistically significant.

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Original Article

Clinical Profile, Predictors of Mortality, and Treatment of Patients after Myocardial Infarction, in an Academic Medical Center Hospital

Leonardo A. M. Zornoff et al. Sérgio A. R. Paiva Vanessa M. Assalin Patrícia M. S. Pola … Luís E. Becker Marina P. Okoshi Luiz S. Matsubara Roberto M. T. Inoue Joel Spadaro

OBJECTIVE: To evaluate clinical profiles, predictors of 30-day mortality, and the adherence to international recommendations for the treatment of myocardial infarction in an academic medical center hospital. METHODS: We retrospectively studied 172 patients with acute myocardial infarction, admitted in the intensive care unit from January 1992 to December 1997. RESULTS: Most patients were male (68%), white (97%), and over 60 years old (59%). The main risk factor for coronary atherosclerotic disease was systemic blood hypertension (63%). Among all the variables studied, reperfusion therapy, smoking, hypertension, cardiogenic shock, and age were the predictors of 30-day mortality. Most commonly used medications were: acetylsalicylic acid (71%), nitrates (61%), diuretics (51%), angiotensin-converting enzyme inhibitors (46%), thrombolytic therapy (39%), and beta-blockers (35%). CONCLUSION: The absence of reperfusion therapy, smoking status, hypertension, cardiogenic shock, and advanced age are predictors of 30-day mortality in patients with acute myocardial infarction. In addition, some medications that are undoubtedly beneficial have been under-used after acute myocardial infarction.

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Case Report

Concomitant Use of Glycoprotein IIb/IIIa Inhibitor and Streptokinase after Unsuccessful Rescue Angioplasty

José Marconi Almeida de Sousa et al. Leonardo Severino Ederlon de Carvalho Rezende Jairon Nascimento Alencar … Valter Correia de Lima João Lourenço V. Hermann

A 38-year-old man with acute myocardial infarction in the lower wall affecting the right ventricle underwent thrombolytic treatment with streptokinase. Approximately 2 hours after the thrombolytic treatment started, he presented with signs of coronary reocclusion. He underwent emergency cineangiocoronariography that revealed that his right coronary artery was completely occluded by a clot. He unsuccessfully underwent angioplasty and stent implantation. After the concomitant use of glycoprotein IIb/IIIa inhibitor, coronary TIMI III flow was achieved without additional dilations, and he was discharged from the hospital 5 days later with no further complications.

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Letter to the Editor

Hurkan Kursaklioglu et al. Atila Iyisoy Ertan Demirtas

Letters

Letter to the Editor,

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Updated

Alternate Angiotensin II-Forming Pathways and Their Importance in Physiological or Physiopathological Conditions

Micheline Monteiro de Resende et al. José Geraldo Mill

Update

Alternate Angiotensin II-Forming Pathways and Their Importance in Physiological or Physiopathological Conditions

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Original Article

Analysis of the Prevalence of Ventricular Late Potentials in the Late Phase of Myocardial Infarction Based on the Site of Infarction

P. R. Benchimol-Barbosa et al. Marcos Oliveira de Sousa Eduardo Correa Barbosa Alfredo de Souza Bomfim … Paulo Ginefra Jurandir Nadal

OBJECTIVE: The initial site of myocardial infarction (MI) may influence the prevalence of ventricular late potentials (VLP), high-frequency signals, due to the time course of ventricular activation. The prevalence of VLP in a period of more than 2 years after acute MI was assessed focusing on the initially injured wall . METHODS: The prevalence of VLP in a late phase after MI (median of 924 days) in anterior/antero-septal and inferior/infero-dorsal wall lesion was analyzed using signal-averaged electrocardiogram in time domain. The diagnostic performance of the filters employed for analysis on was tested at high-pass cut-off frequencies of 25 Hz, 40 Hz and 80 Hz. RESULTS: The duration of the ventricular activation and its terminal portion were larger in inferior than anterior infarction, at high-pass cut-off frequencies of 40 Hz and 80 Hz. In patients with ventricular tachycardia, these differences were more remarked. The prevalence of ventricular late potentials was three times greater in inferior than anterior infarction. CONCLUSION: Late after myocardial infarction, the prevalence and the duration of ventricular late potentials are greater in lesions of inferior/infero-dorsal than anterior/antero-septal wall confirming their temporal process, reflecting their high-frequency content.

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Case Report

Nonrespiratory Sinus Arrhythmia

José Barbosa Filho et al. P. R. Benchimol-Barbosa Ivan Cordovil

We report here 2 cases of sinus arrhythmia considered to be a form of nonrespiratory sinus arrhythmia because they did not have variances in the RR interval sequence within the oscillations modulated by respiration. Because the patients had pulsus alternans similar that observed in bigeminy, and because they did not have signs or symptoms of heart failure, we believe the arrhythmias represent intrinsic alterations of the electric activity of the sinus node

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Original Article

Left Ventricular Hypertrophy Evaluation in Obese Hypertensive Patients: Effect of Left Ventricular Mass Index Criteria

Eduardo Cantoni Rosa et al. Valdir Ambrósio Moysés Ricardo Cintra Sesso Frida Liane Plavnik … Fernando Flexa Ribeiro Nárcia E. B. Kohlmann Artur Beltrame Ribeiro Maria Tereza Zanella Osvaldo Kohlmann Jr.

PURPOSE: To evaluate left ventricular mass (LVM) index in hypertensive and normotensive obese individuals. METHODS: Using M mode echocardiography, 544 essential hypertensive and 106 normotensive patients were evaluated, and LVM was indexed for body surface area (LVM/BSA) and for height² (LVM/h²). The 2 indexes were then compared in both populations, in subgroups stratified according to body mass index (BMI): or = 30kg/m². RESULTS: The BSA index does not allow identification of significant differences between BMI subgroups. Indexing by height² provides significantly increased values for high BMI subgroups in normotensive and hypertensive populations. CONCLUSION: Left ventricular hypertrophy (LVH) has been underestimated in the obese with the use of LVM/BSA because this index considers obesity as a physiological variable. Indexing by height² allows differences between BMI subgroups to become apparent and seems to be more appropriate for detecting LVH in obese populations.

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Original Article

Assessment of Thromboembolism After the Cox-Maze Procedure for Chronic Atrial Fibrillation Secondary to Mitral Valve Lesion

Renato A. K. Kalil et al. Paula L. M. Nesralla Gustavo G. Lima Tiago L. Leiria … Rogério Abrahão Paulo Moreno Paulo R. Prates João R. M. Sant'Anna Ivo A. Nesralla

OBJECTIVE: To assess the occurrence of late thromboembolism after surgical repair of chronic atrial fibrillation (AF) simultaneously with repair of mitral valve using the Cox-Maze procedure. METHODS: 69 patients underwent Cox 3 procedure, with no cryoablation simultaneously with mitral valvuloplasty or prosthesis. Mean age was 49.9±13.2 years. Mean follow-up was of 31.7±19 months. Types of lesion were as follows: 33 (48%) stenoses, 23 (33%) insufficiencies, and 13 (19%) double lesions. Procedures were: 64 (93%) valvuloplasties, 3 (4%) biological and 2 (3%) mechanical prosthesis placement. There were 9 (13%) patients with previous systemic embolism and 2 (3%) had left atrial thrombi. RESULTS: Early mortality was 7% and late 1%. 2 patients (3%) were reoperated for mitral placement. At last evaluation, 10 patients (15%), were in AF. The remaining 59 (85%) were either in sinus / atrial rythm (74%) or under pacing (12%). There were no occurrence of early or late, systemic or pulmonary embolism. Permanent anticoagulation was employed in 16 cases, 10 in regular rythm and 6 in AF. The remaining 47 (75%), 2 in AF and 45 in regular rythm, did not receive anticoagulants. CONCLUSIONS: These results are in accordance with others series, where the occurrence of embolism was rare after maze procedure. Permanent systemic anticoagulation seems to be unnecessary in those cases.

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Correlação Clínico-Radiográfica

Caso 4/2002 – Instituto do Coração do Hospital das Clínicas da FMUSP

Edmar Atik

Correlação Clínico-Radiográfica

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Original Article

Heart Weight and Heart Weight/Body Weight Coefficient in Malnourished Adults

Daniel Ferreira da Cunha et al. Selma Freire de Carvalho da Cunha Marlene Antônia dos Reis Vicente de Paula Antunes Teixeira

OBJECTIVE: To compare the heart weight and the heart weight/body weight coefficient of adults with and without chronic malnutrition. METHODS: In an initial case series of 210 autopsies performed in adults, we recorded body and heart weights and calculated the heart weight/body weight coefficients (HW/BW x 100). The exclusion criteria were as follows: positive serology for Chagas’ disease, edema, obesity, heart diseases, hepatopathies, nephropathies, and systemic arterial hypertension. Malnutrition was characterized as a body mass index <18.5kg/m². Differences with p<0.05 were considered significant. RESULTS: Individuals in the malnourished (n=15) and control (n=21) groups were statistically different, respectively, in regard to body mass index (15.9±1.7 versus 21.3±2.5kg/m²), heart weight (267.3±59.8 versus 329.1±50.4g), and the HW/BW coefficient (0.64±0.12 versus 0.57±0.09%). A positive and significant correlation was observed between heart weight and body mass index (r=0.52), and between heart weight and body weight (r=0.65). CONCLUSION: Malnourished individuals have lighter hearts and a greater HW/BW coefficient than non-malnourished individuals do. These findings indicate a possible preservation of the myocardium in relation to the intensity of weight loss associated with the probable relative increase in cardiac connective tissue and heart blood vessels.

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Letter to the Editor

Dear Dr. Kursaklioglu and colleagues

Luiz A. Mattos

Letters

Dear Dr. Kursaklioglu and colleagues,

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