Myocardial Ischemia – ABC CARDIOL

IJCS

Editorial

The Importance of Observational Studies

Paolo Blanco Villela et al. Larissa Franco de Andrade

Discussing coronary artery disease without beginning with the traditional phrase “cardiovascular diseases are the leading cause of death worldwide” becomes challenging – especially because that statement, unfortunately, is no longer sufficient. There is no way to avoid it except by expanding upon it: in addition to leading global mortality statistics, cardiovascular diseases represented the primary cause of disability-adjusted life years (DALYs) in 2023, accounting for 437 million (95% UI: 401–465 million) DALYs worldwide – a 1.4-fold increase compared with 1990.

Naturally, ischemic heart diseases are included in this group and ranked first, with 193 million DALYs in 2023 and an age-standardized mortality rate of 99.8 (89.9–108.4) per 100,000 inhabitants, according to data from the Global Burden of Disease (GBD).

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Viewpoint

New Insights Into Ischemic Heart Disease in Women: The Central Role of Coronary Microvascular Dysfunction Current Insights, Diagnostic Advances, And Therapeutic Uncertainties

Elizabeth Regina Giunco Alexandre et al. Isabelle Salomão Larissa Neto-Espíndola Rafaela Penalva … Mayara Lídia Da Silva Claudio Tinoco Mesquita

Introduction

This viewpoint discusses emerging evidence and the clinical implications of coronary microvascular dysfunction (CMD) in women, offering a focused perspective on pathophysiologic, diagnostic, and therapeutic features that distinguish ischemic heart disease (IHD) in women from that in men. Beyond summarizing available data, we highlight the growing body of evidence supporting CMD as an important and often underrecognized contributor to ischemic symptoms and cardiovascular risk in women. We emphasize key concepts and ongoing controversies without intending to provide definitive therapeutic recommendations.

Ischemic heart disease (IHD) remains a leading cause of morbidity and mortality worldwide. Recent evidence also highlighted sex-based differences in ischemic pathophysiology and vascular aging in women.

[…]

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Editorial

Strengthening Our Understanding of Muscle Metaboreflex Control in Patients with Coronary Artery Disease: (Dis)association Between Physical Fitness and Hemodynamic Responses

André L. Teixeira

Ischemic Heart Disease remains a leading cause of mortality worldwide. In addition to pharmacologic therapy and coronary revascularization, healthy lifestyle interventions such as diet and exercise are essential components of disease management. Although exercise training is a Class I recommendation for patients with ischemic heart disease, physical exertion is not without risk in this population. Indeed, an exercise stress test is a well-established method for inducing myocardial ischemia. Furthermore, patients with ischemic heart disease often exhibit abnormal cardiovascular responses during exercise, which makes exercise prescription both challenging and potentially risky in this clinical population. Therefore, understanding the physiological mechanisms underlying the altered cardiovascular control at rest and during exercise, as well as the cardioprotective effects of exercise training in patients with ischemic heart disease, is critical for improving treatment strategies and optimizing disease management.

The cardiovascular responses to exercise are orchestrated by several integrative neural control mechanisms, including central command, the exercise pressor reflex, the arterial and cardiopulmonary baroreflexes, and the central and peripheral chemoreflexes. The exercise pressor reflex comprises group III and IV skeletal muscle afferents that discharge in response to mechanical deformation (i.e., muscle mechanoreflex) and the accumulation of metabolic by-products of muscle contraction (i.e., muscle metaboreflex).^, Inputs from group III/IV afferent fibers synapse within cardiovascular control areas in the brainstem that reflexively decrease parasympathetic and increase sympathetic nerve activity, leading to increased Heart Rate (HR), cardiac output, total peripheral resistance, and arterial blood pressure during exercise.^, It has been shown that the blood pressure responses to exercise and metaboreflex activation are directly associated with absolute muscle strength in young, healthy adults.^, Moreover, exercise training-induced improvements in cardiorespiratory fitness can modulate metaboreflex control. Nevertheless, the extent to which the cardiovascular responses to muscle metaboreflex activation are related to markers of physical fitness in patients with Coronary Artery Disease (CAD) is currently unknown.

[…]

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Original Article

Association between Cardiovascular Responses to Muscle Metaboreflex and Markers of Physical Fitness in Patients with Coronary Artery Disease

Vanessa Cunha de Oliveira Coelho et al. Gabriel da Silva Gama Caio Luan Farias Costa Marcus Vinicius dos Santos Rangel Juliana Borges

Abstract

Background:

The muscle metaboreflex regulates cardiovascular responses during exercise. In patients with coronary artery disease (CAD), this reflex primarily increases blood pressure via sympathetic-mediated vasoconstriction, thereby increasing peripheral vascular resistance (PVR) rather than enhancing stroke volume (SV). This response may result in early fatigue during physical exertion. However, the specific mediators of this response are unclear.

Objective:

To investigate the association between cardiorespiratory and muscle fitness with cardiovascular responses to muscle metaboreflex activation in patients with CAD.

Methods:

Twenty patients underwent an exercise test and a maximal voluntary contraction (MVC) test using handgrip strength. Hemodynamic variables were assessed using photoplethysmography during muscle metaboreflex activation via a post-exercise circulatory arrest (PECA) protocol. Changes (Δ) in mean arterial pressure (MAP), SV, and PVR at rest were used to assess the metaboreflex response.

Results:

Participants (61.7±8.0 years; 28.4±3.9 kg/m²) had a mean VO_2max of 31.96±5.70 mL/kg/min, and a MVC of 90.5±21.1 lbs. Metaboreflex activation significantly increased MAP (+14.74±9.56 mmHg, p<0.0001) and PVR (+0.13±0.07 mmHg.s/mL, p<0.0001), but not SV (+1.91±5.54 mL, p=0.13). MVC was directly associated with ΔSV (R=0.54 and p=0.01), but not with ΔMAP (R=0.23 and p=0.31) or ΔPVR (R=-0.10 and p=0.65). In multiple linear regression models adjusted for age and sex, ΔSV emerged as a predictor of MVC (β=+1.37 and p=0.03). Conversely, no significant associations were found between VO_2max and ΔSV (R=0.29 and p=0.22), ΔMAP (R=0.14 and p=0.54), or ΔPVR (R=0.05 and p=0.83).

Conclusions:

These findings underscore the association between SV and muscle fitness during metaboreflex activation in patients with CAD.

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IJCS

Original Article

Obstructive Sleep Apnea as a Risk Factor for Ischemic Heart Disease

Soham Samajpaty et al. Alexander Konstantinovich Zhuravlov Emilianovich Dmitrii Ilin Yuriy Sergeivich

Abstract

Background:

Obstructive sleep apnea (OSA) is increasingly recognized as a potential risk factor for ischemic heart disease (IHD), but its role remains underexplored. This study investigated the association between OSA and IHD using a case-control design.

Objectives:

The objective of this study was to establish OSA as a risk factor for developing IHD.

Methods:

A total of 122 participants were recruited and categorized into two groups: patients with a recent history of IHD (< 7 days) (wIHD group, n = 61) and controls without IHD but with hypertension (cIHD group, n = 61). The STOP-Bang questionnaire was used to assess OSA risk, and statistical analyses, including odds ratio (OR), relative risk (RR), and attributable risk (AR), were performed. A significance level of 0.05 was adopted for all statistical analyses.

Results:

Patients in the wIHD group had significantly higher STOP-Bang scores than the control group (p 1). The level of statistical significance was found to be 0.05.

Conclusion:

This study identifies OSA as an important risk factor for IHD, supporting the need for routine OSA screening in cardiovascular risk assessment. Larger studies are needed to further explore this relationship

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Case Report

ECG's AVR ST elevation Analysis by Perfusion Scintilography in the Context of Myocardial Ischemia

Miriana Basso Gomes et al. Carolina Feijó Bombana Felipe C. Fuchs

Introduction

The presence of ST-segment elevation in two or more contiguous leads indicates a current subepicardial lesion that often requires early intervention, either by angioplasty or thrombolytic therapy.^, ST elevation, only in aVR, may also indicate the presence of an acute infarction. This finding was first made by Wellens et al. However, this is not always true, and physicians should be aware of the details surrounding changes in Right Vector amplification (aVR).

The medical literature has a wide range of articles reporting on the association between ST elevation in aVR during exercise testing and left main coronary artery injury.^– However, this concept began at a time when fewer imaging tests and catheterizations were performed. Altered stress tests are a common indication of myocardial scintigraphy, which is why the Nuclear Medicine laboratory is the perfect place to perform this type of analysis. There is now evidence that aVR elevation in this context may not indicate coronary lesions and may be present, for example, in patients with aortic stenosis, hypertrophy and hypoxia..^– Since these are stress tests, it is important to analyze the heart rate in which the aVR elevation occurs as well as the pattern of the other leads.

[…]

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IJCS

Editorial

Myocardial Ischemia and the Emerging Role of Coronary Flow Reserve Quantification

Ana Carolina do Amaral Henrique de Souza

Recent years have seen remarkable advances in nuclear cardiology. The introduction of cardiac positron emission tomography (PET) and the development of cadmium-zinc-telluride (CZT) imaging systems have significantly improved diagnostic accuracy, clinical decision-making, and ultimately outcomes for patients with coronary artery disease (CAD). In this issue, Giubbini and Milan review key concepts related to myocardial ischemia and explore the emerging importance of quantifying coronary flow reserve (CFR) in patients with known or suspected CAD.

PET imaging has become a preeminent modality in the evaluation of ischemic heart disease, providing high diagnostic and prognostic value. PET imaging offers several advantages over other imaging modalities, including low radiation exposure, accurate assessment of left ventricular function and perfusion, and the ability to quantitatively measure myocardial blood flow (MBF) and CFR. CFR is defined as the ratio of exercise MBF to resting MBF and reflects not only obstructive CAD but also diffuse atherosclerosis and microvascular dysfunction (CMD) throughout the coronary system. The ability to measure absolute flow and flow reserve is particularly beneficial in cases of multivessel disease or CMD, complementing traditional perfusion imaging, as both conditions can occur even when perfusion appears normal.

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IJCS

Review Article

Cardiovascular Disease in Latin American Women Gaps and opportunities

Karen Alexandra Dueñas-Criado et al. Angela Herrara Peña Maria Juliana Rodriguez-González Astrid Fajardo

Abstract

Cardiovascular disease (CVD) remains the leading cause of death in women. This review will address the known disparities in cardiovascular care concerning diagnosing and treating of heart disease in Latin American (LA) women. Gender-specific differences regarding the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Today, we identify that women have cardiovascular risk factors (CRFs), specifying the traditional, emerging, unique, or sex-specific determinants and the social and biological determinants that play a leading role in the prevention of CVD. The purpose of this article is to review the literature on cardiovascular disease in LA women, focusing on ischemic heart disease (IHD), valve disease (VD), heart failure, and cardiac rehabilitation (CR), where disparities continue to affect outcomes. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in CVD.

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IJCS

ORIGINAL ARTICLE

Garlic Extract Reverses Ischemic Heart Disease in Female Rats Exposed to Combined Oral Contraceptive Pills

Onitsha Enebrayi Nelson et al. Gborienemi George Simeon Okutu Jackson Borobuebi Mie-Ebi Martin Wankasi Ezeiruaku Ferdinand Chukwuma

Abstract

Background

Garlic is an herbal medicinal plant with several pharmacological properties used for the management of various ailments. However, its potential in the reversal of ischemic heart disease induced by combined oral contraceptive pills is not well reported.

Objective

This study investigated the cardioprotective potential of aqueous garlic extract against cardiotoxicity induced by oral contraceptive pills.

Methods

Forty-six rats were used for this study. Six were used to determine the lethal dose (LD₅₀), and 40 rats were divided randomly into 5 groups of 8 rats each. Group A received feed and distilled water. Group B received 0.6 mg/kg of oral contraceptive pills. Group C received 500 mg/kg of garlic extract. Group D received 0.6 mg/kg of oral contraceptive pills + 500 mg/kg garlic extract. Group E received 0.6 mg/kg of oral contraceptive pills + 700 mg/kg garlic extract. The animals were sacrificed, and blood and tissue samples were collected for biochemical and histological analysis. Statistical analysis was done using SPSS, and p values < 0.05 were considered significant.

Results

The acute toxicity dose of combined oral contraceptive pills was 1.5 mg/kg for albino rats. Combined oral contraceptive pills induced ischemic necrosis as revealed by the photomicrographs, in addition to elevation of serum cardiac troponin-1, lactate dehydrogenase, creatine kinase, and malondialdehyde levels. Treatment with garlic extract demonstrated significant reduction in cardiac troponin-1 (p = 0.000), lactate dehydrogenase (p = 0.002), creatine kinase (p = 0.001), and malondialdehyde (p = 0.001) levels, as well as restoration of the cardiac cytoarchitecture changes caused by the combined oral contraceptive pills.

Conclusion

This study has demonstrated that aqueous garlic juice can reverse ischemic heart disease, lessen cytoarchitectural alterations of the heart caused by combined oral contraceptive pills, and thus ameliorate cardiac dysfunction.

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Viewpoint

Coronary Artery Microfistulas: Historical Description and Contemporary Clinical Relevance

Stans Murad Netto et al. Rachel Vianna O'Neill de Souza Victor Murad Evandro Tinoco Mesquita

Introduction

Coronary microfistula was initially described as an anatomical finding in the late 1960s by Murad and colleagues, and it was later recognized as a morphofunctional abnormality of the coronary arteries capable of causing clinical findings (). This often asymptomatic entity is still poorly recognized in clinical practice, although it can be readily identified in the catheterization laboratory, cineangiography studies, and more recently by coronary CT angiography.

Initially, this condition was not taken into consideration, and it was justified as a possible “error” in cineangiography technique. Different studies have demonstrated its existence and its potential as a nosological entity responsible for myocardial ischemia, cardiac chamber overload, arrhythmias, and even heart failure.^,

[…]

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IJCS

Original Article

General Approach to Acute Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Systematic Review

Marcos Aurélio Barboza de Oliveira et al. Alan Vinicius Gamero Ósti Bruno Vargas Teixeira Cavalheiro Déborah Barbosa Naves … Emanuelle Ribeiro de Oliveira Gabriel Freitas de Campos Gabriel Mael Sussuarana Silva Lobo Gabriely de Oliveira Marcela Paula Mainardi Marília Cardoso Guimarães Robert Filipe Barbosa Vilian Veloso de Moura Fé

Abstract

Background

Acute myocardial infarction (AMI) without obstructive coronary arteries (MINOCA) is a medical condition of great relevance, with clinical characteristics of AMI, but without evidence of coronary artery obstruction. The mechanism involved in the pathophysiology of the disease and its possible etiologies are important objects of study due to their impact on the morbidity and mortality of affected patients.

Objectives

The aim of this study was to systematically review MINOCA and its characteristics, with emphasis on the clinical profile of patients, etiology, pathophysiology, diagnosis, and treatment of the syndrome.

Methods

Relevant articles related to MINOCA were analyzed in the PubMed and LILACS databases. In the initial search stage, 619 eligible articles were obtained, with final inclusion criteria being: original systematic reviews with clinical, epidemiological, diagnostic, or treatment data on MINOCA, published in Portuguese or English, with an abstract, and a publication date limit of September 2020.

Results

A total of 10 articles classified as systematic reviews that considered clinical data on MINOCA were included in this review.

Conclusion

After analyzing various literature, the present study provided a tool to better understand MINOCA, not only regarding its casuistry but also in grouping parameters and information that contribute to a healthy approach to this clinical situation. It was possible to identify and better outline the clinical profile of patients who presented this condition and the use of appropriate tools for correct diagnosis and ideal treatment.

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IJCS

Original Article

The Influence of Primary Atherosclerotic Diseases on the Occurrence of Secondary Disease

Paula Monique Chiconi de Picoli et al. Creusa Sayuri Tahara Amaral Eliane Trovatti

Abstract

Background

Atherosclerosis is a condition in which fats, cholesterol, fibrin, and other substances accumulate into plaque on the arterial walls. Plaque can harden and narrow the arteries, in turn limiting the blood flow and resulting in diseases, such as acute myocardial infarction (AMI), ischemic stroke (IS), or peripheral arterial disease (PAD). There is a fairly high risk of a secondary atherosclerotic event if patients are not treated after the primary episode.

Objective

To calculate the statistical probability of developing AMI, IS, or PAD after treating the primary disease.

Methods

Data for statistical probability studies included 507,690 patients with primary atherosclerotic disease, who were in treatment during the study period and who did or did not develop a secondary atherosclerotic disease event.

Result

Statistical probability data indicate that few AMI patients can develop IS (2.99%) or PAD (2.86%) as a secondary disease. Patients with primary diagnoses of IS showed a 5.07% risk of developing PAD and a 0.95% risk of developing AMI; however, PAD patients showed a higher probability for both AMI (9.17%) and IS (8.79%).

Conclusion

Secondary atherosclerotic disease episodes after IS, AMI, and PAD were confirmed by statistical probability and are consistent with data from the literature. The study revealed that a primary PAD event leads to high rates of secondary episodes, and special attention should be given to the diagnosis and treatment of PAD in order to decrease the occurrence of secondary events.

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IJCS

Review Article

Chronic Coronary Syndrome: Medical Therapy or Myocardial Revascularization?

Antônio Sérgio Cordeiro da Rocha et al. Paulo Roberto Dutra da Silva

Abstract

The best therapeutic strategy for chronic coronary syndrome (CCS) is still controversial. The lack of contemporaneity of medical treatment in many randomized clinical trials prior to the large-scale use of statins, antiplatelet agents, anti-diabetic drugs with cardiovascular protection, and changes in life habits with well-established goals limits the applicability of such studies in current clinical practice.

Medical treatment is the only therapeutic option capable of reducing atherosclerotic damage and, therefore, of acting effectively in preventing the progression of this disease.

The purpose of this brief review is to critically analyze the main contemporary studies that confront medical treatment with myocardial revascularization in CCS.

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Case Report

Cardiac Manifestations Associated With Coronavirus Disease: A Case Report

Gabriela Ribeiro Prata Leite Barros et al. Raphaela Tereza Brigolin Garofo Bernardo Noya Alves de Abreu Adriano Camargo de Castro Carneiro André Luiz Esteves Mendonça

Abstract

This study presents a 47-year-old female patient, with a history of diabetes, who contracted SARS-CoV-2 and exhibited cardiovascular complications.

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Review Article

Closing the Gender Gap in Ischemic Heart Diseases and Myocardial Infarction

Maria Cristina Meira Ferreira et al. Mayara Viana de Oliveira Maria Sanali Moura Paiva Viviana Lemke … Fernanda Mangione Gláucia Maria Moraes de Oliveira

Mortality due to myocardial infarction

Myocardial infarction (MI) is the leading cause of death in Brazil nowadays. The MI mortality rate decreased between 1996 and 2019, in both sexes, especially among females, being more relevant in the state capitals than in the inner areas.

According to the Brazilian Unified Health System (SUS) Department of Information Technology (DATASUS), there were 142 982 hospital admissions for MI in 2018, with in-hospital mortality of 11%. In 2018, the DATASUS registered 10 811 primary angioplasties for MI, with in-hospital mortality of 6.3% and a mean length of hospital stay of 5.1 days. In 2018, the total amount reimbursed for coronary interventional procedures by the SUS was R$ 569 314 580 (Int$ 280 727 110), of which R$ 73 429 322 (13%) (Int$ 36 202 821) were for primary angioplasties.

[…]

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Review Article

Autonomic Innervation Evaluation in Cardiac Disease

Adriana Xavier de Brito et al. Adriana Glavam Ana Inês Bronchtein Paulo Henrique Rosado-de-Castro

Abstract

Cardiovascular diseases are among the leading causes of mortality and morbidity in the world. In different cardiac diseases, the neuronal function of the heart is impaired. Nevertheless, the development of a simple method to assess the autonomic effects on the heart and/or autonomic dysfunction is a challenge. The evaluation of autonomic innervation in cardiac diseases has helped to improve the knowledge of the pathophysiology of these conditions, as well as to provide information on their prognosis. Single photon emission computed tomography (SPECT) and positron emission tomography (PET) are currently the only imaging methods that allow in vivo assessment of cardiac innervation. The majority of SPECT and PET radiotracers evaluate sympathetic neuronal integrity using presynaptic imaging agents that are either labeled as endogenous transmitters or analogues. Postsynaptic imaging agents have also been developed to study sympathetic neuronal integrity, as well as tracers to investigate the parasympathetic nervous system. These methods may be used to analyze the innervation of the heart and allow for early detection of abnormalities caused by, for example, ischemia, heart failure, cardiomyopathies, cardiotoxicity, and arrhythmogenic disorders. This review provides an overview of cardiac innervation evaluation and their application in the assessment of heart disease.

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Original Article

Mortality Trends from Cardiovascular Diseases in the State of Bahia, Brazil, between 2000 and 2015

Yana Mendonça Nascimento et al. Adriana Lopes Latado

Abstract

Background:

Mortality from cardiovascular diseases has reduced in Brazil in recent decades, but this phenomenon is not clear in the northeast region of the country.

Objectives:

To describe the mortality trends from cardiovascular disease in Bahia from 2000-2015, in total population and by sex and age groups, and by specific causes (ischemic heart disease, cerebrovascular diseases, rheumatic heart disease and heart failure).

Methods:

This was a time series study. Data were obtained from SIM-DATASUS and IBGE, and the 10th revision of the ICD used for disease classification. Mortality rates (per 100,000 inhabitants) were calculated from total cardiovascular disease and specific causes, by sex and age groups. Direct standardization was used to adjust for age, using the population of 2010 as reference. Linear regression models estimated percentage variation. The significance level of 5% was adopted.

Results:

In Bahia, crude mortality rates from cardiovascular disease increased in the period; however, after standardization by age, mortality rates became stable for the total and female populations, with a slight reduction for the male population. An increase in mortality rates from cardiovascular disease was found in the elderly groups. For ischemic heart disease, a progressive increase in adjusted mortality rates was observed: 43%, 24% and 29% for the total, male, and female population, respectively. There was a progressive reduction in crude and age-standardized mortality rates from heart failure in all groups, a modest reduction in age-adjusted mortality rates from cerebrovascular diseases, and a slight reduction in age-standardized mortality rate from rheumatic heart disease, especially in the subgroup <40 years.

Conclusions:

Mortality from cardiovascular disease in Bahia did not follow the decreasing trend of other Brazilian states, especially in relation to ischemic heart disease, which showed an increase in mortality rates.

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Case Report

Acute Coronary Syndrome in a Patient With Single-Vessel Coronary Artery: Case Report

Bruno Dala Vedova Gomes Beato et al. Carolina de Souza Galvão Eduardo Belisário Falchetto Eduardo Kei Marquesini Washizu … Fábio Ávila Tofani Juliano Moreira Reis Filho

Introduction

Anomalies of coronary arteries affect 1-2% of the population.^, They are associated with increased risk of sudden death and coronary artery injury during surgical procedures.^, Among the coronary artery anomalies, the single-vessel coronary artery disease subtype has a low incidence – 0.03-0.04% in patients without other heart diseases and 0.024% in patients with other heart diseases. Concomitant presence of acute coronary syndrome in these patients may have an impact on their prognosis and survival.

Here we report a rare and challenging case of an 81-year-old woman with high-risk unstable angina undergoing emergency catheterization which indicated the presence of single-vessel coronary artery disease with lesions in multiple segments.

[…]

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Case Report

Case Report: Myocardial Bypass in Left Descending Artery – A Rare Congenital Anomaly

Vergílio Pereira Carvalho et al. Eraldo Ribeiro Ferreira Leão de Moraes João Emílio Hanum Paes Daniela Textor … Hugo Leonardo Shigenaga Ribeiro Amara Chebli Baptista Stephanie Borges Vilela Ana Paula Fontana Isabella Beatriz Silva Rocha Jair Pereira Melo Junior

Abstract

Myocardial bypass (MB) is known to have scientific relevance and is present in several studies with great statistical significance regarding its clinical manifestations and complications. There are still questions about MB in its relationship with heart disease and repercussion in life-threatening conditions. We present a case report of a MB in the left anterior descending coronary artery, whose objective is to identify this rare congenital anomaly and to highlight the patient’s clinical outcome in order to elicit greater contributions about the presence of this variant in the emergency room, its diagnosis by angiography and therapeutic management.

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Original Article

QT Interval Dispersion Behavior in Patients With and Without Obstructive Coronary Artery Disease Undergoing Exercise Test

Alexandre Maulaz Barcelos et al. Marcelo Perim Baldo Sérgio Lamego Rodrigues José Geraldo Mill

Abstract

Background:

Stress test is used to detect coronary artery disease (CAD). The QTc interval dispersion (dQTc) is an electrocardiographic index of ventricular repolarization heterogeneity. Some researchers have linked transient myocardial ischemia induced by physical exertion with increased heterogeneity of ventricular repolarization measured by dQTc.

Objectives:

To study the patterns of dQT in patients with and without chronic obstructive CAD and to define a reliable cutoff point for dQT that could become a diagnostic criterion for myocardial ischemia.

Methods:

We retrospectively analyzed the electrocardiogram in resting and in exercise of 63 patients submitted to exercise test and cardiac catheterization. We divided the patients into three groups: true negative (VN), true positive (VP) and false positive (FP). VN: patients with coronary lesion lower than 70% and exercise test without myocardial ischemia; VP: individuals with stenosis greater than 70% in coronary arteries and a test suggestive of myocardial ischemia; FP: people with stenosis lower than 70% in the coronary arteries and stress test with ischemia criteria. Values of p < 0.05 were considered statistically significant.

Results:

Resting dQTc was not different among the three groups. However, for the dispersion of the QTc interval in exercise was, respectively, 47 ± 17 ms, 72 ± 42 ms, and 61 ± 31 ms for VN, VP and FP (p = 0.003).

Conclusions:

Obstructive chronic coronary disease patients have an increase in dQTc during exercise. Measurement of dQTc may be helpful in the diagnosis of myocardial ischemia in the stress test.

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Original Article

Correlation between Clinical and Educational Factors and Delayed Hospital Arrival in Myocardial Infarction

Andressa Sardá Maiochi Takagui et al. Daniel Medeiros Moreira Ana Teresa Glaser Carvalho Thays Fraga Duarte … Roberto Léo da Silva Tammuz Fattah

Abstract

Background:

Acute myocardial infarction is one of the main causes of morbidity and mortality in the world, and one of the factors with the greatest prognostic impact is early specialist care, but there are still many factors that delay patient’s arrival at the hospital.

Objective:

To correlate social, educational, cognitive and clinical factors with time to hospital arrival after the onset of acute myocardial infarction’s first symptoms.

Methods:

Time interval to search for medical care was measured by patient’s report of the onset of infarction’s first symptoms and hospital admission verified through electronic medical data of the emergency service. The correlation between delta-T and other variables was performed through Kendall’s correlation. Values of p < 0.05 were considered statistically significant.

Results:

There was no correlation between delta-T and scholarity, or between delta – T and Mini Mental State Examination performance, as well as no association between the presence of hypertension, diabetes mellitus, dyslipidemia, family history, sedentary lifestyle or smoking with arrival time at the hospital. Comparisons between delta-T and marital status were also not statistically significant. Transfer from another health service and city of origin were the most determinant delay factors in our population’s arrival at the hospital.

Conclusion:

The present study suggests that, in our population, educational, social and cognitive factors are not directly related to the delay in arriving at the hospital.

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Original Article

Clinical significance of transient left ventricular dilation assessed during myocardial Tc-99m sestamibi scintigraphy

Paulo Schiavom Duarte et al. Paola Emanuela Smanio Carlos Alberto Oliveira Luiz Roberto Martins … Luiz Eduardo Mastrocolla Julio César Pereira

OBJECTIVE: To assess the clinical significance of transient ischemic dilation of the left ventricle during myocardial perfusion scintigraphy with stress/rest sestamibi. METHODS: The study retrospectively analyzed 378 patients who underwent myocardial perfusion scintigraphy with stress/rest sestamibi, 340 of whom had a low probability of having ischemia and 38 had significant transient defects. Transient ischemic dilation was automatically calculated using Autoquant software. Sensitivity, specificity, and the positive and negative predictive values were established for each value of transient ischemic dilation. RESULTS: The values of transient ischemic dilation for the groups of low probability and significant transient defects were, respectively, 1.01 ± 0.13 and 1.18 ± 0.17. The values of transient ischemic dilation for the group with significant transient defects were significantly greater than those obtained for the group with a low probability (P<0.001). The greatest positive predictive values, around 50%, were obtained for the values of transient ischemic dilation above 1.25. CONCLUSION: The results suggest that transient ischemic dilation assessed using the stress/rest sestamibi protocol may be useful to separate patients with extensive myocardial ischemia from those without ischemia.

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Original Article

Neonate Aortic Stenosis: Importance of Myocardial Perfusion in Prognosis

Marco Aurélio Santos et al. Vitor Manuel Pereira Azevedo

OBJECTIVE: To analyze our experience with percutaneous aortic balloon valvuloplasty in newborn infants with aortic stenosis, emphasizing the extraordinary importance of myocardial perfusion.METHODS: Over a 10-year-period, 21 neonates underwent percutaneous aortic balloon valvuloplasty. Age ranged from 2 to 27 days, weight ranged from 2.2 to 4.1 kg and 19 were males. All patients presented with congestive heart failure that could not be treated clinically. The onset of symptoms in the first week of life occurred in 9 patients considered as having critical aortic stenosis. Severe aortic stenosis occurred in 12 patients with the onset of symptoms in the second week of life.RESULTS: Mortality reached 100% in the patients with critical aortic stenosis. The procedure was considered effective in the 12 patients with severe aortic stenosis. Vascular complications included the loss of pulse in 12 patients and rupture of the femoral artery in 2 patients. Cardiac complications included acute aortic regurgitation in 2 patients and myocardial perforation in one. In an 8.2±1.3-year follow-up, 5 of the 12 patients died (2 patients due to septicemia and 3 patients due to congestive heart failure). Five of the other 7 patients underwent a new procedure and 2 required surgery.CONCLUSION: Percutaneous aortic valvuloplasty in neonates is not an effective procedure in the 1st week of life, because at this age the common presentation is cardiogenic shock. It is possible that, in those patients with critical aortic stenosis, dilation of the aortic valve during fetal life may change the prognosis of its clinical outcome.

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Original Article

Electrocardiographic and Blood Pressure Alterations During Electroconvulsive Therapy in Young Adults

Demetrio Ortega Rumi et al. Maria Cecília Solimene Júlio Yoshio Takada César José Grupi … Dante Marcelo Giorgi Sérgio Paulo Rigonatti Protásio Lemos da Luz José Antonio Franchini Ramires

OBJECTIVE – To study cardiovascular alterations in young patients with no apparent organic disease who underwent electroconvulsive therapy. METHODS – The study comprised 47 healthy patients (22 males and 25 females) with a mean age of 30.3 years, who underwent electroconvulsive therapy. Ambulatory blood pressure monitoring and continuous electrocardiographic monitoring (Holter monitor) were performed during 24 hours. Blood pressure and heart rate were assessed 4 hours prior to electric shock administration, during electric shock administration, and 3 hours after electric shock administration. Arrhythmias and alterations in the ST segment in 24 hours were recorded. RESULTS – On electroconvulsive therapy, a significant increase in blood pressure and heart rate was observed and the measurements returned to basal values after 25 minutes. Three females had tracings with depression of the ST segment suggesting myocardial ischemia prior to and after electroconvulsive therapy. Coronary angiography was normal. No severe cardiac arrhythmias were diagnosed. CONCLUSION – 1) Electroconvulsive therapy is a safe therapeutic modality in psychiatry; 2) it causes a significant increase in blood pressure and heart rate; 3) it may be associated with myocardial ischemia in the absence of coronary obstructive disease; 4) electroconvulsive therapy was not associated with the occurrence of severe cardiac arrhythmias.

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