2002;79(1) – ABC CARDIOL

Original Article

Comparison between Adventitial and Intimal Inflammation of Ruptured and Nonruptured Atherosclerotic Plaques in Human Coronary Arteries

Maria L. Higuchi et al. Paulo S. Gutierrez Hiram G. Bezerra Suely A. Palomino … Vera D. Aiello Júlia M. L. Silvestre Peter Libby José A. F. Ramires

OBJECTIVE: To verify the possible role of adventitial inflammation in atherosclerotic plaque vulnerability and coronary artery remodelling. METHODS: We compared the mean numbers of lymphocytes in the adventitia and in the plaque of ruptured thrombosed and stable equi-stenotic coronary segments of 34 patients who died due to acute myocardial infarction. We also analysed adventitial microvessels, adventitial fibrosis and the external elastic membrane. RESULTS: In the adventitia, the numbers of lymphocytes and microvessels/mm² were 69.5±88.3 and 60.9± 32.1 in culprit lesions and 16.4 ± 21.1 and 44.3±16.1 in stable lesions (p<0.05); within the plaques, the mean number of lymphocytes was 24±40.8 in culprit lesions and 10.9±13.2 in stable ones (p=0.17). The mean percent area of adventitial fibrosis/cross-sectional area of the vessel was significantly lower in unstable plaques (p<0.001). The confocal images showed holes in the external elastic membrane. CONCLUSION: Unstable plaques exhibit chronic pan-arteritis, accompanied by enlargement, medial thinning, and less fibrosis than in stable lesions, which is compatible with vessel aneurysm. Adventitial inflammation may contribute significantly to atheroma instability.

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Original Article

Assessment of the Cardiovascular Risk and Physical Activity of Individuals Exercising at a Public Park in the City of São Paulo

Cláudia L. M. Forjaz et al. Taís Tinucci Teresa Bartholomeu Tiago E. M. Fernandes … Vivian Casagrande José Geraldo Massucato

OBJECTIVE: Physical exercise helps to prevent cardiovascular disorders. Campaigns promoting exercise have taken many people to the parks of our city. The most appropriate exercise for preventing cardiovascular disorders is the aerobic modality; inappropriate exercise acutely increases cardiovascular risk, especially in individuals at higher risk. Therefore, assessing the cardiovascular risk of these individuals and their physical activities is of practical value. METHODS: In the Parque Fernando Costa, we carried out the project “Exercício e Coração” (Exercise and Heart) involving 226 individuals. Assessment of the cardiovascular risk and of the physical activity practiced by the individuals exercising at that park was performed with a questionnaire and measurement of the following parameters: blood pressure, weight, height, and waist/hip ratio. The individuals were lectured on the benefits provided by exercise and how to correctly exercise. Each participant received a customized exercise prescription. RESULTS: In regard to risk, 43% of the individuals had health problems and 7% of the healthy individuals had symptoms that could be attributed to heart disorders. High blood pressure was observed in a large amount of the population. In regard to the adequacy of the physical activity, the individuals exercised properly. The project was well accepted, because the participants not only appreciated the initiative, but also reported altering their exercise habits after taking part in the project. CONCLUSION: Data obtained in the current study point to the need to be more careful in assessing the health of individuals who exercise at parks, suggesting that city parks should have a sector designated for assessing and guiding physical activity.

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Original Article

Percutaneous Stent Implantation for Treating Multivessel Coronary Disease in Patients with and without Involvement of the Proximal Segment of the Anterior Descending Coronary Artery

Sandro Salgueiro et al. Augusto Daige da Silva Ricardo José Tofano Vinicius Carvalho da Costa … Karina Pizarro Adnan Ali Salman José Armando Mangione

OBJECTIVE: To assess coronary stent placement in patients with multivessel coronary disease and involvement of the proximal portion of the anterior descending coronary artery. METHODS: We retrospectively analyzed the in-hospital and late evolution of 189 patients with multivessel coronary disease, who underwent percutaneous coronary stent placement. These patients were divided into 2 groups as follows: group I (GI) – 59 patients with involvement of the proximal segment of the anterior descending coronary artery; and group II (GII) – 130 patients without involvement of the proximal segment of the anterior descending coronary artery. RESULTS: No significant difference was observed in the success rate of the procedure (91.5% versus 97.6%, p=0.86), nor in the occurrence of major adverse cardiac events (5.1% versus 1.5%, p=0.38), nor in the occurrence of major vascular complications (1.7% versus 0%, p=0.69) in the in-hospital phase. In the late follow-up, the incidence of major adverse cardiac events (15.4% versus 13.7%, p=0.73) and the need for new revascularization (13.5% versus 10.3%, p=0.71) were similar for both groups. CONCLUSION: The in-hospital and late evolution of patients with multivessel coronary disease with and without involvement of the proximal segment of the anterior descending coronary artery treated with coronary stent placement did not differ. This suggests that this revascularization method is an effective procedure and a valuable option for treating these types of patients.

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Case Report

Cardiac Damage from Chronic Use of Chloroquine: A Case Report and Review of the Literature

Ricardo Alkmim Teixeira et al. Martino Martinelli Filho Luiz Alberto Benvenuti Roberto Costa … Anísio A. Pedrosa Silvana A. D. Nishióka

Chloroquine has been widely used in rheumatological treatment, but potential severe side effects require careful follow-up. Cardiac damage is not a common consequence, but its clinical relevance has not yet been described. We report the case of a 58-year-old woman with rheumatoid arthritis, in whom chronic chloroquine use resulted in major irreversible cardiac damage. She presented with syncopal episodes due to complete atrioventricular block confirmed by electrophysiological study whose changes were concluded to be irreversible and a permanent pacemaker was indicated. Endomyocardial biopsy was also performed to search for histopathological and ultrastructural cardiac damage. We also reviewed the 22 cases of chloroquine-induced cardiopathy described to date as well as its pathophysiology.

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Original Article

Body Mass Index: A Scientific Evidence-Based Inquiry

Djalma Rabelo Ricardo et al. Claudio Gil Soares de Araújo

OBJECTVE: To objectively and critically assess body mass index and to propose alternatives for relating body weight and height that are evidence-based and that eliminate or reduce the limitations of the body mass index. METHODS: To analyze the relations involving weight and height, we used 2 databases as follows: 1) children and adolescents from Brazil, the United States, and Switzerland; and 2) 538 university students. We performed mathematical simulations with height data ranging from 115 to 190 cm and weight data ranging from 25 to 105 kg. We selected 3 methods to analyze the relation of weight and height as follows: body mass index – weight (kg)/height (m²); reciprocal of the ponderal index – height (cm)/weight1/3 (kg); and ectomorphy. Using the normal range from 20 to 25 kg/m² for the body mass index in the reference height of 170 cm, we identified the corresponding ranges of 41 to 44 cm/kg1/3 for the reciprocal of the ponderal index, and of 1.45 to 3.60 for ectomorphy. RESULTS: The mathematical simulations showed a strong association among the 3 methods with an absolute concordance to a height of 170 cm, but with a tendency towards discrepancy in the normal ranges, which had already been observed for the heights of 165 and 175 cm. This made the direct convertibility between the indices unfeasible. The reciprocal of the ponderal index and ectomorphy with their cut points comprised a larger age range in children and adolescents and a wider and more central range in the university students, both for the reported (current) and desired weights. CONCLUSION: The reciprocal of the ponderal index and ectomorphy are stronger and are more mathematically logical than body mass index; in addition, they may be applied with the same cut points for normal from the age of 5 ½ years on.

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Original Article

Prevalence of Cardiac Arrhythmias During and After Pregnancy in Women with Chagas' Disease without Apparent Heart Disease

Renato Enrique Sologuren Achá et al. Marco Túlio Oliveira Rezende Rimmel Amador Guzmán Heredia Aguinaldo Coelho da Silva … Elmiro Santos Rezende Cleber Augusto Oliveira Souza

OBJECTIVE: To evaluate cardiac arrhythmias during and after pregnancy in women with Chagas’ disease without apparent heart disease using dynamic electrocardiography. METHODS: Twenty pregnant women with Chagas’ disease without apparent heart disease aged 19 to 42 years (26.96 ± 3.6) and a control group of 20 non-chagasic pregnant patients aged 16 to 34 years (22.5 ± 4.8). The patients were submitted to passive hemagglutination and indirect immunofluorescence for the detection of Trypanosoma cruzi evaluation, and electrocardiography, echocardiography and 24-h dynamic electrocardiography. RESULTS: Supraventricular premature depolarizations were observed in 18 (90%) patients and ventricular premature depolarization in 11 (55%) patients of both groups during pregnancy. After delivery, supraventricular premature depolarizations were present in 13 (60%) chagasic patients and in 16 (89.4%) control patients (P<=0.05). Ventricular premature depolarization were observed in 9 (45%) chagasic patients and 11 (57.8%) control patients. CONCLUSION: The prevalence of ventricular premature depolarization was similar for the chagasic and control groups during and after pregnancy. The incidence of supraventricular premature depolarizations was similar in the two groups during pregnancy, while after delivery a predominance was observed in the control group compared to the chagasic group.

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Case Report

Supravalvular Congenital Mitral Stenosis

Fernando Moraes et al. Cleuza Lapa Cristina Ventura Rejane Santana … Euclides Tenório Claudio Gomes Carlos R. Moraes

Congenital supravalvular mitral stenosis is a rare malformation characterized by the presence of a shelf-like fibrous membrane, with 1 or 2 small orifices, covering and obstructing the mitral valve. The membrane is positioned closely to the mitral valve (and sometimes it is attached to it); therefore, a preoperative diagnosis is inevitably difficult, even with the use of biplane echocardiography. Two patients with supravalvular mitral stenosis aged 3 years and 3 months are described. In 1 patient, a preoperative diagnosis was made, and both successfully underwent correction.

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Original Article

Correlations Between the Collagen Content of the Human Left Ventricular Myocardium, Measured by Biochemical and Morphometric Methods

José Duarte de Morais Lopes et al. Roseli Aparecida da Silva Gomes Valdemar Hial Isabel Cristina Rezende Lopes … Marlene Antônia dos Reis Vicente de Paula Antunes Teixeira

OBJECTIVE: To assess, in myocardium specimens obtained from necropsies, the correlation between the concentration of hydroxyproline, measured with the photocolorimetric method, and the intensity of fibrosis, determined with the morphometric method. METHODS: Left ventricle myocardium samples were obtained from 45 patients who had undergone necropsy, some of them with a variety of cardiopathies and others without any heart disease. The concentrations of hydroxyproline were determined with the photocolorimetric method. In the histologic sections from each heart, the myocardial fibrosis was quantified by using a light microscope with an integrating ocular lens. RESULTS: A median of, respectively, 4.5 and 4.3 mug of hydroxyproline/mg of dry weight was found in fixed and nonfixed left ventricle myocardium fragments. A positive correlation occurred between the hydroxyproline concentrations and the intensity of fibrosis, both in the fixed (Sr=+0.25; p=0.099) and in the nonfixed (Sr=+0.32; p=0.03) specimens. CONCLUSION: The biochemical methodology was proven to be adequate, and manual morphometry was shown to have limitations that may interfere with the statistical significance of correlations for the estimate of fibrosis intensity in the human myocardium.

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Original Article

Late Clinical Outcomes of the Fontan Operation in Patients with Tricuspid Atresia

Eduardo T. Mastalir et al. Renato A. K. Kalil Estela S. K. Horowitz Orlando Wender … João R. Sant'Anna Paulo R. Prates Ivo A. Nesralla

OBJECTIVE: Evaluation of the long-term clinical results of the Fontan operation in patients with tricuspid atresia. METHODS: A retrospective analysis was made at the Instituto de Cardiologia do Rio Grande do Sul (Institute of Cardiology of Rio Grande do Sul), from August 1980 through January 2000, of 25 patients with a long-term follow-up, out of a series of 36 patients who underwent the Fontan operation or one of its variants due to tricuspid atresia. Their mean age at surgery was 5.4±3.1 years, and their mean weight was 15.8±6.1 kg, the majority of them (63.9%) being males. Four patients underwent the classical Fontan operation, 12 the Kreutzer variant, 6 the Björk variant, 9 total cavopulmonary shunt with a fenestrated tube, and 5 total cavopulmonary shunt with a nonfenestrated tube. RESULTS: The patients were followed-up on an outpatient basis, with a mean long-term survival time of 5.5±4.2 years (50 days to 17.8 years) and a late mortality rate of 8%. Arterial saturation increased from 77.2±18.8% in the preoperative period to 91±6.7% upon the last outpatient visit (p>0.05). At the final check, most (67%) patients were asymptomatic and 87% could tolerate exercise. Ten (40%) patients experienced some kind of complication during the long-term follow-up, such as cardiac arrhythmia, cyanosis, protein-losing enteropathy, neurological events, right heart failure, intolerance to exercise and reoperation. CONCLUSION: The results indicate that, once the immediate postoperative period is over, during which the adaptations to the new circulatory physiology occur, the evolution of patients with tricuspid atresia who underwent the Fontan operation is satisfactory, in spite of a low, yet significant, morbidity.

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