2004;83(2) – ABC CARDIOL

Artigo Original

Quantification of left ventricular infarcted mass on cardiac magnetic resonance imaging: comparison between planimetry and the semiquantitative visual scoring method

Clerio Francisco de Azevedo Filho et al. Marcelo Hadlich João Luiz Fernandes Petriz Luís Antonio Mendonça … Jorge Neval Moll Filho Carlos Eduardo Rochitte

OBJECTIVE: To compare a new semiquantitative visual scoring method with quantitative digital planimetry for determining left ventricular infarcted mass by use of cardiac delayed contrast-enhanced magnetic resonance imaging. METHOD: Seventy-seven patients with previous myocardial infarction underwent delayed contrast-enhanced magnetic resonance imaging using a 1.5T device for assessing myocardial viability and calculating the infarcted mass. Cine magnetic resonance imaging was used for assessing left ventricular function with the Simpson method. The infarcted mass was calculated on the delayed contrast-enhanced images according to the following 2 methods: planimetry and the scoring method. Simple linear regression and correlation and agreement between the methods and observers according to the Bland-Altman plot were used. RESULTS: The infarcted areas in all 77 patients were detected by use of cardiac delayed contrast-enhanced magnetic resonance imaging. The size of the infarction measured by planimetry was similar to that obtained with the scoring method, with a mean difference between measurements of only 1.03% of the left ventricular mass. Inter- (0.41%) and intraobserver (0.34%) variabilities indicated an excellent reproducibility of the scoring method. Infarcted mass showed a good correlation with ejection fraction and indexed end-diastolic and end-systolic volumes, r=-0.76, r=0.63, and r=0.67, respectively. CONCLUSION: In patients with previous myocardial infarction, delayed-enhanced magnetic resonance imaging provides accurate infarct size quantification by planimetry and by semiquantitative score.

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Artigo Original

Analysis of heart rate variability in hypertensive patients before and after treatment with angiotensin II-converting enzyme inhibitors

Antônio da Silva Menezes Júnior et al. Humberto Graner Moreira Murilo Tavares Daher

OBJECTIVE: To compare heart rate variability in normotensive and hypertensive individuals and to observe the behavior of the autonomic nervous system after treatment with angiotensin II-converting enzyme inhibitors. METHOD: The study comprised 286 patients diagnosed with arterial hypertension (AH) for the first time and divided into 4 groups according to diastolic blood pressure (DBP) levels: group A – DBP110 mmHg. Group A (110 healthy individuals) and group C (79 patients with moderate AH) underwent 24-hour Holter-ECG with analysis of heart rate variability in time domain (TD) and frequency domain (FD). The group C patients were treated with ACE inhibitors for 3 months, and, after this period, they underwent a new 24-hour Holter-ECG study for assessing heart rate variability, the values being compared with those of normotensive individuals. RESULTS: The SDNN and PNN50 parameters (TD), and the LF spectrum (FD) were significantly different in the 2 groups, with clearly reduced values in hypertensive individuals (P<0.05). Group C patients, after treatment with ACE inhibitors, showed a recovery in all variables of heart rate variability, achieving values close to those of normotensive individuals. CONCLUSION: Heart rate variability was reduced in hypertensive patients when compared with that in normotensive individuals, indicating a decrease in the baroreceptor reflex. A functional autonomic adjustment after the antihypertensive treatment with ACEI was observed, indicating recovery of parasympathetic tonus.

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Artigo Original

Validation of the 4-second exercise test in the orthostatic position

Marcos Bezerra de Almeida et al. Djalma Rabelo Ricardo Claudio Gil Soares de Araújo

OBJECTIVE: To test the operational viability of and validate the 4-second exercise test (4sET) protocol in the orthostatic position (ORTHO). METHODS: The ORTHO protocol, an alternative to the conventional protocol (CYCLO), was used. The ORTHO protocol consists of performing sudden exercise in the orthostatic position – accelerated stationary walking (alternate upward flexion of the thighs) – from the fourth to the eighth second of a 12-second maximum inspiratory apnea, instead of rapid cycling without load. The adimensional cardiac vagal index (CVI) was calculated using the ratio between the longest RR interval (RRB) – the one immediately before, or the first during exercise – and the shortest RR interval during exercise – usually the last (RRC) – measured on electrocardiographic tracings at a 10-ms resolution. Forty-seven individuals (40±17 years, 169±9 cm, 72±14 kg) of both sexes, healthy or unhealthy, randomly underwent 3 consecutive repetitions of the 2 protocols, the first being performed only to acquaint patients with the procedure. RESULTS: Although differences in the CVI were found in both protocols (1.48±0.04 vs 1.42±0.04; P<0.001), no physiological relevance was observed. In 5 (11%) cases, a clinically significant difference between the ORTHO and CYCLO protocols was observed for CVI. The results of RRB, RRC, and CVI in the 2 protocols were strongly correlated, being 0.84, 0.85, and 0.93, respectively (P<0.001). CONCLUSION: The 4sET performed in the orthostatic position proved to be a valid option for assessing the vagal cardiac tonus in laboratories lacking a cycloergometer, without jeopardizing clinical interpretation. In addition to simplicity and applicability, the procedure also provides low operational costs.

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Artigo Original

Anti-beta2-glycoprotein I antibodies as risk factors for acute myocardial infarction

Aline Ranzolin et al. Jussara Marilú Bohn Gary L. Norman Euler Manenti … Luis Carlos Bodanese Carlos Alberto von Mühlen Henrique Luiz Staub

OBJECTIVE: To determine whether high levels of antibodies against the phospholipid beta2-glycoprotein I (beta2-gpI) cofactor are associated with an increase in the risk of acute myocardial infarction. METHODS: The study comprised 82 patients with acute myocardial infarction and 82 controls, who were assessed in regard to age, sex, race, hypertension, smoking, previous heart disease, history of diabetes mellitus, and hypercholesterolemia. The following antibodies were detected using immunoassay: anticardiolipin and anti-beta2-gpI IgA, IgG, and IgM. Adjusted odds ratios (OR) for risk factors were obtained through logistic regression. RESULTS: The mean ages of the cases and controls were, respectively, 57.7 and 51.1 years (P=0.003). Men (P=0.005) and the white race predominated in both groups (P=0.798). Of the risk factors, a history of diabetes (OR=5.3; 95% CI: 1.9 to 14.9; P=0.001) and previous heart disease (OR=4.7; 95% CI: 2.0 to 10.7; P<0.001) were the most consistent associations with myocardial infarction. The frequency of anticardiolipin IgG, IgM, and IgA antibodies did not differ between cases and controls (P=1.000). Anti-beta2-gpI IgA antibodies were more frequent in cases than in controls (P=0.054). The adjusted OR for anti-beta2-gpI IgA antibodies was 3.4 (95% CI: 1.3 to 9.1; P=0.015). CONCLUSION: Anti-beta2-gpI IgA antibodies, but not anticardiolipin antibodies, seemed to behave as independent risk factors for myocardial infarction, which may represent a link between autoimmunity and atherosclerosis in patients with acute myocardial infarction.

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Artigo Original

Acute renal failure after coronary artery bypass surgery with extracorporeal circulation: incidence, risk factors, and mortality

Fernando Oliveira Santos et al. Marco Antonio Silveira Roberto Barreto Maia Marcelo Dantas Cerqueira Monteiro Reinaldo Martinelli

OBJECTIVE: To identify the incidence, risk factors, and mortality of acute renal failure (ARF) in patients undergoing myocardial coronary artery bypass surgery with extracorporeal circulation. METHODS: All patients undergoing myocardial coronary artery bypass surgery were prospectively studied, and their clinical and laboratory variables were assessed using uni- and multivariate analysis (logistic regression). RESULTS: Acute renal failure occurred in 16.1% of the 223 patients studied; 4.9% of patients required dialysis. Risk factors associated with ARF in the univariate analysis were age > 63 years, OR 3.6 (95% CI=1.6 to 8.3); preoperative serum creatinine > 1.2 mg/dL, OR 5.9 (95% CI=2.4 to 14.6); duration of extracorporeal circulation > 90 min, OR 2.1 (95% CI=1.0 to 4.4); use of intraaortic balloon, OR 2.6 (95% CI=1.2 to 5.5); need for inotropic drugs, OR 4.4 (95% CI=1.9 to 10.2). In the multivariate analysis, independent factors associated with ARF were: age > 63 years, OR 3.0 (95% CI=1.3 to 7.2); preoperative serum creatinine > 1.2 mg/dL, OR 4.3 (95% CI=1.6 to 11.4); need for inotropic drugs, OR 3.2 (95% CI=1.3 to 8.0). Mortality in the patients with ARF was 25.0% compared with 1.1% in those without ARF and 63.6% in those who required dialysis. CONCLUSION: Acute renal failure after myocardial coronary artery bypass surgery is a frequent complication associated with a high mortality rate. The independent risk factors are age, previous renal failure, and the need for inotropic drugs.

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Artigo Original

Risk factors, morbidity, and mortality associated with atrial fibrillation in the postoperative period of cardiac surgery

Rogério Gomes da Silva et al. Gustavo Glotz de Lima Andréia Laranjeira Altamiro Reis da Costa … Edemar Pereira Rubem Rodrigues

OBJECTIVE: To determine the incidence of atrial fibrillation in the postoperative period of cardiac surgery, its impact on morbidity, mortality, and hospital stay, and to analyze the risk factors in the pre, trans, and postoperative periods. METHOD: Contemporary cohort study with 158 adult patients undergoing cardiac surgery, of whom those with atrial fibrillation in the preoperative period were excluded. The patients were assessed with continuous cardiac monitoring and daily electrocardiograms. Any episode of irregular rhythm with the presence of f waves of variable morphology and amplitude was considered atrial fibrillation. RESULTS: The general incidence of atrial fibrillation was 28.5%, being 21.6% for revascularized patients and 44.3% for those undergoing valvular repair. Factors independently associated with atrial fibrillation were left heart failure in the preoperative period (p=0.05; RC=2.2), total fluid balance (p=0.01; RC=1.0), duration of surgery (p=0.03; RC=1.01) [and other associated factors, age > 70 years, aortic valvular disease, psychomotor agitation, length of installation of the drains, pulmonary congestion and respiratory insufficiency in the postoperative period]. The use of beta-blockers (p=0.01; RC=0.3) was a protective factor. Atrial fibrillation in the postoperative period was associated with an increase in the length of hospital stay (16.9±12.3 days versus 9.2±4.0 days, p<0.001) and a greater incidence of stroke or postoperative death (p=0.02). CONCLUSION: The incidence of atrial fibrillation in the postoperative period of cardiac surgery was high and caused a significant increase in morbidity, mortality, and the length of hospital stay. Among the independent risk factors, excessive fluid balance is significant. The use of beta-blockers was identified as a protective factor.

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Artigo Original

Hypertensive crisis profile: prevalence and clinical presentation

José Fernando Vilela Martin et al. Érika Higashiama Evandro Garcia Murilo Rizzatti Luizon José Paulo Cipullo

OBJECTIVE: To assess the prevalence of hypertensive crisis, related clinical findings, and the organic lesions involved. METHOD: This retrospective study comprised the analysis of the medical records of symptomatic patients with an elevation in diastolic blood pressure levels > 120 mmHg, who sought the emergency unit of a university-affiliated hospital over 12 months. Hypertensive urgency was characterized as the symptomatic elevation of blood pressure levels with no evidence of target-organ lesions, and hypertensive emergency was characterized as the symptomatic elevation of blood pressure levels with evidence of acute or ongoing target-organ lesion. RESULTS: This study comprised 452 patients with hypertensive crisis, accounting for 0.5% of all clinicosurgical emergencies, of which, 273 (60.4%) were hypertensive urgencies and 179 (39.6%) were hypertensive emergencies. Eighteen percent of the patients ignored their hypertensive condition. Smoking and diabetes were risk factors associated with the development of a hypertensive crisis in 1/4 and 1/5 of the patients, respectively. The patients with a hypertensive emergency were older (59.6±14.8 versus 49.9±18.6 years, p < 0.001) and had greater diastolic blood pressure (129.1±12 versus 126.6±14.4 mmHg, p < 0.05) than those with hypertensive urgencies. Ischemic stroke and acute pulmonary edema were the most common hypertensive emergencies, being in accordance with the most frequently found clinical manifestations of neurologic deficit and dyspnea. CONCLUSION: Hypertensive crises accounted for 0.5% of all emergency cases studied and for 1.7% of all clinical emergencies, hypertensive urgency being more common than hypertensive emergency. Ischemic stroke and acute pulmonary edema were the most frequent target-organ lesions in hypertensive emergencies.

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Case Report

Generalized edema and hyperdynamic circulation: a possible case of beriberi

Marcos F. Minicucci et al. Leonardo A. M. Zornoff Mirna Matsue Roberto M. T. Inoue … Luiz S. Matsubara Marina P. Okoshi Katashi Okoshi Álvaro O. Campana Sergio A. R. Paiva

CASE REPORT

Generalized edema and hyperdynamic circulation. A possible case of beriberi

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Quantification of left ventricular infarcted mass on cardiac magnetic resonance imaging: comparison between planimetry and the semiquantitative visual scoring method

Analysis of heart rate variability in hypertensive patients before and after treatment with angiotensin II-converting enzyme inhibitors

Validation of the 4-second exercise test in the orthostatic position

Anti-beta2-glycoprotein I antibodies as risk factors for acute myocardial infarction

Acute renal failure after coronary artery bypass surgery with extracorporeal circulation: incidence, risk factors, and mortality

Risk factors, morbidity, and mortality associated with atrial fibrillation in the postoperative period of cardiac surgery

Hypertensive crisis profile: prevalence and clinical presentation

Generalized edema and hyperdynamic circulation: a possible case of beriberi

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