2005;85(1) – ABC CARDIOL

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Case Report

Eikenella corrodens infective endocarditis

Juliano Novaes Cardoso et al. Marcelo Eidi Ochiai Múcio T. Oliveira Jr. Paulo Morgado … Robinson Munhoz Fernanda E. Andretto Alfredo José Mansur Antonio Carlos Pereira Barretto

The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) account for 3% of the cases of endocarditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of upper respiratory tract and oropharynx1,2. The following characteristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings¹; difficult diagnosis due to the fastidious nature of the microorganisms; and negative cultures3,4. The Eikenella corrodens endocarditis was first described in 1972(5). That microorganism continues to be a rare etiological agent. We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.

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Artigo Original

Cost analysis of the treatment of acute decompensated heart failure: levosimendan versus dobutamine

Mucio Tavares Oliveira Jr et al. Wilson Follador Maria Lucia Orlandi Martins Roberta Canaviera … Rosana Lima Garcia Tsuji Airton Scipioni Antonio Carlos Pereira Barretto

OBJECTIVE: To assess whether the treatment with levosimendan is more expensive than the usual one with dobutamine, since price of medications does not usually represent the greatest expense in the treatment of cardiac decompensation. METHODS: The cost of treatment of 18 inpatients with cardiac decompensation, 9 of which treated with dobutamine (dobuta group) and 9 with levosimendan (levo group), was compared. Groups were similar concerning age, sex, functional class and cardiac function. RESULTS: Treatment costs were similar for both groups. In the levo group, the costs with the drug were higher than in the dobuta group, but those related to the length of stay in intensive care unit and to the material used during admission were lower. Levo – drug: R$ 5,414.00; material: R$ 399.90; hospital daily rates: R$ 5,061.20; professional honorarium: R$ 3,241.80; total costs: R$ 14,117.00. Dobuta – drug: R$ 2,320.10; materials: R$ 1,665.70; hospital daily rates: R$ 6,261.90; professional honorarium: R$ 3,894.30; total costs: R$ 14,142.00. CONCLUSION: Despite the higher price of levosimendan, the global cost of the treatment was similar for patients who were treated either with dobutamine or levosimendan. Patients who were treated with levosimendan had a shorter length of stay in intensive care unit.

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Artigo Original

Surgical strategy for transposition of the great arteries with intact ventricular septum after the neonatal period

Bayard Gontijo Filho et al. Fernando A. Fantini Cristiane Martins Roberto Max Lopes … Roberto de S. Thiago Pereira Sonia Maria Rabelo Eliana Heyden Érika Vrandecic Mario O. Vrandecic

OBJECTIVE: To assess the surgical results in patients with transposition of the great arteries and intact ventricular septum undergoing surgery after the neonatal period. METHODS: From January 1998 to March 2004, 121 children with transposition of the great arteries with intact ventricular septum were treated, 29 (24%) of whom after the neonatal period. Selection for surgical treatment was based on echocardiographic assessment by use of the calculation of left ventricular mass and configuration of the ventricular septum. Of the 29 children, 12 were selected for primary anatomic correction, 12 for 2-stage correction after surgical preparation of the left ventricle, and 5 underwent atrial correction. RESULTS: In the group undergoing primary anatomic correction, one (8.3%) patient died at the hospital due to sepsis. In the group undergoing 2-stage correction, 5 patients underwent slow preparation with correction 3-6 months after the first stage, 4 of whom died after the first stage. This fact caused a change in our protocol, with adoption of the rapid preparation technique in the other 7 patients, of whom all achieved the second stage. Of the 8 children undergoing the second stage, one died at the hospital and another died later. Late clinical evolution of the children in both groups is excellent. CONCLUSION: The echocardiographic selection allowed a safe choice of the best surgical approach for patients with transposition of the great arteries and intact ventricular septum after the neonatal period.

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Artigo Original

Anthropometric indexes of obesity as an instrument of screening for high coronary risk in adults in the city of Salvador – Bahia

Francisco José Gondim Pitanga et al. Ines Lessa

OBJECTIVE: To compare some anthropometric indexes of obesity and identify among them which one best discriminates the high coronary risk (HCR). METHODS: A cross-section study, with sample consisting of 968 adults, between 30 and 74 years old, being 391 (40.4%) men. Many Receiver Operating Characteristic (ROC) curves were obtained and compared to areas under them among the conicity index (C index), body mass index (BMI), waist-hip circumference ratio (WHCR), waist circumference (WC) and HCR. The sensitivity and specificity to identify and compare the best cut-off point among the many indexes of obesity to discriminate the HCR were also identified. A confidence interval of 95% was used. RESULTS: The largest area under ROC curve was found between the C index and the HCR, in individuals of male sex, 0.80 (0.74-0.85), significantly differing from the other indexes of obesity. In women, the largest area found under the ROC curve was 0.76 (0.71-0.81), being equal between C, WHCR and HCR indexes. CONCLUSION: Those results show that C and WHCR indexes are the best indexes of obesity to discriminate HCR. WC has intermediate discriminatory power and the BMI was the least suitable anthropometric index of obesity to discriminate HCR. Those data suggest that the indexes of abdominal obesity are better to discriminate HCR than the indexes of general obesity.

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Artigo Original

Maximal heart rate in exercise tests on treadmill and in a cycloergometer of lower limbs

Claudio Gil Soares de Araújo et al. Vivian Liane Mattos Pinto

OBJECTIVE: To compare, retrospectively, the values of maximum heart rate (MHR) and the decrease of the heart rate at the first minute of recovery, which were obtained in an exercise test (ET) performed in two different ergometers and at different moments. METHODS: Sixty individuals (from 29 to 80 years old), submitted to cardiopulmonary ET in a cycle of lower limbs (CLL) in our laboratory and who had previous ET (up to 36 months) in a treadmill (TRM) in other laboratories, under identical conditions of medications of negative chronotropic action. RESULTS: MHR was similar in CLL: 156±3 and TRM: 154±2 bpm (p=0.125), whereas dHR was higher in CLL: 33±2, EST: 26±3 bpm (mean ± standard error of the mean) (p<0.001). In hemodynamic variables studied, the systolic blood pressure and the double product were higher in the ET-CLL (p<0.001). The electrocardiogram (ECG) was similar in both ETs, except due to more frequent supraventricular arrhythmias in CLL. CONCLUSION: a) With some diligence from the examiner and previous knowledge of MHR in a previous ET it is possible to obtain high levels of MHR in an ET-CLL; b) interrupting the MHR-based ET forecast through equations tends to lead to sub-maximum efforts; c) dHR differs in active and passive recoveries; d) new ways to analyze the HR behavior under exercise, which is not only the value of MHR, are necessary to characterize an ET as maximum.

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Artigo Original

Weaning from mechanical ventilation by using pressure support or T-tube ventilation: comparison between patients with and without heart disease

Alexandre Doval da Costa et al. Marcelo de Mello Rieder Silvia Regina Rios Vieira

OBJECTIVE: To assess cardiorespiratory variables during weaning from mechanical ventilation by using the T-tube and pressure support techniques, and to compare them in groups of patients with and without heart disease. METHODS: To assess the following parameters of 20 patients (57±15 years) undergoing weaning from mechanical ventilation: oxygenation; CO2 elimination; respiratory and heart rates; tidal and minute volumes; blood pressure; and electrocardiographic alterations. Data were recorded by using both techniques at the following times: zero, 15, and 30 minutes, and after a 30-minute interval. The patients were divided into 2 groups, with heart disease (n=11) and without heart disease (n=9), and then compared. RESULTS: The pressure support ventilation showed significantly more elevated oxygenation and CO2 elimination values, and reduced respiratory rate as compared with those of the T-tube ventilation. No difference was found in regard to blood pressure and heart rate. More patients with heart disease had alterations in the ST segment [7 (64%) patients versus 2 (22%)] and arrhythmias [3 (27%) versus 1 (11%)], as compared with patients without heart disease. A lower frequency of tachycardia was observed in those with heart disease. CONCLUSION: When comparing pressure support ventilation with T-tube ventilation, a better response was observed in the measurements of the respiratory and oxygenation parameters when using pressure support ventilation. No significant difference was observed in the measurements of cardiovascular parameters. In both weaning techniques, patients with heart disease had tachycardia less frequently, more alterations in the ST segment, and a greater tendency towards the occurrence of arrhythmias.

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Case Report

Prevailing right ventricular myocardiopathy for previous myocarditis or arrhythmogenic dysplasia?

Edmar Atik et al. Carlos Eduardo Rochitte Luis Francisco R. de Ávila Luiz J. Kajita Renata Bacic Palhares

A clinical case of a 10-year-old male patient is reported. His dilated and prevailing right ventricular myocardiopathy shows diagnostic difficulties between previous myocarditis etiology and arrhythmogenic dysplasia. As the elements are not pathognomonic of one or other cause, the increase of cardiac enzymes in subacute stage maybe tends to the supposition of previous myocarditis. Hence, the questioning that many cases labeled as arrhythmogenic dysplasia can truly correspond to the possibility of evolutional myocarditis. The controversial clinic management is disputable.

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Artigo Original

Cardiovascular risk factors and mortality: long-term follow-up (up to 20 years) in a preventive program carried out by occupational medicine

Luiz Alberto de Souza Ciorlia et al. Moacir Fernandes de Godoy

OBJECTIVE: The decrease in mortality due to cardiovascular diseases (CVD) has been achieved in the United States and the same decrease has been happening in developing countries, thanks to favorable changes in lifestyle and risk factors. Despite such consideration, the volume of information available on the distribution and behavior of that type of disease and its risk factors in Brazil is still little. METHODS: The assessment of changes in total cholesterol (TC), levels of blood pressure (BP), body mass index (BMI) and smoking was carried out, besides the occurrence of fatal (F) and non-fatal (NF) cardiovascular events, under dietary and behavioral intervention and long-term follow-up (up to 20 years) in a closed group, consisting of 621 electric power company workers of both sexes, with average age of 29.1±7.1 years old, varying from 15 to 59 years old. Actuarial curves were obtained to analyze the F and NF cardiovascular events. RESULTS: The TC mean showed significant reduction due to dietary guidance. The smoking habit decreased significantly with behavioral changes. The mean of the BPs decreased significantly with a better detection and hygienic measures, and the adhesion by definite hypertensive people to the treatment showed an index of 56.6%. On the other hand, the BMI showed an expressive and gradual increase. The probability for the individuals to remain free of any cardiovascular event was of 98.1%, whereas for the fatal events, it was 99.2%. CONCLUSION: Those results prove that initiatives directed towards the prevention must be priorities, aiming at modifying the morbimortatility rates of CVD.

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Artigo Original

Lipid profile and risk factors for cardiovascular diseases in medicine students

Vanessa Gregorin Coelho et al. Loeni Fátima Caetano Raphael Del Roio Liberatore Júnior José Antônio Cordeiro Dorotéia Rossi Silva Souza

OBJECTIVE: To analyze the lipid profile and its correlation with risk factors for cardiovascular diseases (CVD) among medicine students. METHODS: We assessed 153 students, regardless of sex, with age between 18 and 31 years old, submitted to lipid profile analysis, including serum levels of total cholesterol (TC), fraction of cholesterol of low (LDLc), high (HDLc) and very low density (VLDLc) lipoproteins and triglycerides (TG), besides of life habits and anthropometric data. Statistic analysis was employed, including the test of Mann Whitney, chi-square test, Pearson’s correlation and multivariate analysis, by adopting a significance level for a value of p<0.05. RESULTS: Sedentary lifestyle (43.1%) and familial history for CVD, particularly hypertension (74.5%), were distinguished. The lipid profile showed desirable, although altered levels of TC, LDLc and TG were detected in 11.8%, 9.8% and 8.5% from the students, respectively, and reduced levels of HDLc in 12.4% of them. Women showed significantly reduced values for LDLc and high values for HDLc compared to men's (p=0.031 and p<0.0001, respectively). There was a significant association between lipid profile and, preferably, body mass index (BMI), sedentary lifestyle, ingestion of alcohol, contraceptive use, familial antecedents of cerebrovascular accident and dyslipidemia. CONCLUSION: Familial history for CVD, sedentary lifestyle and contraceptive use among medicine students showed frequent and associated to the lipid profile, as well as ingestion of alcohol and BMI. Although with desirable lipid profile, regardless of sex, higher levels of LDLc and reduced levels of HDLc in male sex provide a disadvantage to men compared to women.

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Artigo Original

Annual cost of ischemic heart disease in Brazil: public and private perspective

Rodrigo A. Ribeiro et al. Renato G. B. Mello Raquel Melchior Juliana C. Dill … Clarissa B. Hohmann Angélica M. Lucchese Ricardo Stein Jorge Pinto Ribeiro Carisi A. Polanczyk

OBJECTIVE: To estimate the annual cost of coronary artery disease (CAD) management in Public Health Care System (SUS) and HMOs values in Brazil. METHODS: Cohort study, including ambulatory patients with proven CAD. Clinic visits, exams, procedures, hospitalizations and medications were considered to estimate direct costs. Values of appointments and exams were obtained from the SUS and the Medical Procedure List (LPM 1999) reimbursement tables. Costs of cardiovascular events were obtained from admissions in public and private hospitals with similar diagnoses-related group classifications in 2002. The price of medications used was the lowest found in the market. RESULTS: The 147 patients (65±12 years old, 63% men, 69% hypertensive, 35% diabetic and 59% with previous AMI) had an average follow-up of 24±8 months. The average estimated annual cost per patient was R$ 2,733.00, for the public sector, and R$ 6,788.00, for private and fee-for-service plans. Expenses with medications (R$ 1,154.00) represented 80% and 55% of outpatient costs, and 41% and 17% of total expenses, in public and non-public sectors, respectively. The occurrence of cardiovascular event had a great impact (R$ 4,626.00 vs. R$ 1,312.00, in SUS, and R$ 13,453.00 vs. R$ 1,789.00, for HMOs, p<0.01) on the results. CONCLUSION: The average annual cost of CAD management was high, being the pharmacological treatment the main determinant of public costs. Such estimates may subsidize economical analyses in this area, and foster related healthcare policies.

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Editorial

Economic impact of chronic ischemic cardiopathy treatment in Brazil: the challenge of new cardiovascular technology inclusion

Denizar Vianna Araujo et al. Marcos Bosi Ferraz

EDITORIAL

Economic impact of chronic ischemic cardiopathy treatment in Brazil. The challenge of new cardiovascular technology inclusion

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Artigo Original

Postprandial lipemia: influence of aging

Jaqueline Scholz Issa et al. Jayme Diament Neusa Forti

OBJECTIVE: To investigate the behavior of postprandial lipemia assessed by means of repeated measurements of triglyceride levels in healthy individuals aged from 20 to 50 years, divided into the following 3 age groups: GI – from 20 to 30 years; GII – from 31 to 40 years; and GIII – from 41 to 50 years. METHODS: Triglyceride levels were measured in 3 conditions: after a 12-hour fast, and 2 and 6 hours after a standard meal containing 40 g of fat. RESULTS: The repeated-measures analysis of triglyceride levels showed a distinct behavior of the age groups throughout the 6 hours. The younger participants (GI) had a reduction in the triglyceride levels in the sixth hour; the elderly (GIII) had increasing values in the sixth hour; and those in the intermediate age group (GII) maintained their triglyceride levels, when comparing the second and sixth hours of blood collection. The differences in behavior were significant (P=0.01). CONCLUSION: In a healthy adult population sample, aging influences the postprandial lipemia behavior.

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Artigo Original

Coarctation of the aorta in infants under one year of age: an analysis of 20 years of experience

Gabriel Lorier et al. Orlando Wender Renato A.K. Kalil Javier Gonzalez … Gustavo Hoppen Christiano Barcellos Abud Homsi-Neto Paulo R. Prates João R.M. Sant'Anna Ivo A. Nesralla

OBJECTIVE: A review of experience with techniques of correction used, in the last 20 years, in children younger than one year old. METHODS: In the period from 1978 to 1998, 148 patients (pt) with coarctation of the aorta (CoAo), under one year of age, with or without associated intracardiac defects, were submitted to surgery. Median age 50 days, 92 female pt (62.1%). The average weight was 4,367± 1,897 gr. The average follow-up was 1,152±1,462 days. The population was divided in 3 groups: Group I, isolated CoAo: 74 pt (50%); Group II, CoAo and interventricular communication (IVC): 41 pt (27.7%) and Group III, CoAo with complex intracardiac malformations: 33 pt (22.3%). RESULTS: The total mortality was of 43 patients (29%). In patients younger than 30 days, the mortality was 53%, p=0.009, DR=4.5, between 31 and 90 days, 14.7%, p=0.69, and over 91 days, 15%, p=0.004. The probability of actuarial survival of the whole population was 67% at 5 and 10 years. Thirty-six patients (24.3%) had recoarctation, from which 18 patients (50%) were younger than 30 days, DR=6.,35. The incidence of recoarctation was with Waldhausen technique in 4 patients (10%) and with the classic termino-terminal technique in 19 patients (26%) p=0.03, and isthmusplastic operation in 6 patients (37.5%). The patients younger than 30 days showed a relative risk for recoarctation de DR=6.35. The probability of actuarial survival, free of coarctation repair, at 5 and 10 years was of 69% with Waldhausen’s technique and 63% with the classic termino-terminal technique. CONCLUSION: Patients younger than 30 days showed increased mortality and recoarctation risk. Waldhausen’s technique in patients older than 30 days showed effective. The classic termino-terminal technique did not show to be a good option in all age ranges, being imperative to carry out more radical technical variations, such as the extended termino-terminal.

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Atualização

Thrombolytic therapy in prosthetic valve thrombosis

Marcelo Katz et al. Flavio Tarasoutchi Max Grinberg

UPDATE

Thrombolytic therapy in prosthetic valve thrombosis

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Case Report

Right atrial aneurysm associated to fetal hydrops: diagnosis through fetal echocardiography

Marcia Ferreira Alves Barberato et al. Silvio Henrique Barberato Cláudio Correa Gomes Sérgio Luis Costa Alfred Krawiec

Right atrium aneurysms are entities which are rarely reported in cardiologic practice, especially in intrauterine life, and may be mistaken with pericardial effusion and Ebstein’s anomaly. We show a review of the literature and illustrate with a case of prenatal diagnosis of right atrium aneurysm running through with hydropsy signs.

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Point of view

Therapeutics in clinical cardiovascular practice: experiences and evidence

Flávio Danni Fuchs

POINT OF VIEW

Therapeutics in clinical cardiovascular practice. Experiences and evidence

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