2006;87(5) – ABC CARDIOL

Point of view

The International Liaison Committee on Resuscitation (ILCOR): roll in guidelines 2005-2010 for cardiopulmonary resuscitation and emergency cardiovascular care

Sergio Timerman et al. Maria Margarita Castro Gonzalez Evandro Tinoco Mesquita Flavio Rocha Brito Marques … José Antônio Franchini Ramires Ana Paula Quilici Ari Timerman

POINT OF VIEW

The International Liaison Committee on Resuscitation (ILCOR). Roll in guidelines 2005-2010 for cardiopulmonary resuscitation and emergency cardiovascular care

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Progression of ventricular repolarization in left bundle branch block in non-compaction of the myocardium

Lurildo Ribeiro Saraiva et al. Giordano Bruno Parente Ricardo Loureiro Thiago B. Saraiva Leão

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Progression of ventricular repolarization in left bundle branch block in non-compaction of the myocardium

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Point of view

Magnetic resonance is useful in heart valvular disease

Marcelo Nigri et al. Carlos Eduardo Rochitte Max Grinberg

POINT OF VIEW

Magnetic resonance is useful in heart valvular disease

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Case Report

Tilt table test in the differential diagnosis of refractory "epilepsy"

Renata Rodrigues Teixeira de Castro et al. Antonio Claudio Lucas da Nóbrega

Epilepsy is one of the most frequent causes of neurological disorders in young adults. We report the case of a patient who lived with the diagnosis of refractory epilepsy for twelve years, when actually the cause of the symptoms could be found with the performance of a tilt table test. Cardiologists should be aware of the possible diagnosis of neurocardiogenic syncope in patients previously diagnosed with epilepsy, especially in those with difficult therapeutic control.

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Artigo Original

Assessment of the general knowledge of emergency physicians from the hospitals of the city of Salvador (Brazil) on the care of cardiac arrest patients

Nivaldo Menezes Filgueiras Filho et al. Antônio Carlos Bandeira Thales Delmondes Adriano Oliveira … Alberto Soares Lima Junior Vinicius Cruz Fábio Vilas-Boas Álvaro Rabelo Junior

OBJECTIVE: To identify the proportion of emergency physicians certified in immersion courses (ACLS – Advanced Cardiac Life Support and ATLS – Advanced Trauma Life Support) correlating the variables of age, gender, medical specialty, academic title, and type of hospital with the level of theoretical knowledge on the care of Cardiac Arrest (CA) victims. METHODS: Emergency physicians from public and private hospitals of the city of Salvador, State of Bahia – Brazil, were consecutively evaluated from November, 2003 to July, 2004. They volunteered to participate in the study, and responded to a questionnaire consisting of information on the following variables of interest: professional profile, participation or not in ACLS and ATLS immersion courses, and cognitive assessment with 22 objective questions on Cardiopulmonary Resuscitation (CPR). A score of correct answers was calculated for each participant, and then designated as score variable. This questionnaire was validated based on the result of the score obtained by ACLS course instructors in Salvador, BA. RESULTS: Of the 305 physicians who responded to the questionnaire, 83 (27.2%) had attended the ACLS course and had a mean score variable of 14.9+3.0 compared with the 215 physicians (70.5%) who had not attended the course and whose mean was 10.5+ 3.5 (p=0.0001). The mean score of the 65 cardiologists (21.5%) was 14.1+3.3 compared with the mean of 9.7+3.7(p=0.0001) of the 238 physicians (78.5%) from other specialties. No difference was observed in the mean scores between physicians who had attended the ATLS course or not (p=0.67). CONCLUSION: In the sample studied, theoretical knowledge on CPR was higher among physicians who had attended the ACLS course, as opposed to those who had attended the ATLS course. Cardiologists who had attended the ACLS demonstrated a higher theoretical knowledge on the care of CA patients when compared to physicians from other specialties taken as whole – Internal Medicine, Surgery, and Orthopedics.

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Case Report

Myocardial infarction associated with the use of a dietary supplement rich in ephedrine in a young athlete

Rafael Yared Forte et al. Daniel Precoma-Neto Nelson Chiminacio Neto Francisco Maia José Rocha Faria-Neto

Dietary supplements containing ephedrine and other alkaloids related to ephedrine are largely consumed in various countries, with the purpose of energetic stimulation and weight loss. Despite the fact that it is not approved for marketing in Brazil, these products may be freely purchased over the Internet or at gyms/fitness centers. We report the case of a young athlete with no risk factors for cardiovascular disease who experienced a myocardial infarction during the period in which he used an ephedrine-rich supplement.

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Artigo Original

Acute coronary syndrome registry at a cardiology emergency center

Elizabete Silva dos Santos et al. Luiz Minuzzo Marcos Paulo Pereira Maria Teresa Cabrera Castillo … Manoel Ângelo Gomes Palácio Rui Fernando Ramos Ari Timerman Leopoldo Soares Piegas

OBJECTIVE: Describe clinical characteristics of patients (P) admitted to hospital with suspected acute coronary syndrome (ACS), identifying medical treatment and in-hospital mortality. METHODS: Evaluated were 860 patients with ACS from January through December, 2003. We evaluated baseline characteristics, ACS mode of presentation, medication during hospital stay, indication for clinical treatment or myocardial revascularization (MR) and in-hospital mortality. RESULTS: Five hundred and three (58.3%) were male, mean age 62.6 years (± 11.9). Seventy-eight (9.1%) were discharged with the diagnosis of acute ST-elevation myocardial infarction (STEMI), 238 (27.7%) with non-ST-elevation myocardial infarction (non-STEMI), 516 (60%) with unstable angina (UA), two (0.2%) with atypical manifestations of ACS and 26 (3%) with non-cardiac chest pain. During hospitalization, 87.9% of patients were given a beta-blocker, 95.9% acetylsalicylic acid, 89.9% anti-thrombin therapy, 86.2% intravenous nitroglycerin, 6.4% glycoprotein (GP) IIb/IIIa receptor inhibitor, 35.9% clopidogrel, 77.9% angiotensin-converting enzyme inhibitor, and 70,9% statin drugs. Coronary arteriography was performed in 72 patients (92.3%) with STEMI, and in 452 (59.8%) with non-STEMI ACS (p< 0.0001). Myocardial revascularization (MR) surgery was indicated for 12.9% and percutaneous coronary intervention for 26.6%. In-hospital mortality was 4.8%, and no difference was recorded between the proportion of deaths among patients with STEMI and non-STEMI ACS (6.4% versus 4.8%; p = 0.578). CONCLUSION: In this registry, we provide a description of ACS patient, which allows the evaluation of the demographic characteristics, medical treatment prescribed, and in-hospital mortality. A greater awareness of our reality may help the medical community to adhere more strictly to the procedures set by guidelines.

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Editorial

Evaluation of coronary stent by cardiac computed tomography

Carlos Eduardo Rochitte

EDITORIAL

Evaluation of coronary stent by cardiac computed tomography

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Artigo Original

Intima-media thickness in the origin of right subclavian artery as an early marker of cardiovascular risk

Carlos Alberto Engelhorn et al. Ana Luiza Engelhorn Maria Fernanda Cassou Cassiana Casagrande Zanoni … Carlos José Gosalan Emerson Ribas Adriana Pacholok Marcela de Fátima Koehler

OBJECTIVE: Common carotid artery intima-media thickness (IMT) is considered a factor of cardiovascular risk and an early marker of coronary artery disease. This study aimed to investigate the existence of a correlation between IMT in the carotid arteries and at the origin of the right subclavian artery, as well as to evaluate IMT in the subclavian artery as an earlier marker of cardiovascular risk. METHODS: One hundred and six consecutive patients, 52 males and 54 females, average age 51 years, underwent color Doppler ultrasonography to evaluate carotid and right subclavian arteries. The relationship between carotid IMT and right subclavian IMT was assessed using the Pearson’s correlation coefficient analysis and a 95% confidence interval. Reliability of right subclavian artery IMT measurement for the diagnosis of early thickening (considering a > 0.8 mm carotid thickness as reference) was described as to sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Cut-off values for the right subclavian IMT were indicated by the ROC curve, and p values 0.8 mm. The mean IMT value for the carotid artery was 0.87 mm (SD = 0.23) and for the subclavian artery, 1.17 mm (SD = 0.46), with a 0.31 correlation coefficient (95% CI: 0.12; 0.47). The ROC curve analysis indicated a cut-off value of 0.7 mm for the right subclavian artery IMT, using as reference a 0.8 mm cut-off value for the carotid artery (91% sensitivity, 27% specificity, 66% PPV, 65% NPV, and 66% accuracy). CONCLUSION: Our study showed that carotid artery IMT correlates well with right subclavian artery IMT. With a 0.7 mm cut-off value, it is possible to detect IMT in the right subclavian artery earlier than in the carotid arteries. The IMT at the origin of the right subclavian artery can be considered an earlier marker for the assessment of cardiovascular risk.

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Artigo Original

Evolutive echocardiographic study of the structural and functional heart alterations in obese individuals after bariatric surgery

Luciana de Cerjat Bernardes P. Cunha et al. Cláudio L. Pereira da Cunha Admar Moraes de Souza Nelson Chiminacio Neto … Ricardo Soares Pereira Henrique Lacerda Suplicy

OBJECTIVE: To evaluate with Doppler echocardiography the reversibility of structural and hemodynamic changes in obeses after bariatric surgery. METHODS: Twenty-three patients (19 women = 82.6%) were studied. Mean age was 37.9 years. All subjects had Class III or Class II obesity with comorbidity and were submitted to bariatric surgery. Clinical and echocardiographic evaluation were performed preoperatively, in 6 months and 3 years after surgery. RESULTS: Preoperatively, the mean weight and blood pressure (BP) were respectively 128.7± 25.8 kg and 142.2 ± 16.2 / 92.2 ± 10.4 mmHg. Postoperatively, they showed important body weight reduction in 6 months (97.6 ± 18.3 kg) and 3 years (83.6 ± 13.5 kg), and BP reduction in 6 months (128.5 ± 16.1/80.7 ± 9.9 mmHg) that remain stable in 3rd year. On echocardiogram, preoperatively, there was hypertrophy of the septum and posterior wall associated with normal diastolic dimension; the predominant LV geometric pattern was concentric remodeling (74%). At six months, thinning of the ventricular septum and LV posterior wall, and increase in LV diastolic dimension were demonstrated. At 3rd year, the predominant LV pattern was normal (69%), with reduction of LV mass and LV mass/height² index. We noticed improved diastolic function, with an increased E/A ratio and a decreased LV isovolumic relaxation time. The Myocardial Performance Index was obtained retrospectively in 13 patients and improved in 6 months. There was an increase of the ejection time in 6 months and an elevation of the ejection fraction in 3rd year, suggesting improvement of the LV systolic function. CONCLUSION: The weight loss obtained with bariatric surgery promotes both structural and functional myocardial changes that improve cardiac performance.

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Artigo Original

Cardiac morphofunctional injuries in patients with hepatitis C virus: doppler echocardiographic evaluation

Carlos Tosta et al. Ricardo Ladeira Betty Guz João Pimenta

OBJECTIVE: To evaluate the possible morphological and functional heart injuries in hepatitis C virus patients. METHODS: Control-case study analyzing Doppler echocardiographic aspects in 31 hepatitis C virus patients and 20 controls. RESULTS: There were no significant difference in relation to the myocardial thickening, left ventricular diameters, circumferential shortening, ejection fraction, mitral valve flow velocities, tissue sistolic and diastolic mitral annular ones. CONCLUSION: Individuals with hepatitis C virus in the initial phases of the disease did not show morpho-functional abnormalities of the heart when evaluated by doppler echocardiography.

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Point of view

How long…? Possibilities, limits, criteria

Max Grinberg

POINT OF VIEW

How long…? Possibilities, limits, criteria

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Case Report

Multivessel percutaneous treatment of Takayasu Arteritis

Rogério Tadeu Tumelero et al. Júlio César Canfield Teixeira Norberto Toazza Duda Alexandre Pereira Tognon Mateus Rossato

We report the case of a female patient with obstructive lesions in the right and left carotid, right renal, left subclavian and left common iliac arteries which were percutaneously treated.

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Editorial

Periodontal disease as a potential risk factor for acute coronary syndromes

Carlos Vicente Serrano Jr. et al. Juliana Ascenção de Souza

EDITORIAL

Periodontal disease as a potential risk factor for acute coronary syndromes

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Case Report

Angina pectoris in patient with hyperthyroidism and normal angiography coronary

Alessandra Ferri Casini et al. Ilan Gottieb Leonardo V. Neto Carla A. Almeida … Regina H. A. Fonseca Mario Vaisman

In the presence of angina pectoris in a premenopausal woman without significant risk factors for coronary disease, we have to rule out other causes of coronary lesion of non atherosclerotic origin. The relations between hyperthyroidism and the cardiovascular system are well known, but hyperthyroidism is responsable for less than 5% of all causes of chest pain. We present a clinical case of a 47 year old woman with typical chest pain and eletrocardiogram (EKG) suggesting coronary ischemia but with normal laboratory data. Anamnesis, clinical and the laboratory data confirmed the diagnosis of hyperthyroidism. Further investigation showed a normal coronary angiography. After treatment with radioiodine and the establishment of euthyroidism, the patient remained asymptomatic and EKG and myocardial scintilography were negative for ischemia. These results suggest a cause and effect relationship between thyroid overactivity and myocardial ischemia, implying a probable etiological role for hyperthyroidism in the clinical and EKG findings.

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Electrocardiographic abnormalities preceding ventricular premature beats

Eder Trezza

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Electrocardiographic abnormalities preceding ventricular premature beats

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Artigo Original

Increase in systolic blood pressure during exercise testing after heart transplantation: correlation with the clinical condition and ventricular function assessed by dobutamine stress echocardiography

Ana Fátima Salles et al. Cristiano Vieira Machado Adriana Cordovil Wagner Aparecido Leite … Valdir Ambrósio Moisés Dirceu Rodrigues de Almeida Antonio Carlos Camargo Carvalho Japy Angelini Oliveira Filho

OBJECTIVE: Patients who underwent heart transplantation (HTX) experience a reduction in the elevation that is usual in systolic blood pressure during exercise testing. Of unknown origin, this phenomenon varies in frequency and intensity. The aim of this study was to analyze the relationship between systolic blood pressure increase (delta SBP) and clinical aspects, as well as variables measured during exercise testing (ET) and dobutamine stress echocardiography (DSE) in patients in the late post-transplantation course. METHODS: Forty-five men, mean age 49.04 ± 10.19, underwent clinical assessment, ET and DSE 40.91 ± 27.46 months after heart transplantation. Left ventricular wall motion score index and ejection fraction were assessed. Delta SBP < 35mmHg during ET was considered abnormal (SBC,1995). RESULTS: No significant correlation was found between delta SBP and post-transplantation time, graft ischemic time, history of rejection, diltiazem dosage, oxygen uptake, ejection fraction, and wall motion score index (WMSI). Delta SBP was normal in 17 patients (Group I) and abnormal in 28 (Group II). Patients of both groups did not differ significantly in regard to clinical features and ET and DSE results. CONCLUSION: Unlike other populations, no correlation was found between delta SBP during exercise testing and clinical condition or left ventricular function in heart transplant patients. Pathophysiological factors associated with delta SBP reduction during exercise testing remain unknown.

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Clinical Update

The role of aerobic exercise on endothelial function and on cardiovascular risk factors

Jeffer Eidi Sasaki et al. Maria Gisele dos Santos

CLINICAL UPDATE

The role of aerobic exercise on endothelial function and on cardiovascular risk factors

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Saddle shape of mitral valve annulus: three-dimensional transthoracic echocardiography

Marcelo Luiz Campos Vieira et al. Prasad Maddukuri Natesa G. Pandian Wilson Mathias Jr. José Antônio F. Ramires

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Saddle shape of mitral valve annulus: three-dimensional transthoracic echocardiography

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Case Report

Tadalafil as treatment for idiopathic pulmonary arterial hypertension

Adriana Castro de Carvalho et al. André Luiz Hovnanian Caio Julio César dos Santos Fernandes Mônica Lapa … Carlos Jardim Rogério Souza

Phosphodiesterase inhibitors like sildenafil have already been shown to improve functional capacity and hemodynamics in the treatment of pulmonary arterial hypertension. Few studies address the effects of new phosphodiesterase inhibitors as tadalafil. We report a case of a patient with idiopathic pulmonary arterial hypertension in functional class IV (New York Heart Association) with significant response to treatment with tadalafil.

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Case Report

In-hospital and late outcomes after coronary stenting in patient with unstable angina and myelodysplastic syndrome

Oliveira Wercules et al. George César Ximenes Meireles Allan Longhi Pedro Beltrão João Pimenta

Sixty-one-year-old male patient with diagnosis of myelodysplastic syndrome and unstable angina was submitted to coronary angiography and implant of stent. His Blood vell count revealed 40,000 platelets/mm³. Coronary angiography with previous platelet transfusion showed obstruction of 80% of the right coronary artery (RCA). Following the administration of clopidogrel, the patient was submitted to another platelet transfusion and stent implantation in the RCA lesion. No bleeding was observed after the introducers removal. After 6 months, treadmill test was positive and new coronary aniography, in the same conditions, showed in-stent restenosis. This case report suggests that coronary stent implantation in patients with thrombocytopenia is a safe procedure, provided that prophylactic platelet transfusion is performed, although late restenosis may occur.

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Artigo Original

Trends in the risk of death from cardiovascular, cerebrovascular and ischemic diseases in thirteen States of Brazil from 1980 to 1998

Antonio de Padua Mansur et al. Maria de Fátima Marinho de Souza Ari Timerman Solange Desirée Avakian … José Mendes Aldrighi José Antonio Franchini Ramires

OBJECTIVE: Analyze the trends in the risk of death from circulatory diseases (CD) in thirteen states in Brazil between 1980 and 1998. METHODS: Data on mortality from CD, ischemic heart diseases (IHD), and cerebrovascular diseases (CVD) in thirteen states were obtained from the Ministry of Health data base. Populational estimates from 1980 to 1998 were calculated through interpolation, using the Lagrange method, based on data from the 1970, 1980, 1991 censuses, and 1996 populational count. The trends were analyzed by multiple linear regression model. RESULTS: Mortality due to CD showed a trend towards decrease in most states. In Pernambuco state males presented increase in all age ranges, whereas in Goiás increase was shown from 40 years of age on, and in Bahia and Mato Grosso, from 50 years of age. Females showed increase starting at 30 in Mato Grosso, at 40 in Pernambuco, and in Goiás, in the age ranging from 30 to 49 years of age. In Goiás, increase was discreet in all other age ranges. As for IHD, mortality increase was reported in all age ranges in Mato Grosso and Pernambuco; in Bahia, Goiás and Pará, from 40 on. As for CVD, mortality increase was reported in all age ranges in Mato Grosso and Pernambuco; and from 40 on in Bahia and Goiás. CONCLUSION: Significant increase in the risk of death from circulatory diseases could be observed in less developed states in Brazil.

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Artigo Original

Ten-year experience with the Ross operation

Francisco Diniz Affonso da Costa et al. Elaine Welk Lopes Pereira Luiz Eduardo Barboza Hermínio Haggi Filho … Claudinei Collatusso Carlos Henrique Gori Gomes Sérgio Augusto Veiga Lopes Evandro Antônio Sardetto Andréa Dumsch de Aragon Ferreira Marise Brenner Affonso da Costa Iseu Affonso da Costa

OBJECTIVE: To evaluate the 10-year outcomes of the Ross Operation, analyzing survival rate, incidence of reoperations, and late performance of pulmonary autografts and homografts in the reconstruction of the right ventricular outflow tract. METHODS: Two hundred and twenty seven patients with a mean age of 29.1±11 years underwent Ross operation from May 1995 to February 2005. The most prevalent etiology was rheumatic disease in 61% of the cases. Autografts were implanted using the total root replacement technique in 202 cases, with intraluminal cylinder in 20, and in the subcoronary position in 5. The right ventricular outflow tract was conventionally reconstructed with cryopreserved homografts (n = 160), with proximal extension of the homograft with pericardium (n = 41), and with decellularized homografts (n = 26). The postoperative follow-up ranged from 1 to 118 months (mean = 45.5 months). RESULTS: Hospital mortality was 3.5%, and long-term survival was 96.9% at ten years. No episodes of thromboembolism and only two cases of endocarditis occurred. Eleven patients underwent reoperation because of problems related to the auto and/or homograft, progression of rheumatic mitral valve disease, and iatrogenic coronary insufficiency. After 10 years, 96.4% and 96.2% of the patients were free from reoperation in the autograft and homograft groups, respectively. No late autograft dilatation was observed. Reconstruction of the left ventricular outflow tract with decellularized homografts significantly reduced the incidence of gradients on late follow-up. CONCLUSION: Late outcomes with the Ross Operation were associated with an excellent long-term survival and a low incidence of reoperations and late morbidity. We consider this procedure the best option for the surgical treatment of aortic valve disease in children and young adults.

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Case Report

Surgical correction of total anomalous pulmonary venous drainage in an adult

Walter Villela de Andrade Vicente et al. Paulo Savoia Dias-da-Silva Luciana de Morais Vicente Solange Bassetto … Mina Moreira Dias Romano César Antonio Ferreira Lycio Umeda Dessote Paulo Henrique Manso Paulo Roberto Barbosa Évora Alfredo José Rodrigues

Total anomalous pulmonary venous drainage (TAPVD) is rarely seen in adults, because this congenital heart disease almost always requires surgical treatment in the neonatal period, often on an emergency basis. We report a patient that, despite being diagnosed during childhood, underwent surgical repair at age 25, about one year after his clinical condition worsened.

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