2008;91(3) – ABC CARDIOL

Anatomopathological Session

Case 5/2008: 44-year-old male patient that died of cardiogenic shock on the 6th postoperative day asfter orthotopic heart transplant

Rodrigo Pinto Pedrosa et al. Mariane Venturoli Ferreira Paulo Sampaio Gutierrez

ANATOMOPATHOLOGICAL SESSION

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Artigo Original

Economic burden of severe cardiovascular diseases in Brazil: an estimate based on secondary data

Maria Inês Reinert Azambuja et al. Murilo Foppa Mário Fernando de Camargo Maranhão Aloyzio Cechella Achutti

BACKGROUND: The scarce amount of data available in Brazil on the economic burden of cardiovascular diseases (CVD) does not justify the growing concern in regard to the economic burden involved. OBJECTIVE: The present study aims at estimating the costs of severe CVD cases in Brazil. METHODS: Cases of severe CVD were estimated based on hospitalized cases lethality and total CVD mortality rates. National data bases and sample studies were used to estimate costs of hospitalization, outpatient care, and social security benefits. Loss of income was estimated from the Burden of Disease in Brazil data. RESULTS: Approximately two million cases of severe CVD were reported in 2004 in Brazil. That accounts for 5.2% of the population over 35 years of age. The resulting annual cost was at least R$ 30.8 billion (36.4% for health care, 8.4% for social security and employers’ reimbursements, and 55.2% due to loss in productivity). That corresponded to R$ 500.00 per capita (considering 35 year-old and older population) and R$ 9,400.00 per patient. Direct costs with health care from severe CVD cases accounted for 8% of total national expenditure on health and 0.52% of 2004 GNP (R$ 1,767 billion = US$ 602 billion). That corresponded to an yearly average direct cost of R$182.00 per capita (R$ 87.00 from public resources) and of R$ 3,514.00 per case. CONCLUSION: Total annual costs per severe CVD case were estimated to be significant. Costs per capita and total costs corresponding to this sub-group of CVD patients are expected to escalate as the population ages and the prevalence of severe cases increases.

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Artigo Original

Effect of local anesthetics with and without vasoconstrictor agent in patients with ventricular arrhythmias

Maria Teresa Fernández Cáceres et al. Ana Cristina P. P. Ludovice Fabio Sândoli de Brito Francisco Carlos Darrieux … Ricardo Simões Neves Mauricio Ibrahim Scanavacca Eduardo A. Sosa Denise Tessariol Hachul

BACKGROUND: The routine use of local anesthetics associated to vasoconstrictors for the dental treatment of patients with cardiopathies is still controversial, due to the risk of adverse cardiovascular effects. OBJECTIVE: To evaluate and compare the hemodynamic effects of the use of local anesthetics with a non-adrenergic vasoconstrictor in patients with ventricular arrhythmia, when compared to the use of anesthetics without vasoconstrictor. METHODS: A prospective randomized study evaluated 33 patients with positive serology for Chagas’ disease and 32 patients with coronary artery disease that presented complex ventricular arrhythmia at Holter monitoring (>10 EV/h and NSVT), of which 21 were females, aged 54.73 + 7.94 years, submitted to routine dental treatment with pterygomandibular anesthesia. These patients were divided in two groups: group I received prilocaine 3% associated with felypressin 0.03 IU/ml and group II received lidocaine 2% without vasoconstrictor. The number and complexity of extrasystoles were analyzed, as well as the heart rate and systemic arterial pressure of the patients on the day before, one hour before, during the procedure and one hour after the dental procedure. RESULTS: No hemodynamic alterations or increase in the number and complexity of the ventricular arrhythmia related to the anesthetic used in the dental procedure were observed in either group. CONCLUSION: The results suggest that prilocaine 3% associated to a felypressin 0.03 IU/ml can be safely used in patients with Chagas’ disease or coronariopathy with complex ventricular arrhythmia.

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Relato de Caso

Right ventricular tumor in a patient with melanoma

Vinícius Daudt Morais et al. Flávio Dalbem Krás Borges Vicente Restelli

Primary tumors of the heart are not common. However, metastatic neoplasms affecting the heart are more commonly found. Postmortem studies have shown that some tumors have reported secondary cardiac implants to be over 50%. Such involvement is to be taken into account for patients with a history of neoplasm and who present conduction disorders, murmur, cardiomegaly or arrhythmia. This is to report the case of a 39-year-old man who had been referred due to fatigue and dyspnea on effort. Echocardiogram evidence showed large tumoral mass in right ventricle. Medical history showed previous melanoma; further evaluation showed metastasis to lungs, heart and brain. Outcome was death. The uniqueness in this case relies on the large metastatic mass in right ventricle, thus illustrating a rare clinical condition of guarded prognosis.

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Point of view

In contraposition to the article: carotid endarterectomy is the best choice for patients with carotid disease

Manuel Nicolas Cano

POINT OF VIEW

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Artigo Original

Ventricular dyssynchrony index: comparison with two-dimensional and three-dimensional ejection fraction

Marcelo L. C. Vieira et al. Alexandre F. Cury Naccarato Gustavo Wercules A. Oliveira … Cláudia G. Monaco Adriana Cordovil Ana C. T. Rodrigues Edgar B. Lira Filho Cláudio H. Fischer Samira S. Morhy

BACKGORUND: Left ventricular (LV) electromechanical coupling (synchrony) is important in the analysis of the systolic performance, especially for the indication of cardiac resynchronization therapy in patients with advanced CHF. OBJECTIVE: To compare LV synchrony as analyzed by real-time three-dimensional (3D) echocardiography (ECHO) with LVEF measurements as obtained with 2D and 3D ECHO. METHODS: Prospective study of 92 individuals (56 men, 47 ± 10 years of age), of which 60 had normal heart structure (ECHO) and ECG (N group), and 32 had dilated cardiomyopathy (DCM group). Using 3D ECHO, LVEF, volumes and dyssynchrony index (%DI) for 16 LV segments were measured. Using 2D ECHO, LVEF (Simpson’s method), and LV systolic and diastolic volumes were measured. Statistical analysis: Pearson’s correlation coefficient, 95% CI, linear regression model, Bland & Altman analysis, p<0.05. RESULTS: %DI ranged from 0.2900 to 28.1000 (5.2014±6.3281), 3D LVEF ranged from 0.17 to 0.81 (0.52±0.17); and 2D LVEF ranged from 0.3 to 0.69 (0.49±0.11). The correlation between DI and 3D LVEF was (r): -0.7432, p<0.0001, CI: -0.8227 to -0.6350, the linear relation between DI (x) and 3D LVEF (y) was y = 19.8124 + (-27.9578) x, p<0.0001. The correlation between DI and 2D LVEF was (r): -0.7012, p<0.0001, CI: -0.7923 to -0.5797. CONCLUSION: In this case series, a good negative correlation was observed between LV electromechanical three-dimensional systolic coupling and LVEF as measured by echocardiography (3D and 2D).

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Artigo Original

Angiotensin-converting enzyme in pericardial fluid: comparative study with serum activity

Roseli Aparecida da Silva Gomes et al. Lívia das Graças Vieito Lombardi Teodoro Isabel Cristina Rezende Lopes Patrícia Alessandra Bersanetti … Adriana Karaoglanovic Carmona Valdemar Hial

BACKGROUND: The characterization of an angiotensin-converting enzyme (ACE) in human pericardial fluid is relevant, considering its role in the angiotensin II release and thus, the role of the pericardium in cardiovascular homeostasis. OBJECTIVE: To isolate and characterize an ACE from human pericardial fluid and to compare the angiotensin I converting activities of the pericardial fluid with that of the serum in patients submitted to cardiovascular surgery. METHODS: The enzyme from human pericardial fluid was purified through chromatographic steps and characterized by polyacrylamide gel electrophoresis (SDS-PAGE), hydrolysis of angiotensin I, bradykinin, Hip-His-Leu and synthetic substrates with internal fluorescence suppression. Lisinopril was used as inhibitor. The ACE activity was measured in blood and pericardial fluid samples of 23 patients submitted to cardiovascular surgery. RESULTS: The purified ACE (MM = 140 kDa), releases angiotensin II, hydrolyses bradykinin and the Hip-His-Leu substrate. The kinetic parameters k cat,(s-1) and k cat/Km (µM-1. s-1) were, respectively: Hip-His-Leu (1.14 and 7 x 10 -4) ; Abz-YRK(Dnp)P-OH (2.60 and 0.77), Abz-LFK(Dnp)-OH (2.77 and 0.36) and Abz-SDK(Dnp)P-OH (1.92 and 0.19). The angiotensin I converting activities (mean ± SD) in the pericardial fluid and in blood, were, respectively: 3.16 ± 0.90 mU x mg -1x min-1 and 0.33 ± 0.11 mU x mg -1x min-1. The difference was significant between the two fluids. CONCLUSION: An ACE that bears great similarity with the somatic enzyme was isolated from human pericardial fluid. The angiotensin I converting activity is higher in the pericardial fluid when compared to the serum activity. These data are important evidence of the role of the pericardial fluid in the metabolism of active peptides.

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Artigo Original

Hyperkalemia during spironolactone use in patients with decompensated heart failure

Marcelo Villaça Lima et al. Marcelo Eidi Ochiai Juliano Novaes Cardoso Paulo César Morgado … Robinson Tadeu Munhoz Antonio Carlos Pereira Barretto

BACKGROUND: The incidence of hyperkalemia related to spironolactone use is low in stable heart failure; however, it has not been studied during decompensation. OBJECTIVE: To evaluate the influence of spironolactone on serum potassium in decompensated heart failure (HF). METHODS: In a cohort study, patients that had been hospitalized due to decompensated HF, with left ventricular ejection fraction (LVEF) 6.0 mEq/l) and the use of calcium polystyrene. A multivariate analysis through logistic regression was carried out and values of p 60.5 mg/dl during the hospitalization presents a relative risk of 9.6 (95%CI 8.03 – 11.20; p = 0.005) for the occurrence of hyperkalemia. CONCLUSION: The incidence of hyperkalemia was two-fold higher with spironolactone use, but it was not statistically significant. The increase in urea levels was associated to the hyperkalemia. Randomized studies are necessary to clarify this issue.

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Point of view

Carotid endarterectomy is the best choice for patients with carotid disease

Telmo Pedro Bonamigo et al. Márcio Luís Lucas

POINT OF VIEW

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Página do Presidente

Focusing top quality continuing education

Antonio Carlos Palandri Chagas

THE PRESIDENT’S PAGE

Focusing top quality continuing education

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Artigo Original

What is the angiography error when defining myocardial ischemia during percutaneous coronary interventions?

Fernando Mendes Sant'Anna et al. Expedito Ribeiro da Silva Leonardo Alves Batista Marcelo Bastos Brito … Fábio Machado Ventura Haroldo Adans Ferraz Leonardo Buczynski Carlos Alberto Mussel Barrozo Nico Pijls

BACKGROUND: The angiography has been used as a reference standard to define coronary artery disease (CAD), although its limitations are well-known. The significance of the myocardial fractional flow reserve (FFR) in the assessment of CAD is well established. OBJECTIVE: The aim of this study was to evaluate the accuracy of angiography when defining ischemic lesions and its correlation with FFR. METHODS: Two hundred and fifty consecutive patients (471 arteries) were included in this study. All stenoses > 50% at the angiography visual estimate (AVE) were assessed by FFR measurements. When FFR was 0.75, no interventional treatment was carried out. Offline quantitative coronary angiography (QCA) was performed in all stenoses, which were divided in intermediate (< 70% – 327) and severe (125). The correlation coefficients between the diameter of the stenosis (%DS) and FFR and the accuracy of VA of the angiography when assessing ischemia were determined. RESULTS: FFR could be obtained in 452 lesions (96%). Mean %DS and FFR were 56 ± 8% and 0.74 and 76 ± 6% and 0.48 for moderate and severe stenoses, respectively. Concordance between QCA and FFR was poor, especially in intermediate stenoses (Spearman's rho = – 0.33, p<0.0001). Visual assessment resulted in an accuracy of 57% and 96% in intermediate and severe lesions, respectively. CONCLUSION: Neither the visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, which emphasizes the importance of associating it to a functional evaluation of the coronary circulation, resulting in an adequate treatment of these stenoses.

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Artigo Original

Based treatment algorithm for essencial hypertension with olmesartan medoxomil

Marco Antônio Mota Gomes et al. Audes Diógenes de Magalhães Feitosa Wille Oigman José Márcio Ribeiro … Emílio Hideyuki Moriguchi José Francisco Kerr Saraiva Dalton Bertolim Précoma Artur Beltrame Ribeiro Celso Amodeo Andréa Araujo Brandão

BACKGROUND: The national and international guidelines emphasize the importance of the effective treatment of essenssial hypertension. Nevertheless, low levels of control are observed, as well as low attainment of the recommended goals, indicating that it is important to plan and implement better treatment strategies. OBJECTIVE: To evaluate the efficacy of a based treatment algorithm with olmesartan medoxomil. METHODS: This is an open, national, multicentric and prospective study of 144 patients with primary arterial hypertension, stages 1 and 2, naïve to treatment or after a 2-to-3 week washout period for those in whom treatment was ineffective. The use of olmesartan medoxomil was assessed in a treatment algorithm divided into 4 phases: (i) monotherapy (20 mg), (ii-iii) associated to à hydrochlorothiazide (20/12.5 mg and 40/25 mg) and (iv) addition of amlodipine besylate (40/25 mg + 5 mg). RESULTS: At the end of the phased-treatment, 86% of the study subjects attained the goal of BP 20 mmHg) and of diastolic responders (DAP > 10 mmHg) was 87.5% and 92.4%, respectively. CONCLUSION: The study was based on a treatment regimen that was similar to the therapeutic approach in daily clinical practice and showed that the use of olmesartan medoxomil in monotherapy or in association with hydrochlorothiazide and amlodipine was effective in the attainment of the recommended goals for hypertension stage 1 and 2 hypertensive individuals.

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Relato de Caso

Cardiac resynchronization therapy improves the uptake of MIBI-99mTc and cardiac function

Simone Cristina Soares Brandão et al. Maria Clementina Giorgi Silvana D'Orio Nishioka Martino Martinelli Filho … José Soares Jr. José Cláudio Meneghetti

This case shows the improvement promoted by cardiac resynchronization therapy (CRT) on myocardial perfusion and left ventricular (LV) performance assessed by gated myocardial perfusion scintigraphy. The patient had idiopathic dilated cardiomyopathy, left bundle branch block and severe heart failure despite optimized medical treatment. After CRT, clinical improvement, QRS reduction and improvement of previously hypoperfused anterior and septal walls were observed. There was also decrease in LV end-diastolic and systolic volumes and increase in LV ejection fraction.

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Artigo Original

Prevalence of coronary artery disease and preoperative assessment in patients with valvopathy

Roney Orismar Sampaio et al. Vívian Masutti Jonke João L. Falcão Sandra Falcão … Guilherme S. Spina Flávio Tarasoutchi Max Grinberg

BACKGROUND: Coronary angiography has been indicated in the preoperative phase for patients with valvopathy over 35 years of age. However, the actual prevalence of obstructive coronary artery disease (CAD) in this population has been little studied. OBJECTIVE: To assess the prevalence of and the risk factors for CAD in candidates for valve surgery in Brazil. METHODS: Coronary angiography was performed in 3,736 patients who were candidates for valve surgery; prevalence of and risk factors for CAD associated with valvopathy were assessed. RESULTS: CAD was associated with valvopathy in 121 patients (prevalence of 3.42%). In 79 patients (68.1%), CAD was diagnosed by means of preoperative coronary angiography. Of these 79 patients, 50 (63.3%) had isolated aortic valvopathy or aortic valvopathy associated with mitral valvopathy. Smoking habit was observed in 54 patients (68.3%), hypertension in four (43%), family history in 24 (30.3%), diabetes mellitus in 15 (18.9%), and obesity in eight (10.1%). Of the 121 patients, 95.7% were over 50 years of age. Only five (4.3% of the patients with CAD) were below 50 years of age, and all of them had at least one risk factor for CAD. CONCLUSION: CAD prevalence was low in the patients studied. Aortic valvopathy was the most frequent valvopathy associated with CAD, and most patients were over 50 years of age. The ideal age for routine preoperative coronary angiography in patients with valvopathy should be reassessed.

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Artigo Original

Viable myocardium scintigraphy with intravenous nitroglycerine by computed tomography with Tc-99m (MIBI)

José Ramos Filho et al. Marcos Welber Nascimento Rafael Mariano Gislon da Silva Thiago Negrini de Camargo … Roberto Simões de Almeida Eloá Jacinto Lima

BACKGROUND: The selection of patients with chronic coronary disease for recanalization is based on the detection of the affected myocardium that is potentially viable. OBJECTIVE: To evaluate the potentially viable ischemic myocardium through single photon emission computed tomography (SPECT) with MIBI after a maximum tolerated dose of I.V. nitroglycerin. METHODS: We prospectively investigated by SPECT with Tc-99m (MIBI), from April 2004 to November 2005, 40 patients (mean age: 62 ± 8.9 yrs, 30 men) with coronary obstruction demonstrated angiographically; the myocardium scintigraphy was carried out at rest and after intravenous (I.V.) nitroglycerin, which was started at a dose of 1 µg/kg/min and increased every minute until the systolic blood pressure decreased by 20 mmHg. The decrease in the perfusion of the segments was classified as moderate or severe and compared after the nitroglycerin. The angiographic, hemodynamic and myocardial perfusion variables were analyzed. RESULTS: We analyzed 680 myocardial segments at rest: 538 with a homogenous distribution and 142 with hypoperfusion (54 with moderate and 88 with severe decrease). After the nitroglycerin, there was an increase in the perfusion in 19 (47.5%) of 40 patients and 55 of 142 segments became viable: 33 (61.1%) with moderate and 22 (25%) with severe decrease; both presented a significant increase in the radiotracer distribution (p < 0.001, Chi-square). CONCLUSION: One of the components with Tc-99m is Tc-99m 2-methoxy-isobutyl-isonitrile (MIBI), which, when used with an optimized dose of I.V. nitroglycerin, can increase the radiotracer uptake in areas with moderate and severe hypoperfusion. The results of the present study suggest the increase in the Tc-99m (MIBI) sensitivity by nitroglycerin for the detection of viable myocardium.

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