Coronary arterial disease after electroconvulsive therapy: a case report

Objectives Unipolar depression (UPD) is a leading cause of global burden of diseases, particularly among the elderly, whose treatment may be challenging. In such cases, ECT is often recommended due to its safety and efficacy. This report presents a case of a 67-year-old male inpatient that developed a rare cardiac complication during ECT. Methods Clinical case report with patient’s consent and bibliographic review. Results A 67-year-old male inpatient with recurrent severe psychotic depression was hospitalized and ECT was indicated after failure of the pharmacological treatment. A comprehensive clinical pre-evaluation revealed only nonspecific ST-segment changes in electrocardiogram. During the 7th ECT session, it was observed transitory ST-segment depression followed by a discrete increase of plasma troponin I. Severe tri-vessel coronary artery stenosis was found and a percutaneous coronary angioplasty was performed, with satisfactory psychiatric and cardiac outcomes. Conclusions Unipolar depression (UPD) and cardiovascular disease are often coexistent conditions, especially among the elderly. In the current case, myocardial ischemia was detected lately during ECT therapy and its treatment allowed the UPD treatment to be completed adequately.

Sintomas, complicações e alterações hemodinâmicas associadas a ecocardiografia de estresse com dobutamina

OBJETIVO: Avaliar a segurança e efeitos hemodinâmicos da ecocardiografia de estresse com dobutamina. MÉTODOS: Estudo prospectivo de 735 pacientes consecutivos, submetidos a ecocardiografia de estresse com dobutamina, para avaliar doença coronária e ou miocardiopatia. Inicialmente, a dobutamina foi administrada via endovenosa com doses progressivas de 5, 10, 20, 30µg/kg/min a intervalos de 3min. O protocolo foi modificado para atingir a dose máxima de 40µg/kg/min, e, finalmente, até o limite de 50µg/kg/min. RESULTADOS: A dobutamina aumentou significantemente a freqüência cardíaca (FC) (de 72±12bpm para 117±23bpm, p<0,0005), a pressão sistólica (de 133±21bpm para 157±29mmHg, p<0,0005) e o duplo produto (de 9,635±2,100 para 18,400±4,050, p<0,0001) do estado basal para o pico de infusão, respectivamente. Observou-se aumento significativo (p<0,05) da FC em cada estágio de infusão de dobutamina até dose de 40µg/kg/min, além do qual se mantém inalterado. Não ocorreram morte, infarto do miocárdio ou episódios de taquicardia ventricular. Os efeitos colaterais mais comuns foram náusea, ansiedade, tremor, apreensão e cefaléia em 55 (7,4%) pacientes. Angina de peito ocorreu em 10 (1,4%). As arritmias mais comum foram extra-sístoles ventriculares em 138 (18,7%) pacientes e extra-sistolia supraventricular 36 (4,9%). Houve 4 pacientes que apresentaram taquicardia ventricular não sustentada, sem repercussão hemodinâmica. CONCLUSÃO: Ecocardiografia de estresse com dobutamina é um método seguro e bem tolerado. Doses de infusão de dobutamina >40µg/kg/min não provocam resposta cronotrópica adicional, o que torna questionável a validade do protocolo de ecocardiografia de estresse com doses de dobutamina >40µg/kg/min.

Isquemia miocárdica intermitente após angioplastia cirúrgica do tronco de coronária esquerda

Dois pacientes do sexo masculino (38 e 53 anos) com angina instável, com estudo hemodinâmico revelando grave lesão de óstio de tronco de coronária esquerda (TCE), foram submetidos a angioplastia cirúrgica do TCE com patch de veia safena. Ao final da operação os pacientes apresentaram isquemia miocárdica intermitente, um deles com choque cardiogênico e, em ambos, reversão completa do quadro. O estudo hemodinâmico pós-operatório revelou adequada ampliação do TCE com função ventricular esquerda preservada nos dois pacientes. Embora a angioplastia cirúrgica do TCE seja uma alternativa técnica para os doentes com lesões ostiais, chamamos a atenção para esta grave morbidade operatória, tendo como uma das possíveis causas o espasmo do TCE.

O acometimento isquêmico obstrutivo na cardiomiopatia hipertrófica do tipo septal assimétrico com envolvimento da artéria descendente anterior

OBJETIVO: Avaliar o papel da doença arterial coronária (DAC) com comprometimento da artéria descendente anterior (ADA) na cardiomiopatia hipertrófica (CMH) e sua repercussão na evolução, visto ser controverso o significado da necrose e fibrose do septo interventricular (SIV) nesta cardiomiopatia. MÉTODOS: Entre 158 pacientes com CMH, selecionamos 6 (3,79%) com CMH e DAC com lesão obrigatória de ADA, sendo 4 homens, entre 52 e 70 (x= 65,16) nos, 4 com a forma obstrutiva da CMH. O tempo de diagnóstico da CMH foi de 78 a 182 (x=141) meses e da DAC de 1 dia a 106 (x= 42) meses. Os pacientes foram acompanhados com avaliações clínicas e exames complementares periódicos. RESULTADOS: A forma de apresentação da DAC foi em 5 com angina instável e um com infarto do miocárdio. A ADA estava comprometida entre 60 a 100%, sendo em um lesão única e nos 5 restantes com lesão em 2 ou mais vasos. Na evolução, 3 foram submetidos a revascularização miocárdica (RM), um associada a miomectomia septal, um a angioplastia e 2 somente a tratamento clínico. No período de observação de 76 a 124 meses após o diagnóstico da DAC, ocorreu um óbito. No fim do estudo observamos redução nos valores médios do SIV de 1,53 para 1,40cm, gradiente de pressão entre o corpo e a via de saída do ventrículo esquerdo (VE) de 56 para 15,75mmHg, com discreto aumento no diâmetro diastólico do VE de 4,55 para 4,85cm e do diâmetro sistólico de 2,83 para 3,13cm, sem alterar a dimensão do átrio esquerdo (4,13cm). CONCLUSÃO: A DAC da ADA é bem tolerada na CMH septal assimétrica, participando do processo fibrótico septal e melhorando o desempenho cardíaco, não representando problema adverso na evolução da CMH.

Implante de stent dentro de stent recém-implantado em ponte de veia safena para otimização do resultado angiográfico

Mulher de 60 anos, com angina progressiva e revascularização do miocárdio, há oito anos, com ponte de veia safena para coronária direita e anastomose de artéria mamaria esquerda para artéria descendente anterior. Submetida a implante de stent Gianturco-Roubin II em terço proximal da ponte de veia safena para artéria coronária direita, com resultado insatisfatório pela persistência de lesão residual, provavelmente, decorrente de prolapso para dentro da luz de material aterosclerótico através dos coils. Foi implantado outro stent (Palmaz-Schatz biliar) dentro do stent GRII com sucesso e ótimo resultado angiográfico. Um 2º stent Palmaz-Schatz biliar foi implantado em lesão distal no corpo da ponte, ultrapassando os dois stents, anteriormente implantados, com sucesso. Em algumas situações, implante de stent dentro de outro stent é recurso útil para otimização de resultado angiográfico do implante de um stent.

Efeito da cirurgia de revascularização miocárdica sobre os episódios isquêmicos assintomáticos

OBJETIVO: Avaliar o efeito da cirurgia de revascularização miocárdica (CRM) sobre episódios isquêmicos assintomáticos (EIA). MÉTODOS: Foram estudados 28 homens, com angina estável (idade média 57,3±9,6) anos sem condições relacionadas a alterações de microcirculação e que, após retirada da medicação, apresentaram EIA à eletrocardiografia ambulatorial (ECGA). No pré-operatório e 4 meses após a cirurgia foram analisados os comportamentos dos EIA, segundo sua freqüência, e o de suas freqüências cardíacas (FC). A revascularização miocárdica foi completa em 75% dos casos. RESULTADOS: O número dos EIA foi reduzido de 162 (9 sintomáticos) no pré-operatório para, apenas, 4 no pós-operatório (p<0,05). Nos dois pacientes com EIA no operatório, estudo cinecoronariográfico confirmou obstrução de enxertos aortocoronários. A análise das FC no início e pico dos EIA sugeriram envolvimento de mecanismo de redução de oferta e aumento de consumo de oxigênio pelo miocárdio. CONCLUSÃO: A CRM eliminou os episódios isquêmicos relacionados ou não ao aumento da FC. Quando os EIA encontram-se presentes após CRM, devemos considerar a possibilidade de oclusão de enxerto.

Doenças cardiovasculares observadas durante o seguimento de um grupo de pacientes na forma indeterminada da doença de Chagas

OBJETIVO: Observar, num grupo de pacientes na forma indeterminada da doença de Chagas, o aparecimento de doenças cardiovasculares e sua possível relação com a doença de base. MÉTODOS: Foram seguidos, prospectivamente, 160 pacientes por até 177 meses com avaliações clínicas trimestrais. RESULTADOS: Tornaram-se hipertensos 23 (14,4%) pacientes, sendo 21 (13,2%) com pressão arterial diastólica <110mmHg. Duas pacientes (1,2%) hipertensas tiveram acidente vascular cerebral isquêmico (AVCI). Uma (0,6%) paciente teve hemorragia meníngea por ruptura de aneurisma cerebral. Quatro (2,4%) pacientes apresentaram arritmia clinicamente, dois (1,2%) extra-sístoles ventriculares, um (0,6%) extra-sístoles supraventriculares e um (0,6%) fibrilação atrial aguda. Dois (1,2%) pacientes desenvolveram coronariopatia comprovada angiograficamente, um (0,6%) com infarto agudo do miocárdio, outro com angina estável. Um (0,6%) paciente desenvolveu sinais e sintomas de insuficiência cardíaca, juntamente com o aparecimento de hipertensão arterial sistêmica (HAS). CONCLUSÃO: A doença cardiovascular mais freqüente foi a HAS. Duas hipertensas apresentaram AVCI. As arritmias observadas não foram mais freqüentes que na população normal e a coronariopatia também ocorreu raramente, confirmando um bom prognóstico clínico a longo prazo desse grupo de pacientes.

Intervenção coronária em hospital geral no Piauí

OBJETIVO: Determinar o índice de sucesso e complicações das intervenções coronárias realizadas em hospital geral do Piauí, em um laboratório de hemodinâmica com baixo volume de procedimentos por ano. MÉTODOS: Cento e vinte e dois pacientes, submetidos a 146 procedimentos de intervenção coronária, de agosto/91 a janeiro/98 tiveram seus dados clínicos e angiográficos analisados retrospectivamente. As cineangiocoronariografias e as intervenções foram realizadas em aparelho com sistema de fluoroscopia com câmara e monitor de TV de 525 linhas. As variáveis analisadas foram o sucesso inicial do procedimento (estenose residual <50% e fluxo TIMI III) e as complicações maiores (oclusão aguda, infarto, cirurgia de urgência e óbito). Foram revisados os dados clínicos e as características morfológicas das lesões (ACC/AHA Task Force). RESULTADOS: A média etária foi de 61 anos, variando de 25 a 85, 67% dos pacientes eram do sexo masculino, 85% apresentavam síndrome isquêmica aguda (infarto agudo do miocárdio, angina pós infarto ou angina de repouso), 5% apresentavam-se em choque cardiogênico. 88% das lesões eram tipo B. O índice de sucesso imediato foi de 93%. A taxa de complicações maiores (oclusão aguda, cirurgia de urgência, infarto e óbito) foi de 3,5%. CONCLUSÃO: A despeito de um baixo volume de procedimentos por ano e um equipamento de cineangiocoronariografia convencional, o índice de sucesso desta instituição foi excelente em uma população de pacientes diversa e complexa com taxa de complicações semelhante à encontrada na literatura.

Transmyocardial laser revascularization. Early clinical experience

OBJECTIVE: To analyze the initial clinical experience of transmyocardial laser revascularization (TMLR) in patients with severe diffuse coronary artery disease. METHODS: Between February, 1998 and February, 1999, 20 patients were submitted to TMLR at the Heart Institute (InCor), University of São Paulo Medical School, Brazil, isolated or in association with conventional coronary artery bypass graft (CABG). All patients had severe diffuse coronary artery disease, with angina functional class III/IV (Canadian Cardiovascular Society score) unresponsive to medical therapy. Fourteen patients were submitted to TMLR as the sole therapy, whereas 6 underwent concomitant CABG. Fifty per cent of the patients had either been previously submitted to a CABG or to a percutaneous transluminal coronary angioplasty (PTCA). Mean age was 60 years, ranging from 45 to 74 years. RESULTS: All patients had three-vessel disease, with normal or mildly impaired left ventricular global function. Follow-up ranged from 1 to 13 months (mean 6.6 months), with no postoperative short or long term mortality. There was significant symptom improvement after the procedure, with 85% of the patients free of angina, and the remaining 15 % of the patients showing improvement in functional class, as well as in exercise tolerance. CONCLUSION: This novel technique can be considered a low risk alternative for a highly selected group of patients not suitable for conventional revascularization procedures.

Aortic stenosis. Gender influence on left ventricular geometry and function in patients under 70 years of age

OBJECTIVE: To verify if adaptive left ventricle (LV) characteristics are also present in individuals under 70 years of age with severe aortic stenosis (AS). METHODS: The study comprised 40 consecutive patients under 70 years of age with AS and no associated coronary artery disease, referred for valve surgery. Out of the 40 patients, 22 were men and 18 women, and the mean age was 49.8±14.3 years. Cardiac symptoms, presence of systemic hypertension (SH), functional class according to the New York Heart Association (NYHA), and valve lesion etiology were considered. LV cavity dimensions, ejection fraction (EF), fractional shortening (FS), mass (MS), and relative diastolic thickness (RDT) were examined by Doppler echocardiography. RESULTS: Fourteen (63.6%) men and 11 (61.6%) women were classified as NYHA class III/IV (p=0.70). There was no difference in the frequency of angina, syncope or dyspnea between genders. The incidence of SH was greater in women than in men (10 versus 2, p=0.0044). Women had a smaller LV end-diastolic diameter index (32.1±6.5 x 36.5±5.3mm/m², p=0.027), LV end-systolic diameter index (19.9±5.9 x 26.5±6.4mm/m², p=0.0022) and LV mass index (MS) (211.4±71.1 x 270.9±74.9g/m², p=0.017) when compared with men. EF (66.2±13.4 x 52.0±14.6%, p=0.0032), FS (37.6±10.7 x 27.9±9.6%, p=0.0046) and RDT (0.58±0.22 x 0.44±0.09, p=0.0095) were significantly greater in women than in men. CONCLUSION: It is the patient gender rather than age that influences left ventricular adaptive response to AS.

Coronary artery disease, microalbuminuria and lipid profile in patients with non-insulin dependent diabetes mellitus

PURPOSE: To determine the frequency of coronary artery disease, microalbuminuria and the relation to lipid profile disorders, blood pressure and clinical and metabolic features. METHODS: Fifty-five type 2 diabetic patients (32 females, 23 males), aged 59.9±9 years and with known diabetes duration of 11±7.3 years were studied. Coronary artery disease (CAD) was defined as a positive history of myocardial infarction, typical angina, myocardial revascularization or a positive stress testing. Microalbuminuria was defined when two out of three overnight urine samples had a urinary albumin excretion ranging 20 - 200µg/min. RESULTS: CAD was present in 24 patients (43,6%). High blood pressure (HBP) present in 32 patients (58.2%) and was more frequent in CAD group (p=0.05) HBP. Increased the risk of CAD 3.7 times (CI[1.14-12]). Microalbuminuria was present in 25 patients (45.5%) and tended to associate with higher systolic blood pressure (SBP) (p = 0.06), presence of hypertension (p = 0.06) and know diabetes duration (p = 0.08). In the stepwise multiple logistic regression the systolic blood pressure was the only variable that influenced UAE (r = 0.39, r² = 0.14, p = 0.01). The h ypertensive patients had higher cholesterol levels (p = 0.04). CONCLUSION: In our sample the frequency of microalbuminuria, hypertension, hypercholesterolemia and CHD was high. Since diabetes is an independent risk factor for cardiovascular disease, the association of others risk factors suggest the need for an intensive therapeutic intervention in primary and in secundary prevention.

Percutaneous handling of coronary lesions >20mm through stents. Is there a first choice strategy?

OBJECTIVE - This study compared the early and late results of the use of one single stent with those of the use of multiple stents in patients with lesions longer than 20mm. METHODS - Prospective assessment of patients electively treated with stents, with optimal stent deployment and followed-up for more than 3 months. From February '94 to January '98, 215 patients with lesions >20mm were treated. These patients were divided into 2 groups as follows: Group A - 105 patients (49%) with one stent implanted; Group B - 110 patients (51%) with multiple stents implanted. RESULTS - The mean length of the lesions was 26mm in group A (21-48mm) versus 29mm in group B (21-52mm) (p=0.01). Major complications occurred in one patient (0.9%) in group A (subacute thrombosis, myocardial infarctionand death) and in 2 patients (1.8%) in group B (one emergency surgery and one myocardial infarction) (p=NS). The results of the late follow-up period (>6 months) were similar for both groups (group A = 82% vs group B = 76%; p=NS), and we observed an event-free survical in 89% of the patients in group A and in 91% of the patients in group B (p=NS). Angina (group A = 11% vs group B = 7%) and lesion revascularization (group A = 5% vs group B = 6%; p=NS) also occurred in a similar percentage. No infarction or death was observed in the late follow-up period; restenosis was identified in 33% and 29% of the patients in groups A and B, respectively (p=NS). CONCLUSION - The results obtained using one stent and using multiple stents were similar; the greater cost-effectiveness of one stent implantation, however, seems to make this strategy the first choice.

Chest pain in the emergency room. Importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patient's body temperature was lowered to 32°C. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17% acute myocardial infarction and 43% unstable angina, whereas in route 3 the rates were 2% and 7%, respectively. Patients with normal/non--specific ECG had 6% probability of AMI whereas in those with negative first CKMB it was 7%; the association of the 2 data only reduced it to 4%. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52% and 93%, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.