Short-term follow-up of patients after aneurysmectomy of the left ventricle

OBJECTIVE: Left ventricular aneurysm is a complication of myocardial infarction that can best be treated by reconstructive surgeries that can restore ventricular geometry. We analyzed immediate results in a group of consecutive patients who underwent surgical correction of left ventricular aneurysms. METHODS: From January '90 to August '99, 94 patients - mean age 58.4 (ranging from 36 to 73 years), 65 (69.1%) males and 9 ( 30.8%) females - were operated upon. Pre-operative ejection fraction ranged from 0.22 to 0.58 (mean = 0.52), and the aneurysm was located in the antero-lateral area in 90.4% of the cases. Functional class III and IV (NYHA) was present in 82 (87.2%) patients, and 12 (12.7%) were in functional class I and II. Congestive heart failure was the most frequent cause (77.6%), occurring in isolation in 24.4% or associated with coronary artery diseases in 53.2%. RESULTS: Short-term follow-up showed a 7.4% mortality, and low cardiac output was the main cause of death. Coming off pump was uneventful in 73 patients (77.6%), with a 3.2% mortality and with the use of inotropics in 20 (21.3%). One patient (1%) did not come off the pump. CONCLUSION: Surgical correction was adequate in the immediate follow-up of operated patients, and mortality was higher in patients with higher functional class.

Effects of losartan on ventricular remodeling in experimental infarction in rats

OBJECTIVE: To evaluate the effects of losartan on ventricular remodeling and on survival after myocardial infarction in rats. METHODS: After surgical occlusion of left coronary artery, 84 surviving male Wistar rats were divided into two groups: LO treated with losartan (20mg/kg/day, n=33) and NT (n=51), without medication. After 3 months, we analyzed mortality; ventricular to body mass ratio (VM /BM); myocardial hydroxyproline concentration (HOP); isovolumetric pressure, +dp/dt, -dp/dt, and diastolic volume/left ventricle mass ratio (VO/LV). RESULTS: Mortality was: LO = 22%, and NT = 47% (p<0.05). Ventricular mass,(VM/BM, mg/g) was 4.14 ± 0.76 and 3.54±0.48, in the NT and LO groups, respectively (p<0.05). HOP (median) was 4.92 upsilong/mg in the LO and 5.54 upsilong/g in the NT group (p>0.05). The V0/LV values (median) were 0.24 mL/g in group LO and 0.31 mL/g in group NT (p<0.05) compared to NT group. There were no differences between the groups for +dp/dt and -dp/dt parameters. CONCLUSION: 1- The use of losartan myocardial infarction causes an attenuation of ventricular remodeling, bringing about an increased survival, an attenuation of ventricular hypertrophy and dilation, and an improvement of the isovolumetric pressure; 2- the treatment does not modify the myocardial collagen concentration.

Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

Mechanical versus biological aortic valve implants in the elderly. A comparison of early and mid-term results

OBJECTIVE: Our aim was to compare, in a non randomized study, the surgical outcome in elderly patients with mechanical (Group 1; n=83) and bioprosthetic valve implants (Group 2; n=136). METHODS: During a three year period, 219 patients >75 years underwent Aortic Valve Replacement. The groups matched according to age, sex, comorbidity, valve pathology and concomitant Coronary Artery Bypass Surgery. Follow-up was a total of 469 patient-years (mean follow-up 2.1 years, maximum 4,4 years). RESULTS: Operative mortality was zero and the overall early mortality was 2.3 % (within 30 days). Actuarial survival was 87.5 ± 4.0% and 66.1 ± 7.7% (NS) at 4 years in Group 1 and Group 2, respectively. Freedom from valve-related death was 88.9 ± 3.8% in Group 1 and 69.9±7.9% (NS) in Group 2 at 4 years. CONCLUSION: Aortic Valve Replacement in the elderly (>75 years) is a safe procedure even in cases where concomitant coronary artery revascularization is performed. Only a few anticoagulant-related complications were reported and this may indicate that selected groups of elderly patients with significant life expectancy may benefit from mechanical implants .

Concomitant Use of Glycoprotein IIb/IIIa Inhibitor and Streptokinase after Unsuccessful Rescue Angioplasty

A 38-year-old man with acute myocardial infarction in the lower wall affecting the right ventricle underwent thrombolytic treatment with streptokinase. Approximately 2 hours after the thrombolytic treatment started, he presented with signs of coronary reocclusion. He underwent emergency cineangiocoronariography that revealed that his right coronary artery was completely occluded by a clot. He unsuccessfully underwent angioplasty and stent implantation. After the concomitant use of glycoprotein IIb/IIIa inhibitor, coronary TIMI III flow was achieved without additional dilations, and he was discharged from the hospital 5 days later with no further complications.

Unsupervised Rehabilitation: effects of Exercise Training over the Long Run

OBJECTIVE: To assess the safety and efficacy of unsupervised rehabilitation (USR) in the long run in low-risk patients with coronary artery disease. METHODS: We carried out a retrospective study with 30 patients divided into: group I (GI) - 15 patients from private clinics undergoing unsupervised rehabilitation; group II (GII) - control group, 15 patients from ambulatory clinic basis, paired by age, sex, and clinical findings. GI was stimulated to exercise under indirect supervision (jogging, treadmill, and sports). GII received the usual clinical treatment. RESULTS: The pre- and postobservation values in GI were, respectively: VO2peak (mL/kg/min), 24±5 and 31± 9; VO2 peak/peak HR: 0.18±0.05 and 0.28±0.13; peak double product (DP peak):26,800±7,000 and 29,000 ± 6,500; % peak HR/predicted HRmax: 89.5±9 and 89.3±9. The pre- and post- values in GII were: VO2 peak (mL/kg/min), 27± 7 and 28±5; VO2 peak/peak HR: 0.2±0.06 and 0.2± 0.05; DP peak: 24,900±8,000 and 25,600± 8,000, and % peak HR/predicted HRmax: 91.3±9 and 91.1± 11. The following values were significant: preobservation VO2peak versus postobservation VO2peak in GI (p=0.0 063); postobservation VO2peak in GI versus postobservation VO2peak in GII (p=0.0045); postobservation VO2 peak/peak HR GI versus postobservation peak VO2/peak HR in GII (p=0.0000). The follow-up periods in GI and GII were, respectively, 41.33± 20.19 months and 20.60±8.16 months (p<0.05). No difference between the groups was observed in coronary risk factors, therapeutic management, or evolution of ischemia. No cardiovascular events secondary to USR were observed in 620 patient-months. CONCLUSION: USR was safe and efficient, in low-risk patients with coronary artery disease and provided benefits at the peripheral level.

Myocardial Revascularization Surgery with Regional Anesthesia Without an Endotracheal Tube in Conscious Patients

OBJECTIVE: To report initial experience with myocardial revascularization surgery (MRS) performed on patients who were totally awake and without an endotracheal tube.METHODS: Between January 1994 and May 2001, 272 patients underwent MRS without extracorporeal circulation. In 24, the operations were performed without the use of an endotracheal tube and with the patients totally awake and breathing normally. The age ranged from 51-75 years with the predominant male sex. Epidural thoracic administratios of the anesthesia was performed. Surgery was performed through a habitual anterolateral thoracotomy. During the entire procedure, the left lung remained partially collapsed.RESULTS: The 24 patients progressed well through the surgery. Pneumothorax time ranged from 70-190 minutes. No electrocardiographic, echocardiographic, or enzymatic alterations occurred that characterized pre- and postoperative infarcts. Twenty-three patients were stable enough to be released after 24 hours.CONCLUSION: This technique could be performed on an large number of selected patients. However, more experience is necessary.

Comparison between young males and females with acute myocardial infarction

OBJECTIVE: To assess the differences between young males and females after acute myocardial infarction. METHODS: We retrospectively studied 236 patients (54 females and 182 males) after acute myocardial infarction and during hospital stay assessed the following parameters: risk factors; the treatment used; the pattern of coronary artery obstruction; left ventricular ejection fraction; complications; and, using a logistic regression model, the factors related to the occurrence of reinfarction and death. RESULTS: No significant difference was observed between the sexes in risk factors, pattern of coronary artery obstruction, and left ventricular function. The time interval between symptom onset and treatment was longer in females (p=0.03), who underwent thrombolysis (p=0.01) and angioplasty (p=0.03) less frequently than males did, but not myocardial revascularization. Female sex (OR = 5.98) and diabetes (OR = 14.52) were independent factors related to the occurrence of reinfarction and death. CONCLUSION: Young males and females after acute myocardial infarction did not differ in coronary risk factors, and clinical and hemodynamic characteristics. Females had their treatment started later, and they underwent chemical thrombolysis and angioplasty less frequently than males did. Female sex and diabetes were related to the occurrence of reinfarction and death.

Predictive factors of in-hospital mortality and of severe perioperative complications in myocardial revascularization surgery

OBJECTIVE: To investigate preoperative predictive factors of severe perioperative intercurrent events and in-hospital mortality in coronary artery bypass graft (CABG) surgery and to develop specific models of risk prediction for these events, mainly those that can undergo changes in the preoperative period. METHODS: We prospectively studied 453 patients who had undergone CABG. Factors independently associated with the events of interest were determined with multiple logistic regression and Cox proportional hazards regression model. RESULTS: The mortality rate was 11.3% (51/453), and 21.2% of the patients had 1 or more perioperative intercurrent events. In the final model, the following variables remained associated with the risk of intercurrent events: age ³ 70 years, female sex, hospitalization via SUS (Sistema Único de Saúde - the Brazilian public health system), cardiogenic shock, ischemia, and dependence on dialysis. Using multiple logistic regression for in-hospital mortality, the following variables participated in the model of risk prediction: age ³ 70 years, female sex, hospitalization via SUS, diabetes, renal dysfunction, and cardiogenic shock. According to the Cox regression model for death within the 7 days following surgery, the following variables remained associated with mortality: age ³ 70 years, female sex, cardiogenic shock, and hospitalization via SUS. CONCLUSION: The aspects linked to the structure of the Brazilian health system, such as factors of great impact on the results obtained, indicate that the events investigated also depend on factors that do not relate to the patient's intrinsic condition.

Surgical myocardial revascularization without extracorporeal circulation

OBJECTIVE: To assess the immediate postoperative period of patients undergoing myocardial revascularization without extracorporeal circulation with different types of grafts. METHODS: One hundred and twelve patients, 89 (79.5%) of whom were males, were revascularized without extracorporeal circulation. Their ages ranged from 39 to 85 years. The criteria for indicating myocardial revascularization without extracorporeal circulation were as follows: revascularized coronary artery caliber > 1.5 mm, lack of intramyocardial trajectory on coronary angiography, noncalcified coronary arteries, and tolerance of the heart to the different rotation maneuvers. RESULTS: Myocardial revascularization without extracorporeal circulation was performed in 112 patients. Three were converted to extracorporeal circulation, which required a longer hospital stay but did not impact mortality. During the procedure, the following events were observed: atrial fibrillation in 10 patients, ventricular fibrillation in 4, total transient atrioventricular block in 2, ventricular extrasystoles in 58, use of a device to retrieve red blood cells in 53, blood transfusion in 8, and arterial hypotension in 89 patients. Coronary angiography was performed in 20 patients on the seventh postoperative day when the grafts were patent. CONCLUSION: Myocardial revascularization without extracorporeal circulation is a reproducible technique that is an alternative for treating ischemic heart disease.

National alert campaign about increased cholesterol: determination of cholesterol levels in 81,262 Brazilians

OBJECTIVE: To determine the levels of total cholesterol in a significant sample of the Brazilian population. METHODS: Blood cholesterol was determined in 81.262 individuals > 18 years old (51% male, 44.7 ± 15.7 years), using Accutrend equipment, in the cities São Paulo, Campinas, Campos do Jordão, São José dos Campos, Santos, Santo André, Ribeirão Preto, Porto Alegre, Rio de Janeiro, Belo Horizonte, Curitiba, Brasília, Salvador and documented in the presence of other risk factors (RF) for coronary artery disease (CAD) (systemic hypertension, CAD in the family, smoking, and diabetes). Participants were classified according to sex, age, and the presence or absence of RF, respectively, as 0 RF, 1 RF and > 2 RF. The percentage of individuals with cholesterol > 200 mg/dL and > 240 mg/dL was evaluated. RESULTS: The prevalence of individuals with 0, 1, and > 2 risk factors was 30% (n = 24,589), 36% (n =29,324), and 34% (n = 27,349) respectively, (P=0.657), and the mean total cholesterol of the population was 199.0 ± 35.0 mg/dL. Cholesterol levels above 200 and 240 mg/dL were found, respectively, in 40% (n = 32,515) and 13% (10.942) of individuals. The greater the number of risk factors the higher the levels of cholesterol (P<0.0001) and the greater the proportion of individuals with cholesterol > 200 mg/dL (P=0.032). No difference existed in the proportion of individuals with cholesterol > 240 mg/dL (P=0.11). CONCLUSION: A great percentage of individuals with cholesterol levels above those recommended to prevent coronary artery disease was found.

Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room

OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. RESULTS: The mean age of the patients studied was 51.7±12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated.

Secular trends in a population with ischemic heart disease admitted to the Instituto do Coração in São Paulo

OBJECTIVE: To assess the clinical and demographic characteristics of a population with ischemic heart disease admitted in the final decades of the 20th century. METHODS: This study retrospectively assessed patients hospitalized with ischemic heart disease divided into the following 2 groups: acute group - 11.181 patients with acute myocardial infarction admitted from 1/1/82 to 12/31/94; and chronic group - 4.166 patients undergoing coronary artery bypass graft surgery from 1/1/84 to 12/31/94. RESULTS: In the acute group, an increase in the percentage of females (from 22.7% to 27.7%, P<0.001) and diabetic individuals (from 12.4% to 17.5%, P<0.001) was observed, as was an increase in age (from 57.4±11.5 to 59.9±12.1 years, P<0.05). In-hospital mortality was greater among females (27.8% and 15.7%, P=0.001), among diabetic individuals (24.2% and 17.8%, P=0.001), and among the elderly (60.9±15.2 and 57.7±11.8 years, P=0.0001). In the chronic group, an increase in the percentage of females (from 17.5% to 27.2%, P=0.001) was observed, as was an increase in age (from 56.3±8.6 to 60.5±9.6 years, P=0.0001). In-hospital mortality was greater among females (8.3% and 5.8%, P<0.05) and among the elderly (58.1±9.1 and 62.1±7.9 years, P=0.0001). CONCLUSION: The characteristics of the population studied with ischemic heart disease point towards a worse prognosis, due to the greater percentages of females, older patients, and diabetic patients, groups known to have greater in-hospital mortality.

Prevalencia das Doencas Cardiacas Ilustrada em 60 Anos dos Arquivos Brasileiros de Cardiologia

Considerando a relevância histórica e acadêmica dos Arquivos Brasileiros de Cardiologia, posto que sua indexação no MEDLINE iniciou-se em 1950, assumiu-se como hipótese que a análise das publicações de 60 anos poderia refletir as tendências evolutivas das doenças cardíacas no Brasil. Os dados do trabalho foram coletados com um programa desenvolvido para a finalidade, tornando possível a extração automática das informações do banco de dados MEDLINE. As informações do trabalho foram coletadas pesquisando-se "Arquivos Brasileiros de Cardiologia AND parâmetro selecionado em inglês". Foram arbitrados quatro grupos observacionais: (1) principais grupos de doenças do coração (doença arterial coronariana, valvulopatia cardíaca, cardiopatias congênitas e cardiomiopatias); (2) doenças relevantes na prática clínica (arritmias cardíacas, Cor Pulmonale, infarto do miocárdio e insuficiência cardíaca congestiva); (3) fatores de risco cardiovascular (hipertensão arterial, diabete, dislipidemia e aterosclerose), e; (4) grupo arbitrado em função da evolução crescente das publicações sobre insuficiência cardíaca congestiva constadas nos grupos anteriores (insuficiência cardíaca congestiva, infarto do miocárdio, cardiopatia reumática e cardiopatia chagásica). Foram descritas todas as publicações dentro dos grupos estabelecidos, ressaltando-se o crescente aumento da insuficiência cardíaca e do diabete como fatores de risco. Foi possível um levantamento relativamente fácil, com auxílio do programa de computação desenvolvido para a pesquisa bibliográfica de seis décadas. Ressaltando-se as limitações do estudo, sugere-se a existência de um elo epidemiológico entre as doenças cardiológicas prevalentes no Brasil e as publicações dos Arquivos Brasileiros de Cardiologia.