New auxiliary indicators for the differential diagnosis of functional cardiorespiratory limitation in patients with chronic obstructive pulmonary disease and congestive heart failure

OBJECTIVE: To differentiate the nature of functional cardiorespiratory limitations during exercise in individuals with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) and to determine indicators that may help their classifications. METHODS: The study comprised 40 patients: 23 with COPD and 17 with CHF. All individuals underwent maximal cardiopulmonary exercise testing on a treadmill. RESULTS: The values of peak gas exchange ratio (R peak), peak carbon dioxide production (VCO2 peak), and peak oxygen ventilatory equivalent (V E O2 peak) were higher in the patients with CHF than in those with COPD, and, therefore, those were the variables that characterized the differences between the groups. For group classification, the differentiating functions with the R peak, VCO2 peak (L/min), and V E O2 peak variables were used as follows: group COPD: - 44.886 + 78.832 x R peak + 5.442 x VCO2 peak + 0.336 x V E O2 peak; group CHF: - 69.251 + 89.740 x R peak + 8.461 x VCO2 peak + 0.574 x V E O2 peak. The differentiating function, whose result is greater, correctly classifies the patient's group as 90%. CONCLUSION: The R peak, VCO2 peak, and V E O2 peak values may be used to identify the cause of the functional cardiorespiratory limitations in patients with COPD and CHF.

Initial diagnostic errors in children suspected of having heart disease: prevalence and long-term consequences

OBJECTIVE: To access the incidence of diagnostic errors in the initial evaluation of children with cardiac murmurs. METHODS: We evaluated our 7-years of experience in a public pediatric cardiology outpatient clinic. Of 3692 patients who were sent to the hospital, 2603 presented with a heart murmur and were investigated. Patients for whom a disagreement existed between the initial and final diagnoses were divided into the following 2 groups: G1 (n=17) with an initial diagnosis of an innocent murmur and a final diagnosis of cardiopathy, and G2 (n=161) with an initial diagnosis of cardiopathy and a final diagnosis of a normal heart. RESULTS: In G1, the great majority of patients had cardiac defects with mild hemodynamic repercussions, such as small ventricular septal defect and mild pulmonary stenosis. In G2, the great majority of structural defects were interventricular communication, atrial septal defect and pulmonary valve stenosis. CONCLUSION: A global analysis demonstrated that diagnostic error in the initial evaluation of children with cardiac murmurs is real, reaching approximately 6% of cases. The majority of these misdiagnoses were in patients with an initial diagnosis of cardiopathy, which was not confirmed through later complementary examinations. Clinical cardiovascular examination is an excellent resource in the evaluation of children suspected of having cardiopathy. Immediate outpatient discharge of children with an initial diagnosis of an innocent heart murmur seems to be a suitable approach.

Coronary heart disease clinical manifestation and risk factors in Japanese immigrants and their descendents in the city of São Paulo

OBJECTIVE: To assess whether a difference exists in coronary heart disease clinical manifestations and the prevalence of risk factors between Japanese immigrants and their descendents in the city of São Paulo. METHODS: Retrospective analysis of coronary artery disease clinical manifestations and the prevalence of risk factors, comparing 128 Japanese immigrants (Japanese group) with 304 Japanese descendents (Nisei group). RESULTS: The initial manifestation of the disease was earlier in the Nisei group (mean = 53 years), a difference of 12 years when compared with that in the Japanese group (mean = 65 years) (P<0.001). Myocardial infarction was the first manifestation in both groups (P = 0.83). The following parameters were independently associated with early coronary events: smoking (OR = 2.25; 95% CI = 1.35-3.77; P<0.002); Nisei group (OR = 10.22; 95% CI = 5.64-18.5; P<0.001); and female sex (OR = 5.04; 95% CI = 2.66-9.52; P<0.001). CONCLUSION: The clinical presentation of coronary heart disease in the Japanese and their descendents in the city of São Paulo was similar, but coronary heart disease onset occurred approximately 12 years earlier in the Nisei group than in the Japanese group.

ProBNP for stratifying patients with heart failure

OBJECTIVE: To verify whether the serum levels of N-Terminal ProBNP fraction (ProBNP) allow us to identify with accuracy the clinical functional status of patients with heart failure (HF), because the clinical diagnosis of this syndrome is based basically on clinical data when the complementary tests have lower specificity. METHODS: Sixty-nine patients with a history of HF were studied. Their mean age of was 53.5 years and 78.3% were males. All underwent clinical and echocardiographic evaluations and a test to determine the serum dosage of ProBNP. According to clinical manifestation, patients were in the following functional classes (FC), 14% FC I, 40.6% FC II, 28.1% FC III, and 23.4% FC IV. The mean ejection fraction (EF) was 0.28. RESULTS: ProBNP did not differ according to age, sex, and cause of cardiopathy. No correlation existed between EF and the ProBNP serum level. ProBNP levels were significantly lower in patients in FC I than those in FC II (42 vs 326.7 pmol/L; P=0.0001), and in FC II than those in FC III (P=0.01). ProBNP levels did not differ statically between FC III and IV patients (888.1 vs 1082.8 pmol/L; P=0.25). ProBNP values greater than 100 pmol/L identify patients with decompensated HF with a sensitivity of 98%. CONCLUSION: ProBNP values over 100 pmol/L were indicative of HF, and patients with advanced HF had values over 270 pmol/L. A ProBNP dosage test was an excellent auxiliary in the clinical characterization of patients with HF.

Ligation of the thoracic duct for the treatment of chylothorax in heart diseases

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

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.

Cerebral infarction in autopsies of chagasic patients with heart failure

OBJECTIVE: To determine the frequency of encephalic infarction and its contribution to lethality in patients with Chagas' disease and heart failure. METHODS: Medical records and autopsy reports of patients with Chagas' disease complicated by heart failure, who died at the Professor Edgar Santos Hospital of the Federal University of Bahia in the past 45 years were retrospectively analyzed. Data comprised information regarding the clinical history on hospital admission, complementary and anatomicopathological examinations, including the presence of encephalic infarction, the impaired region, and the cause of death. RESULTS: Of the 5,447 autopsies performed, 524 were in patients with heart failure due to Chagas' disease. The mean age was 45.7 years, and 51 (63%) patients were of the male sex. The frequency of encephalic infarction was 17.5%, corresponding to 92 events in 92 individuals, 82 (15.8%) of which involved the brain, 8 (1.5%) involved the cerebellum, and 2 (0.4%) involved the hypophysis. CONCLUSION: Cerebral infarction has been a frequent finding in autopsies of chagasic patients with heart failure, and it has been an important cause of death in our region. The presence of cerebral infarction and its complications have been associated with death in 52% of the cases studied.

Contribuição para o estudo da fibromialgia : análise de variáveis de aptidão física, de composição corporal e capacidade funcional

A presente dissertação pretendeu verificar o efeito de um programa de exercício supervisionado versus domiciliário, de intensidade moderada, com a duração de 16 semanas, na aptidão física de pessoas com fibromialgia. Houve necessidade de ajustamento dos objetivos e analisaram-se os dados obtidos no primeiro momento de avaliação, pretendendo-se analisar a relação entre variáveis de aptidão física, contribuindo para a compreensão da aptidão física de pessoas com fibromialgia. Apresentam-se e analisam-se variáveis de aptidão física e os resultados do efeito do exercício a nível de composição corporal, capacidade cardiorrespiratória e capacidade funcional. Neste âmbito realizaram-se 5 estudos. No estudo I analisou-se a precisão de diferentes equações preditivas de consumo de oxigénio, que utilizam a distância caminhada no teste de marcha de 6 minutos e propõe-se uma atualização para a equação específica para esta população. No estudo II observou-se a relação entre o consumo de oxigénio, composição corporal e força muscular. No estudo III avaliou-se a precisão de equações preditivas de composição corporal utilizando pregas adiposas e a densitometria de raio-X de dupla energia como método de referência. No estudo IV verificou-se qual o índice que melhor reflete a composição corporal destas mulheres. No estudo V analisou-se a associação entre a frequência cardíaca de recuperação, após um teste de esforço máximo e o consumo de oxigénio. Os principais resultados reforçam os resultados anteriores de que a população estudada apresenta diminuição da aptidão física, da capacidade funcional e valores de composição corporal indicativos de excesso de peso. Não apresentaram alterações autonómicas e verificou-se que a distância caminhada durante o teste de marcha de 6 minutos, a idade, percentagem de massa gorda e a massa magra apendicular são preditores do VO2 pico. Após a intervenção as participantes apresentaram alterações positivas a nível da aptidão física.