Assuntos
Aborto Incompleto , Aborto Espontâneo , Infecções Bacterianas/diagnóstico , Coleta de Dados/normas , Endometrite/microbiologia , Imunização/efeitos adversos , Endometrite/diagnóstico , Feminino , Humanos , Imunização/estatística & dados numéricos , Saúde Materna , Período Pós-Parto , Guias de Prática Clínica como Assunto , GravidezRESUMO
INTRODUCTION: The collection of incidence data on HIV infection is necessary to evaluate the status and dynamics of the epidemic and the effectiveness of intervention strategies. However, this is usually difficult in low-income countries. METHODS: Five yearly point HIV prevalence estimations (in 1999, 2003, 2004, 2005 and 2008) were obtained for women between 15 and 45 years of age participating in three studies carried out for other purposes at the Antenatal Clinic (ANC) in Manhiça, Mozambique. HIV incidence was estimated between prevalence points using a previously validated methodology. Two methods were used, one based on mortality rates for three HIV epidemic scenarios, and the other based on survival information after infection. The pattern over time was captured by fitting a log-regression model. RESULTS: The prevalence of HIV infection ranged from 12% in 1999 to 49% in 2008. The HIV incidence increased from approximately 3.5 cases per 100 person-years in 2001 to 14 per 100 person-years in 2004, with stabilization thereafter to levels of around 12 cases per 100 person-years. The incidence estimates were comparable for the two methods used. CONCLUSION: These findings indicate an increase in the prevalence and incidence of HIV infection among women of reproductive age over the 9 years of the analysis, with a plateau in the incidence of infection since 2005. However, the very high figures for both prevalence and incidence highlight the importance of the continuation of the prevention and treatment programmes that already exist, and suggest that implementation of preventive measures is needed in this area.
Assuntos
Infecções por HIV/epidemiologia , Adolescente , Adulto , Países em Desenvolvimento/estatística & dados numéricos , Feminino , Humanos , Incidência , Modelos Logísticos , Pessoa de Meia-Idade , Moçambique/epidemiologia , Gravidez , Prevalência , População Rural , Adulto JovemRESUMO
UNLABELLED: Cystatin C is a marker of renal function and a major cardiovascular risk factor. In the general population, cystatin C appears to be influenced by factors other than renal function alone. However, information for serum cystatin C levels in chronic kidney disease (CKD) is lacking. METHODS: We studied 52 nondiabetic patients (38 men, mean age 49 years) with CKD stage 3 (22), 4 (25) or 5 (5) who had measurements of serum cystatin C levels, estimated glomerular filtration rate (MDRD), inflammatory (C-reactive protein, interleukin-6 and fibrinogen), and oxidative markers (anti-oxidized LDL antibodies, serum paraoxonase-1 activity and concentration), left ventricular mass index by echocardiography and other cardiovascular risk factors. RESULTS: Mean cystatin C levels were 2.35 +/- 0.9 mg/l. Cystatin C was positively correlated with creatinine serum levels, estimated glomerular filtration rate, PTH levels and negatively with anti-oxidized LDL antibodies. On the other hand, cystatin C was not related to inflammatory markers, serum paraoxonase-1 activity and concentration, proteinuria, HDL or LDL cholesterol, serum triglycerides, left ventricular mass index or demographic factors such as age, body mass index and blood pressure. After adjustment for PTH levels and anti- oxidized LDL antibodies, only estimated glomerular filtration rate was independently related serum cystatin C levels (beta = -0.500, p = 0.001). CONCLUSION: In nondiabetic patients with CKD, cystatin C is closely related to the degree of renal dysfunction. In contrast, inflammatory state, oxidative stress, left ventricular mass index and other cardiovascular risk factors are not related to cystatin C levels in this population.
Assuntos
Doenças Cardiovasculares/etiologia , Cistatina C/sangue , Inflamação/etiologia , Nefropatias/complicações , Nefropatias/metabolismo , Estresse Oxidativo , Adulto , Doenças Cardiovasculares/epidemiologia , Doença Crônica , Estudos Transversais , Feminino , Humanos , Nefropatias/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVES: Malaria infection may impact on mother-to-child transmission (MTCT) of HIV-1. Prevention of malaria in pregnancy could thus potentially affect MTCT of HIV. We studied the impact of intermittent preventive treatment during pregnancy (IPTp) on HIV-1 MTCT in southern Mozambique. METHODS: A total of 207 HIV-positive Mozambican pregnant women were enrolled in the study as part of a randomized placebo-controlled trial of two-dose sulfadoxine-pyrimethamine (SP) IPTp in women receiving single-dose nevirapine to prevent MTCT of HIV. HIV RNA viral load, maternal anaemia and peripheral and placental malaria were assessed at delivery. Infant HIV status was determined by DNA polymerase chain reaction (PCR) at 1 month of age. RESULTS: There were 19 transmissions of HIV in 153 mother-infant pairs. IPTp with SP did not have a significant impact on MTCT (11.8% in the SP group vs. 13.2% in the placebo group; P=0.784) or on maternal HIV RNA viral load [16 312 (interquartile range {IQR} 4076-69 296) HIV-1 RNA copies/mL in the SP group vs. 18 274 (IQR 5471-74 104) copies/mL in the placebo group; P=0.715]. In multivariate analysis, maternal HIV RNA viral load [adjusted odds ratio (AOR) 19.9; 95% confidence interval (CI) 2.3-172; P=0.006] and anaemia (haematocrit <33%; AOR 7.5; 95% CI 1.7-32.4; P=0.007) were independent risk factors for MTCT. Placental malaria was associated with a decrease in MTCT (AOR 0.23; 95% CI 0.06-0.89; P=0.034). CONCLUSIONS: IPTp with SP was not associated with a significant impact on MTCT of HIV. Maternal anaemia was an independent risk factor for MTCT.
Assuntos
Antimaláricos/uso terapêutico , Infecções por HIV/transmissão , HIV-1 , Malária Falciparum/tratamento farmacológico , Complicações Infecciosas na Gravidez/prevenção & controle , Pirimetamina/uso terapêutico , Sulfadoxina/uso terapêutico , Adulto , Anemia/parasitologia , Anemia/virologia , Fármacos Anti-HIV/uso terapêutico , Contagem de Linfócito CD4 , Combinação de Medicamentos , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Recém-Nascido , Malária Falciparum/transmissão , Malária Falciparum/virologia , Moçambique , Nevirapina/uso terapêutico , Doenças Placentárias/parasitologia , Doenças Placentárias/virologia , Reação em Cadeia da Polimerase , Gravidez , Complicações Hematológicas na Gravidez/etiologia , RNA Viral , Carga ViralRESUMO
OBJECTIVE: To analyse intensity of treatment of high-risk patients with non-ST elevation acute coronary syndromes (NSTEACS) included in the DESCARTES (Descripción del Estado de los Sindromes Coronarios Agudos en un Registro Temporal Español) registry. PATIENTS AND SETTING: Patients with NSTEACS (n = 1877) admitted to 45 randomly selected Spanish hospitals in April and May 2002 were studied. DESIGN: Patients with ST segment depression and troponin rise were considered high risk (n = 478) and were compared with non-high risk patients (n = 1399). RESULTS: 46.9% of high-risk patients versus 39.5% of non-high-risk patients underwent angiography (p = 0.005), 23.2% versus 18.8% (p = 0.038) underwent percutaneous revascularisation, and 24.9% versus 7.4% (p < 0.001) were given glycoprotein IIb/IIIa inhibitor. In-hospital and six-month mortality were 7.5% versus 1.1% and 17% versus 4.6% (p < 0.001), respectively. A treatment score (> or = 4, 2-3 and < 2) was defined according to the number of class I interventions recommended in clinical guidelines: aspirin, clopidogrel, beta blockers, angiotensin-converting enzyme inhibitors, statins and revascularisation. Independent predictors of six-month mortality were age (odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04 to 1.10, p < 0.001), diabetes (OR 1.92, 95% CI 1.14 to 3.22, p = 0.014), previous cardiovascular disease (OR 4.17, 95% CI 1.63 to 10.68, p = 0.003), high risk (OR 2.20, 95% CI 1.30 to 3.71, p = 0.003) and treatment score < 2 versus > or = 4 (OR 2.87, 95% CI 1.27 to 6.52, p = 0.012). CONCLUSIONS: Class I recommended treatments were underused in high-risk patients in the DESCARTES registry. This undertreatment was an independent predictor of death of patients with an acute coronary syndrome.
Assuntos
Doença das Coronárias/terapia , Idoso , Anticoagulantes/uso terapêutico , Cardiotônicos/uso terapêutico , Doença das Coronárias/mortalidade , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Revascularização Miocárdica/estatística & dados numéricos , Sistema de Registros , Fatores de Risco , Espanha/epidemiologia , Análise de SobrevidaRESUMO
BACKGROUND: There is little information regarding the occurrence and distribution of cardiovascular abnormalities during the course of autosomal-dominant polycystic kidney disease (ADPKD). We conducted a cross-sectional study in three different groups of ADPKD patients to determine the profile and prevalence of cardiac involvement in this population. METHODS: Doppler color echocardiography was performed in 130 ADPKD patients. Patients were divided into normotensive (Group I, n=60), hypertensive (Group II, n=32) and those undergoing hemodialysis (Group III, n=38). RESULTS: There was a progressive increase in left ventricular mass (LVM) index (88.6+/-19.7, 127.6+/-40.4 and 150.5+/-56.5 g/m2, p < 0.0001) and in the prevalence of left ventricular hypertrophy (LVH) (3%, 43%, 62%, p < 0.0001) in Groups I, II and III, respectively. E/A ratio < 1 was found in 2% of normotensives, 46% of hypertensives and 62% of hemodialysis patients (p < 0.0001). Prevalence ofmitral valve prolapse and aortic and/or mitral regurgitation was 4.3% and 8.6%, respectively, in non-dialysis patients. The majority of valvular abnormalities occurred in dialysis patients, and were generally related to annular mitral calcification (28%) or aortic valve calcification (38%). Age, sex, systolic blood pressure (BP) and hemoglobin were independent predictors of LVM index in the entire population, systolic BP and creatinine in non-dialysis patients and systolic BP in dialysis patients. Age, heart rate and diastolic BP in the entire group, and age, heart rate and LVM index in non-dialysis patients remained as independent predictors of abnormal diastolic function. CONCLUSIONS: Cardiac involvement in ADPKD patients is a continuous process that evolves during the course of this disease. It is characterized by a low prevalence of specific valvular abnormalities, a progressive increase in LVM, LVH, and diastolic dysfunction, which are greatest in the latter stages of the disease. This study confirms the major influence of BP on cardiovascular abnormalities of ADPKD patients.
Assuntos
Cardiopatias/complicações , Hipertensão/complicações , Rim Policístico Autossômico Dominante/complicações , Adulto , Estudos Transversais , Diástole , Ecocardiografia Doppler em Cores , Ecocardiografia Doppler de Pulso , Feminino , Cardiopatias/diagnóstico por imagem , Cardiopatias/fisiopatologia , Doenças das Valvas Cardíacas/complicações , Hemodinâmica , Humanos , Hipertrofia Ventricular Esquerda/complicações , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Rim Policístico Autossômico Dominante/terapia , Análise de Regressão , Diálise Renal , Fatores de RiscoRESUMO
Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.
Assuntos
Teste de Esforço/normas , Isquemia Miocárdica/diagnóstico , Adulto , Humanos , Sociedades Médicas , EspanhaRESUMO
Left ventricular hypertrophy (LVH) is a common finding in hypertensive autosomal dominant polycystic kidney disease (ADPKD) patients. There are few studies on the influence of blood pressure (BP) and nonhemodynamic factors on LVH in these patients. The aim of this study was to evaluate the relationship between BP, humoral and neurohormonal factors and left ventricular mass (LVM) in hypertensive ADPKD patients. In 20 hypertensive ADPKD patients, ambulatory BP was monitored for 24 h, left ventricular dimensions were estimated by echocardiography, and plasma renin activity (PRA), plasma noradrenaline (NA), angiotensin II (Ang II), aldosterone, atrial natriuretic peptide (ANP) and insulin-like growth factor I (IGF-I) were also determined. Twenty age- and sex-matched essential hypertensive subjects served as controls. Ambulatory BP and LVM index were similar in the two groups, although male ADPKD patients had higher LVM indices than their matched controls. Eight ADPKD patients (40%) and 6 essential hypertensives (30%) showed LVH. PRA, Ang II, aldosterone, ANP and IGF-I levels were similar in the two groups, but plasma NA levels were higher in ADPKD patients than in controls (281 +/- 158 vs. 160 +/- 62 pg/ml, p = 0.004). ADPKD patients with LVH did not differ from those without LVH with regard to humoral and neurohormonal parameters, but had higher ambulatory BP levels. In ADPKD patients, correlation analysis revealed a significant association between LVM index and 24-hour systolic and diastolic BP, but not with any of the hormonal factors evaluated. On multiple regression analysis, 24-hour diastolic BP was the only independent variable linked to LVM index. In conclusion, ambulatory BP is one of the most important determinants of LVM in hypertensive ADPKD patients. Further studies are warranted to elucidate the role of nonhemodynamic factors in the pathogenesis of LVH in this population.
Assuntos
Pressão Sanguínea/fisiologia , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Rim Policístico Autossômico Dominante/fisiopatologia , Adulto , Análise de Variância , Monitorização Ambulatorial da Pressão Arterial , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Ecocardiografia Doppler , Feminino , Humanos , Hipertensão/complicações , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/sangue , Rim Policístico Autossômico Dominante/complicações , Análise de RegressãoRESUMO
Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.
Assuntos
Cardiologia/normas , Doença das Coronárias/cirurgia , Revascularização Miocárdica/normas , Cardiologia/métodos , Humanos , Revascularização Miocárdica/métodos , Seleção de Pacientes , Fatores de Risco , EspanhaRESUMO
Cardiovascular abnormalities have been considered important extrarenal manifestations of autosomal dominant polycystic kidney disease (ADPKD). However, little is known about their prevalence in patients with ADPKD undergoing hemodialysis (HD). To investigate whether cardiac abnormalities are more prevalent in these patients, clinical and echocardiographic manifestations of cardiovascular disease were evaluated in a group of 32 patients with ADPKD and a matched control group of 32 patients without diabetes treated by chronic HD for more than 6 months. Predialysis systolic and diastolic blood pressure (BP), prevalence of hypertension, and number of patients requiring antihypertensive medications were lower in the ADPKD group than controls. There was no difference in the prevalence of cardiac events, including cardiac failure, ischemic heart disease, and arrhythmia. Systolic dysfunction, diastolic patterns, and left ventricular hypertrophy were similar in the two groups. In patients with ADPKD, simple regression analysis showed left ventricular mass (LVM) index was correlated with hemoglobin level and predialytic systolic and diastolic BPs. In multiple regression analysis, predialysis systolic BP was the only independent variable linked to LVM index. The prevalence of aortic, mitral, and tricuspid valve disease did not differ between groups. In conclusion, the occurrence of cardiovascular complications in patients with ADPKD is similar to that of HD patients with other primary renal diseases, although hypertension is less prevalent.
Assuntos
Ecocardiografia , Cardiopatias/diagnóstico por imagem , Falência Renal Crônica/complicações , Rim Policístico Autossômico Dominante/complicações , Idoso , Arritmias Cardíacas/etiologia , Ecocardiografia Doppler de Pulso , Feminino , Cardiopatias/complicações , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Hipertensão/etiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise RenalRESUMO
Higher left ventricular mass (LVM) has been found in early stages of autosomal dominant polycystic kidney disease (ADPKD). The mechanisms involved in the increase of LVM are unknown. To investigate whether LVM in ADPKD may be influenced by abnormal diurnal BP variations, the 24-h ambulatory BP profile was analyzed in a group of young normotensive ADPKD patients. Ambulatory BP monitoring and two-dimensional echocardiography were performed in 26 young normotensive ADPKD with normal renal function and in 26 healthy control subjects. LVM index was higher in ADPKD patients than in controls (90.8+/-19.6 g/m2 versus 73.9+/-16.1 g/m2, P = 0.001). Average 24-h and daytime systolic, diastolic, and mean BP were similar in both groups. Nighttime diastolic and mean BP, but not systolic BP, were greater in ADPKD patients. The average and percent nocturnal decrease of systolic BP was lower in ADPKD patients than in control subjects (10.0 mm Hg [-3 to 24] versus 15.5 mm Hg [-4 to 31], P = 0.009, and 9.0% [-2 to 22] versus 14.2% [-2 to 25], P = 0.016, respectively). On the basis of their profile BP patterns, 54% of ADPKD subjects and 31% of controls were classified as nondippers (P = 0.092). There were no differences between dippers and nondippers in left ventricular wall thickness, chamber dimensions, and mass indexes. In ADPKD patients, simple regression analysis showed that LVM index was correlated with 24-h, daytime, and nighttime systolic BP. On multiple regression analysis, the 24-h systolic BP was the only variable linked to LVM index. It is concluded that young normotensive ADPKD patients have higher LVM that is closely related to the ambulatory systolic BP. The nocturnal fall in BP is attenuated in these patients, although it is not associated with the higher LVH that they present.
Assuntos
Monitorização Ambulatorial da Pressão Arterial , Pressão Sanguínea/fisiologia , Ecocardiografia , Rim Policístico Autossômico Dominante/diagnóstico por imagem , Rim Policístico Autossômico Dominante/fisiopatologia , Adulto , Determinação da Pressão Arterial/métodos , Feminino , Humanos , Masculino , Visita a Consultório Médico , Valores de ReferênciaRESUMO
Severe hyperkalemia with minimal or nonspecific electrocardiographic (ECG) changes is unusual. We report data on seven patients with renal failure, metabolic acidosis, and severe hyperkalemia (K+ > or =8 mmol/L) without typical ECG changes. Initial ECGs revealed sinus rhythm and PR and QT intervals in the normal range. QRS intervals were slightly prolonged in two patients (110 ms), and incomplete right bundle branch block was evident in one. Thus, the absence of typical ECG changes does not preclude severe hyperkalemia.
Assuntos
Eletrocardiografia , Hiperpotassemia/fisiopatologia , Potássio/sangue , Acidose/sangue , Acidose/complicações , Adulto , Idoso , Bloqueio de Ramo/etiologia , Bloqueio de Ramo/fisiopatologia , Feminino , Seguimentos , Frequência Cardíaca , Humanos , Hiperpotassemia/sangue , Hiperpotassemia/etiologia , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/sangue , Insuficiência Renal/complicações , Estudos RetrospectivosRESUMO
Left ventricular hypertrophy is often found very early in the course of autosomal dominant polycystic kidney disease (ADPKD). Diastolic dysfunction has been shown in hypertensive adult patients with ADPKD with increased left ventricular mass (LVM), but there are no data about diastolic function in the young ADPKD population without hypertension and with normal renal function. To evaluate very early alterations in cardiac structure and diastolic function in young normotensive patients with ADPKD, color Doppler echocardiography was performed in 46 young normotensive patients with ADPKD and 35 healthy subjects. LVM, transmitral pulsed Doppler flow (diastolic function), and valvular abnormalities were studied. Patients with ADPKD showed higher LVM indices (LVMIs) than controls (89.7+/-17.3 v 68.5+/-17.2 g/m2; P < 0.0001). Peak early diastolic velocity (E wave) deceleration time and isovolumic relaxation time were significantly prolonged in patients with ADPKD compared with controls (E wave deceleration time, 182.5+/-51.3 v 149.4+/-34 msec; P=0.002; isovolumic relaxation time, 97.7+/-17.5 v 79+/-15 msec; P=0.0001). No differences were found in valvular abnormalities in the two groups. In conclusion, young normotensive patients with ADPKD showed increased LVMIs and Doppler abnormalities consistent with early diastolic dysfunction.
Assuntos
Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Rim Policístico Autossômico Dominante/diagnóstico por imagem , Adolescente , Adulto , Criança , Diástole , Ecocardiografia/métodos , Ecocardiografia/estatística & dados numéricos , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Hipertrofia Ventricular Esquerda/fisiopatologia , Rim/diagnóstico por imagem , Masculino , Rim Policístico Autossômico Dominante/fisiopatologia , Valores de Referência , Fatores de TempoRESUMO
Microalbuminuria (MA) is present in hypertensive autosomal-dominant polycystic kidney disease (ADPKD) patients, but has not been reported in normotensive ADPKD patients. We examined the prevalence of MA and the effect of different determinants on urinary albumin excretion in a group of 42 normotensive ADPKD patients. Metabolic parameters, plasma renin activity and aldosterone and serum angiotensin-converting enzyme (ACE) activity were determined. A 24-h urine sample two or three times over a 6-month period was collected to evaluate MA. Each patient underwent an echocardiography to measure left ventricular mass. Eight patients (19%) showed MA (61.6 mg/day, range 37-164), whereas 34 patients (81%) were normoalbuminuric (8.8 mg/day, range 2-29). The groups were matched for all possible confounding variables, but microalbuminuric patients showed a tendency towards greater systolic blood pressure, plasma renin activity and left ventricular mass. There was no correlation between MA and age, sex, body mass index, systolic or diastolic blood pressure, plasma renin activity, serum ACE levels or left ventricular index. The present study demonstrates a high prevalence of MA in normotensive ADPKD patients. MA may be a predictor of early renal and vascular damage in these patients.
Assuntos
Albuminúria/diagnóstico , Rim Policístico Autossômico Dominante/urina , Adulto , Albuminúria/epidemiologia , Albuminúria/etiologia , Estudos de Casos e Controles , Ecocardiografia , Feminino , Humanos , Hipertensão Renal/etiologia , Hipertensão Renal/urina , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Masculino , Peptidil Dipeptidase A/sangue , Rim Policístico Autossômico Dominante/complicações , Prevalência , Sistema Renina-Angiotensina , Fatores de RiscoRESUMO
Platelet glycoprotein IIb/IIIa may be involved in the pathogenesis of myocardial infarction as the key element in platelet aggregation and as the binding site of lipoprotein(a) to platelets, inhibiting plasminogen binding and activation. Recently, a strong association between the P1A2 polymorphism of the glycoprotein IIIa gene and acute coronary thrombosis has been reported. although this has not been confirmed. In an associated study, we determined plasma lipoprotein levels, the apo E genotype and the P1A genotype in 250 males under 55 years with myocardial infarction and they were compared with 250 age- and sex-matched controls. Patients showed an over-representation of the epsilon3/4 genotype with respect to the control group. We found that there were no differences in the allelic frequency of P1A2 between case patients and age-matched controls (chi2 = 0.05, P = 0.92) and that subjects bearing the P1A2 allele showed higher plasma lipoprotein(a) concentration than p1A1/P1A1 individuals. Therefore, in this population there is no association between carriage of p1A2 allele and increased risk of myocardial infarction but the carriage of P1A2 is associated with higher plasma Lp(a) concentration.
Assuntos
Lipoproteína(a)/sangue , Infarto do Miocárdio/genética , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/genética , Polimorfismo Genético , Adulto , Alelos , Apolipoproteínas E/genética , Feminino , Frequência do Gene , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Fatores de RiscoRESUMO
A case of acute pulmonary embolism and right atrial thrombus "in transit" treated with recombinant tissue plasmin activator is described. An early echocardiographic study in acute pulmonary embolism can detect right atrial thrombus in 15% of the time. It is well known that this finding is associated with poor prognosis, but the best treatment is controversial. The present case, in accordance with other previous reports, suggests the use of systemic fibrinolytic therapy in patients with right atrial thrombus and pulmonary embolism in course.
Assuntos
Cardiopatias/complicações , Ativadores de Plasminogênio/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Trombose/complicações , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Ecocardiografia , Seguimentos , Cardiopatias/diagnóstico , Cardiopatias/tratamento farmacológico , Humanos , Masculino , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Trombose/diagnóstico , Trombose/tratamento farmacológico , Fatores de TempoRESUMO
BACKGROUND: Ischemia of the myocardium surviving an infarction induces ST segment elevation in infarct-related ECG leads. In cases with no viable tissues, ischemia adjacent to the infarction could induce a similar ECG pattern if there is ST segment potential transmission through the necrotic scar. We analyzed whether acute ischemia adjacent to a healed infarction with no viable tissue may induce ST segment elevation on the surface of the necrotic scar. METHODS AND RESULTS: Epicardial ST segment changes elicited during 30 minutes of acute reocclusion of the left anterior descending (LAD) coronary artery 2 cm above the first diagonal branch were analyzed by 32-channel mapping in 18 chloralose-anesthetized open-chest pigs with 1-month-old anterior infarctions induced by permanent ligature below the first diagonal branch (group 1). The effect of a previous infarction on the magnitude of ischemic ST segment changes was assessed by similar mapping in 21 control pigs submitted to a LAD ligature 2 cm above the first diagonal branch (group 2, n = 11) or just below this branch (group 3, n = 10). Myocardial perfusion after coronary ligature was estimated in 7 pigs with chronic infarction and in 3 control pigs by mapping of myocardial technetium-99m-methoxyisobutyl isonitrile (99mTc-MIBI) activity in transmural samples underlying each epicardial electrode. The width of cell layers surviving the infarction was measured and their viability after 60 minutes of coronary reocclusion was assessed by intracellular glycogen staining. Reocclusion of the LAD induced parallel ST segment elevation at the periinfarction zone and at the necrotic scar, although in the latter region the changes were less marked (maximal ST segment, 8.4 +/- 3.0 mV versus 2.7 +/- 1.8 mV, ANOVA, P < .001). ST segment elevation inside the scar was greater at the margins (3.9 +/- 1.8 mV) than at sites 20 mm toward the center (2.8 +/- 1.7 mV, P = .003). The necrotic area was virtually devoid of surviving cells except for a 0.22 +/- 0.04-mm-wide subendocardial band that continued to show a positive intracellular glycogen reaction after the second LAD ligature. Acute ischemia adjacent to the infarction (group 1) induced lower ST segment elevation than acute ischemia at a comparable cardiac region in noninfarcted pigs (group 2) (ANOVA, P = .02), despite the fact that these areas developed similar underperfusion after coronary occlusion (percent MIBI activity of that in normal myocardium, 7 +/- 8 versus 7 +/- 6, P = NS). ST segment changes in group 2 pigs were comparable to those induced in group 3 pigs with a 2-cm-lower coronary occlusion. CONCLUSIONS: Acute ischemia adjacent to a chronic infarction induces ST segment elevation at the surface of the scar despite the virtual absence of viable tissue within the infarction. Data suggest a passive ST segment potential transmission through the infarction. Moreover, ischemia adjacent to a chronic infarction induces lower ST segment elevation than ischemia not adjacent to a necrosis. The mechanisms accounting for these regional differences are probably independent of collateral myocardial perfusion and ischemia extension.
Assuntos
Eletrocardiografia , Sistema de Condução Cardíaco/fisiopatologia , Infarto do Miocárdio/fisiopatologia , Isquemia Miocárdica/fisiopatologia , Animais , Eletrofisiologia , Coração/diagnóstico por imagem , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/patologia , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/patologia , Miocárdio/patologia , Necrose , Cintilografia , Processamento de Sinais Assistido por Computador , Suínos , Tecnécio Tc 99m SestamibiRESUMO
OBJECTIVE: The aim was to assess the arrhythmogenic potential of acute ischaemia superimposed at the borders of a chronic myocardial infarct and to analyse the effects of myocardial necrosis on local autonomic innervation in pigs. METHODS: Ventricular arrhythmias were measured in alpha chloralose (100 mg.kg-1) anaesthetised open chest pigs during 60 min occlusion of the left anterior descending coronary artery 2 cm above the first diagonal branch (group I, n = 11) or just below this branch (group II, n = 12). These arrhythmias were compared with those induced in pigs with a one month old anteroseptal infarction (coronary ligature as in group II) submitted to a second occlusion 2 cm above the first (group III, n = 12). The area at risk after high or low ligature was measured in 12 control pigs using fluorescein. Sympathetic and parasympathetic innervation of the anteroseptal myocardium was studied in three pigs with a chronic anteroseptal infarction and in six pigs without infarction using adrenergic histofluorescence and acetylcholinesterase reaction. RESULTS: Compared with ischaemia alone, ischaemia at the borders of a chronic infarct induced a lower incidence of ventricular fibrillation (1/12 pigs v 11/11 in group I, p < 0.001, or 6/12 in group II, p < 0.05) and a tendency towards a lower occurrence of ventricular tachycardia (2/12 pigs v 8/11 in group I, p = 0.01, and 4/12 in group II) and fewer ventricular premature beats (mean number: 105 in group I v 30 in group III, p < 0.05). The mass of the ischaemic regions after low or high occlusion was 13.3(SD 3.0) g and 23.2(5.8) g, respectively. Adrenergic and cholinergic denervation was observed inside the necrotic area, along the subendocardium surviving the necrosis, and in a band of normal bordering myocardium [width: 3.2(2.0) mm for adrenergic and 2.1(1.2) mm for cholinergic denervation]. CONCLUSIONS: Acute ischaemia at the borders of a chronic anteroseptal infarct has a low arrhythmogenic potential in pigs. In this model the peri-infarction zone shows a band of sympathetic and parasympathetic denervation secondary to the necrosis.