Mortality and morbidity trends in ischemic heart disease in the autonomous region of Madeira in the ten-year period 1987-1996.

The increase in absolute number of deaths from ischemic heart disease (IHD) in the population aged > or = 65 years, in both sexes, in Madeira, when comparing the years 1987 and 1996, led to significant increases in the corresponding standardized death rates that go against the stabilization seen at national level. Significant increases in these rates for the same years were also seen in the district of Beja and in the Azores. The aim of this study was to ascertain the trends for the incidence, morbidity and mortality from acute myocardial infarction (AMI) in patients admitted in Madeira and its contribution to the increase in these rates, particularly in the population aged < 65 years of both sexes, which the number of deaths from ischemic heart disease did not increase. We studied 119 pts with AMI admitted in 1987 (year A), of whom 53 were aged < 65 years, and 186 pts with AMI admitted in 1996 (year B), of whom 72 were aged < 65 years, whose data were included in the Madeira Ischemic Heart Disease Register (RECIMA), an IHD hospital register that covers 1792 patients admitted with AMI in the Coronary Intensive Care Unit of the Department of Medical and Surgical Cardiology of Funchal Hospital over a period of 15 years (1984-1998). Mortality by the 28th day (fatal AMI admissions) in all ages fell slightly in both sexes in the two years studied (A = 19.3%; B = 16.1%). The number of fatal AMI admissions rose among females in the two age groups considered A = 11; B = 20; delta% = +45) and fell among males (A = 12; B = 10; delta% = -20). In males aged > or = 65 years, this number remained the same (A = 7; B = 7) and fell in males aged > or = 65 years (A = 5; B = 3; delta% = -40). The number of pts who survived to the 28th day (non-fatal AMI admissions) rose in all age groups for both sexes (A = 96; B = 156; delta% = +38.46), as did the ratios with deaths from IHD. These increases were roughly double in the group of patients aged 65 years compared to patients aged < 65 years. We found highly significant positive correlations in the population aged < 65 years between the number of non-fatal AMI admissions (morbidity data) and the number of deaths from IHD (mortality data) recorded in every year of the 10-year period 1987-96, these values being highly significant in both sexes (r = 0.89; p < 0.0001), in males (r = 0.87; p < 0.0001) and in females (r = 0.77; p < 0.0001). Since our study was carried out on an island on which all AMI cases are admitted to a single treatment center, we can conclude that these positive correlations represent a trend towards worsening of morbidity and mortality from IHD in Madeira in the population aged < 65 years, even though the number of deaths from IHD did not rise. The establishment of IHD registers similar to RECIMA in other regions of the country would help to identify trends in morbidity, mortality, and morbidity plus mortality in this population that would be useful in improving the orientation of resources allocated to the prevention and treatment of cardiovascular diseases.

Thrombolytic therapy impact on prognosis after twelve months of first acute myocardial infarction.

INTRODUCTION AND OBJECTIVES: Thrombolytic therapy is still widely used to restore antegrade flow in the infarct related artery (IRA), with unquestionable benefits in mortality reduction of such patients. The aim of this study was to evaluate early (< or = 28 days) and one-year mortality of patients with a first Q wave myocardial infarction (Q AMI), comparing those who underwent thrombolytic therapy with those who did not. POPULATION AND METHODS: A retrospective study was done on 907 patients (median age: 35 +/- 13 years, 66% male) admitted to a Coronary Unit with the diagnosis of first Q AMI, from January 1988 to December 1997, all in the same geographical area (minimum follow-up period of one year, mean follow-up 43 +/- 37 months). We compared demographics and clinical characteristics (coronary risk factors, previous history of angina, MI location and evolution, cardiac events, 28 day and one-year mortality) of patients who underwent thrombolysis (group T = 355) versus those who did not undergo reperfusion therapy (group NT = 552). RESULTS: Of these patients 39% underwent thrombolytic therapy. Group NT had a greater number of female patients (40% vs 25%; p < 0.001), a significantly higher mean age (67 +/- 12.2 vs 61 +/- 12; p < 0.001), and a higher percentage of diabetics (29% vs 19%; p < 0.001), in comparison to group T. The Q AMI developed into Killip class > or = 2 in 43% of patients in group NT and 23% in group T (p < 0.001). A higher number of AV block (NT-13% vs T-8%; p < 0.05) and higher in-hospital mortality (NT-14% vs T-9%; p < 0.05) was observed in patients not undergoing thrombolysis. The early (NT-22% vs T-12%; p < 0.001) and one-year (NT-33% vs T-16%; p < 0.001) mortalities were significantly higher in group NT than in group T, even after multivariate analysis. CONCLUSIONS: 1--Patients who did not undergo thrombolytic therapy initially had a profile of greater severity, and a higher early and one-year mortality rate. 2--Those who underwent thrombolytic therapy presented a significantly lower mortality, a benefit that was still observed after one year of follow-up and after multivariate correction.

Survival analysis within one year of first acute myocardial infarction: comparison between non-Q and Q wave myocardial infarction.

BACKGROUND: Non-Q wave Myocardial Infarction (non-Q AMI) is related pathophysiologically to Q wave AMI, as each represents different stages of plaque rupture and thrombosis. Post-hospital re-infarction and recurrent angina are more frequent in non-Q AMI than in Q wave AMI, offsetting the higher early risk with Q wave AMI, with one-year survival rates similar in the two types of MI. OBJECTIVES: 1--Evaluation of early (< or = 28 days) and one-year total mortality from first non-Q AMI in comparison to QMI. 2--Analysis of recurrent acute ischaemic events (non-fatal reinfarction and unstable angina) in both types of MI in the same periods of time. POPULATION AND METHODS: A retrospective study of 1146 patients, mean age 65 +/- 13 years, 65% male, admitted at CCU with a first MI, from January 1988 to December 1997 (minimum follow-up period of one year, mean follow-up 42 +/- 37 months). We compared the baseline demographics and clinical characteristics (coronary risk factors, previous angina, MI evolution, recurrent cardiac events, 28 day mortality and one year mortality) of patients with non-Q AMI (NQ group = 239) and Q wave AMI (Q group = 907). RESULTS: The NQ group patients were significantly older (mean age: 67 +/- 12.6 vs 65 +/- 12.5 years; p < 0.05), included fewer smokers (29% vs 43%; p < 0.001) and were more symptomatic before the index infarction (stable angina: 40% vs 30%; p < 0.05; unstable angina: 16% vs 6%; p < 0.001), when compared to the Q group patients. There were no significant differences in MI evolution, in Killip-Kimbal class > or = 2, recurrent angina and in-hospital mortality (Q-12% vs NQ-9%; ns), although there was a higher combined risk of arrhythmias and AV conduction disturbances in patients with QMI (Q-34% vs NQ-26%; p < 0.05). The combined risk of unstable angina and reinfarction at one year was significantly higher in group NQ (NQ-13% vs Q-8.1%; p < 0.05). The NQ group showed no significant difference in 28 day total mortality (NQ-14% vs Q-17%; ns) or at one year follow-up (NQ-24% vs Q-26%; ns) when compared to the Q group. CONCLUSION: 1--Despite a lower severity of non-Q AMI in the acute phase, 28 day and one year total mortality were similar in the two groups. 2--Patients with non-Q AMI showed a higher incidence of recurrent ischemic events at one year follow-up.

[Diastolic dysfunction in patients with chronic kidney failure on a hemodialysis program]. / Disfunção diastólica em doentes com insuficiência renal crónica em programa de hemodiálise.

OBJECTIVE: The aim of this study was to analyse different ultrasound parameters for the assessment of isolated left ventricular diastolic dysfunction (LVDD) in patients with chronic renal failure (CRF) on periodic hemodialysis (HD), comparing pulsed wave Doppler with pulsed tissue Doppler. MATERIALS AND METHODS: Forty-seven patients with CRF on HD (61% were male; mean age was 51.0 +/- 16.5 years, mean HD time--3.7 +/- 3.8 years, 38% had hypertension, 17% had diabetes) were studied by echocardiography (bidimensional, M-Mode, flow pulsed Doppler and tissue Doppler imaging). All patients had symptoms of left heart failure-class II NYHA, were in sinus rhythm and had no symptoms of ischemic heart disease. The presence of abnormal LV regional contractility was the exclusion criteria. According to their mitral inflow profile Doppler characteristics, patients were included in two groups: Group A (E/A > 1; n = 21) and B (E/A < 1; n = 26). We compared: LV dimensions and function, left atrial (LA) dimension. Gaasch index, LV mass index. E and A wave velocities (in flow pulsatile Doppler and tissue Doppler). E/N ratio in tissue Doppler, isovolumetric relaxation time (IVRT) and deceleration time (DT). RESULTS: There were no significant differences in the prevalence of age > or = 65 years male sex, hypertension or diabetes between group A and B patients, and almost all patients were on hemodialytic treatment for more than one year (81% vs 85%: NS). LV hypertrophy was present in almost all group A and B patients (A--95% vs B--85.5%; NS). Group A, compared with group B, had a difference in the Gaasch index (2.45 +/- 0.3 vs 2.08 +/- 0.4; p < 0.05), E wave velocity in flow pulsatile Doppler and tissue Doppler (cm/sec) (110 +/- 27 vs 62 +/- 20; p < 0.001 and 41 +/- 15 vs 28.5 +/- 16; p < 0.05), E/A ratio in tissue Doppler (1.3 +/- 0.4 vs 0.8 +/- 0.3; p < 0.001). IVRT (msec) (80.7 +/- 15.2 vs 113.5 +/- 28.3; p < 0.001) and DT (msec) (189.7 +/- 24 vs 278.2 +/- 17.9; p < 0.001). According to the E'/A' ratio in tissue Doppler, group A patients were divided in another two groups: E'/A' > 1 (13/21--62%) and < 1 (8/21--38%) and a significantly longer IVRT (75.8 +/- 9.3 vs 100.9 +/- 3.2; p < 0.001) and DT (178 +/- 15 vs 240 +/- 20; p < 0.001) and a greater LA dimension (37.6 +/- 6.9 vs 44.6 +/- 6.9; p < 0.05) were found. CONCLUSIONS: Pulsed wave Doppler is the most useful non invasive method for assessment of global diastolic dysfunction. In our study, 17% of the patients had E/A < 1 only in the tissue Doppler study. These patients probably had a pseudonormal mitral pattern.

[Role of auxiliary diagnostic tests in the clarification of the etiology of syncope: experience at an arrhythmia center]. / Papel dos exames auxiliares de diagnóstico no esclarecimento etiológico da síncope--experiência de uma consulta de arritmologia.

UNLABELLED: Syncope is a syndrome caused by a reversible reduction of blood to the brain. Three hemodynamic abnormalities can cause syncope: an acute decrease in cardiac output, an acute increase in cerebrovascular resistance and a fall in systemic blood pressure due to ineffective control of peripheral vascular resistance. We made a retrospective study of 121 patients with syncope history, 67 males, and 57 females, with mean age 48 +/- 14 years, and at least six months of clinical follow-up. Twelve patients had valvular disease, two patients had hypertrophic cardiomyopathy, eight patients had dilated cardiomyopathy, 14 patients had ischemic disease, three patients had congenital disease; 82 patients did not have cardiac disease. Syncope etiology was arrhythmic in 69 patients: 47 patients had tachyarrhythmia (supraventricular--in 27 patients and ventricular in 20 patients) and 15 patients had bradyarrhythmia (seven patients had sinus node disease and eight patients had atrioventricular block). Non arrhythmic etiology of syncope was identified in 29 patients (neurologic disease--ten patients, metabolic disease--one patient and iatrogenic--two patients; vasodepressor syncope--14 patients, and hypertrophic cardiomyopathy--two patients). It was not possible to determine the syncope etiology in 30 patients. The assessment of patients who present syncope depends on establishing the basis for the symptoms. The initial step is differentiating patients with normal cardiovascular systems from those with heart disease. In the former, tilt-table testing proved to be the most productive from a diagnostic perspective; in the latter group, electrophysiologic evaluation was the most elucidative from a diagnostic perspective. The ultimate goal is to obtain a sufficiently strong correlation between syncopal symptoms and detected abnormalities to permit an accurate assessment of prognosis and to develop an effective treatment plan. CONCLUSIONS: It is very important to establish the etiology of syncope for optimal management of patients and it is therefore possible to control the symptoms in the majority of them. The patients who present syncope require a complete history and a physical examination for an appropriate workup to be initiated. Tilt-table testing was the most accurate for the diagnosis of vasodepressor syncope while electrophysiologic testing provides an accurate method for assessing the etiology of tachyarrhythmic syncope.

[Value of exercise test for risk stratification acute myocardial infarction]. / Valor da prova de esforço na estratificação de risco após enfarte agudo do miocárdio.

OBJECTIVES: To assess the prognostic value of predischarge exercise testing (ET) in patients hospitalized for acute myocardial infarction (AMI). CONTEXT: Department of Cardiology in a reference hospital for Interventional Cardiology METHODS: Between January 1990 and December 1994, 178 patients hospitalized for AMI were discharged and referred to the outpatient clinic (mean follow up, 1049 +/- 612 days). Eighty-two percent of these patients were men, mean age--56 +/- 12 years. Patients that did not perform predischarge ET (Group A, n 77) were retrospectively compared with those who did (Group B, n = 101). In relation to demographic and clinical characteristics; we analysed cardiac events (CE) and death during the first 18 months after discharge in both groups. In group B patients, we studied the relation of ET parameters (duration of exercise, occurrence of exercise-induced ischaemia and arrhythmias, maximum heart rate, blood pressure response, rate pressure product and severity score) to CE and death during the first 18 months after AMI. RESULTS: The proportion of patients aged 70 years or older was greater in group A (23% vs 3%, P < 0.001). In this group, there was a greater prevalence of recurrent ischaemia (51% vs 29%, P < 0.001) and left ventricular dysfunction (42% vs 25%, P < 0.05). Group A patients were also submitted to less thrombolysis (45% vs 62%, P < 0.05) and to revascularization procedures (25% vs 41%, P < 0.05). In group B patients, the incidence of CE did not differ with respect to duration of ET, rate pressure product or maximum heart rate. Incidence of CE was greater in patients with exercise-induced ischaemia (38% vs 15%, P < 0.05), severity score > 2 (45% vs 18%, P < 0.02) and inadequate rise (< 30 mmHg) in systolic blood pressure (39% vs 13%, P < 0.02). The total incidence of CE and revascularization was also greater in patients with exercise-induced ischaemia (88% vs 49%, P < 0.001), severity score > 2 (95% vs 56%, P < 0.02) and inadequate rise in systolic blood pressure (93% vs 45%, P < 0.001). CONCLUSIONS: In patients without indication for ET as part of risk stratification after AMI, clinical characteristics were more severe as defined by age greater than 70 years, residual ischaemia and left ventricular dysfunction. Patients that performed ET had smaller risk, except when presenting exercise-induced ischaemia, severity score > 2 and inadequate rise in systolic blood pressure.

[Hemangioma of the right ventricle]. / Hemangioma do ventrículo direito.

A 36-year-old male with unspecific symptoms and normal physical examination had right cardiac enlargement on chest X-ray. Two-dimensional echocardiographic and thoracic computed tomography demonstrated an intracardiac mass. The tumor was surgically resected and the pathological diagnosis was mixed-type epicardial hemangioma. We discuss this case and review the literature.

[Catheter ablation with radiofrequency energy in 100 patients with Wolff-Parkinson-White syndrome]. / Ablação por cateter com energia de radiofrequência de 100 doentes com síndrome de Wolff-Parkinson-White.

OBJECTIVE: The aim of this paper was to evaluate our results of radiofrequency catheter ablation (RFCA) of accessory pathways in patients with WPW syndrome. STUDY PATIENTS: We studied 100 consecutive patients with WPW syndrome, 52 men and 48 women, mean age 37 +/- 15 years who underwent RFCA. All patients were symptomatic, with documented episodes of supraventricular tachycardia and 9% of patients had underlying cardiac disease. METHODS: The RFCA was performed without antiarrhythmic drugs in the same session of the electrophysiologic diagnosis. The location of the accessory pathway site was obtained by catheter mapping, based on the premature and/or the presence of Kent potentials. According to the location of the accessory pathway, the ablation catheter was introduced either by the femoral vein or artery with mapping of the tricuspid or mitral ring. In the first cases performed energy application was manually controlled and thereafter was temperature guided with an upper temperature limit of 70 degrees C. We considered primary success criteria the disappearance of the delta wave in the surface ECG and the absence of ventricular preexcitation under atrial pacing and after adenosine injection. Clinical success was defined as the absence of clinical recurrence of tachycardia during the follow-up period. RESULTS: The primary success rate achieved was 88%; 91% in the left free wall pathways, 100% in the right free wall and 85% in the septal pathways (antero-septal-83%; right postero-septal-76.5%; left postero-septal-92%). A second ablation procedure was performed in seven of the twelve patients with primary unsuccess obtaining a final success rate of 93% (left free wall-94.5%; septal pathways-91.6%). After a mean follow-up period of 8 +/- 7 months clinical recurrence occurred in 9% (eight patients), five of which are under anti-arrhythmic therapy (62.5%). Clinical success rate at the end of the follow-up period was 88%. CONCLUSIONS: In our experience RFCA has shown to be safe and with a high success rate in patients with symptomatic pre-excitation. In this group of patients it was an effective therapy.

[Value of "cardiac event recorders" in the assessment of sporadic cardiac symptoms]. / Valor do "registador de eventos" no esclarecimento de sintomas cardíacos esporádicos.

OBJECTIVES: To determine the value of the Cardiac Event Recorder (CER) in the diagnosis and treatment orientation of bradydysrhythmias, tachydysrhythmias and ischaemic events, based on our experience at the Santa Cruz Hospital. METHODS: We retrospectively analysed 100 consecutive patients tested with a CER between January 1990 and December 1996 (mean follow-up, 272 +/- 202 days); the mean age of the patients (66 women and 34 men) was 45 +/- 18 years (range: 7 to 83); structural cardiac disease was present in 34% of the patients. CER was indicated for the investigation of symptoms suggestive of bradydysrhythmias (pre-syncope and/or syncope)--Group B--in 24 patients, tachydysrhythmias (palpitations and/or tachycardia sensation)--Group T--in 72 patients and ischaemic events--Group I--in the remaining four patients. We compared these groups with respect to demographic characteristics, prevalence of structural cardiac disease and efficacy of the test in the investigation of symptoms; periodicity of symptoms and duration of CER testing were analysed. In patients that experienced typical symptoms during the test, we analysed the electrocardiogram recorded at the time of the event and we investigated whether abnormal ECG findings influenced the therapeutic approach and whether this led to better symptomatic outcome. RESULTS: Patients in groups B and T were mainly women (54 percent vs 74 percent, NS). Group B patients were older than group T patients (mean age, 56.4 +/- 17.8 vs 40.0 +/- 16.0 yrs, P < 0.001). In group B, structural cardiac disease was less prevalent (37.5% vs 78.0%, P < 0.001) and symptom periodicity was greater (weekly: 12.5% vs 78.0%, monthly: 87.5% vs 15.2%, P < 0.001) than in group T. Duration of CER testing and number of events recorded were similar in the two groups. In both, CER testing was an important aid for therapeutic approach. Twenty two patients (eight B, 13 T and one I) had no typical symptomatic episodes during the CER test; in the remaining 78 patients (16 B, 59 T and three I), an electrocardiogram recording during such episodes was available for analysis. The ECG was abnormal in 44 of these patients, 12 (75%) being of group B and 32 (54%) of group T. Symptom periodicity was a few weeks in 65% of all patients (6 B, 57 T and two I). Duration of CER testing was < or = two weeks in 91 percent of the patients (22 B, 65 T and four I). CER testing guided the therapeutic approach in 78% of all patients. Changes of treatment strategy were more frequent in patients with CER documented typical symptomatic episodes than in those without (46% vs 9%, P < 0.02). When changes of treatment occurred, symptomatic outcome was better (97% vs 55%, P < 0.001). CONCLUSIONS: The CER is an important guide for the diagnostic and therapeutic approach for patients with intermittent arrhythmia suggesting, symptoms (78% of patients). A recording of normal ECG during typical symptoms reassures the patient and excludes potentially toxic treatments. Our selection of patients for CER testing seemed adequate since most typical symptomatic events occurred during the first two weeks of the test; longer duration of CER testing seems unnecessary.

[Acute myocardial infarct in a young cocaine user]. / Enfarte agudo do miocárdio num jovem consumidor de cocaína.

In patients less than 40 years of age, acute myocardial infarction (AMI) has special clinical and pathophysiologic characteristics. Its prevalence varies between 5 and 10%. In such patients, AMI associated with chronic cocaine abuse has a non-negligible prevalence of 6%. The purpose of this report is to describe the case of a 24-year old male patient with smoking habits and chronic abuse of cocaine and hallucinogenic drugs. This patient developed clinical, enzymatic and electrocardiographic criteria of anterior AMI, two hours after the ingestion of an LSD-like hallucinogenic drug. The coronary angiography revealed a critical stenosis of the medium segment of the left anterior descendent artery, and a pre-stenotic aneurysmatic dilatation. In order to determine the etiology of the aneurysm, various laboratory and histologic tests were performed. The results of these were normal. We review the pathophysiology, clinical manifestations and prognosis of cocaine-associated AMI.

[Experience with dl-sotalol in the treatment of supraventricular arrhythmia]. / Experiência com dl-sotalol na terapêutica de arritmias supraventriculares.

OBJECTIVES: To review the results of our experience with oral dl-sotalol for preventive treatment of supraventricular tachyarrhythmias (atrial fibrillation and paroxysmal supraventricular tachycardia). POPULATION: 51 patients, 28 female and 23 male, mean age 46.2 +/- 14.4 years, from outpatient arrhythmology clinics of our institution, with recurrent supraventricular tachyarrhythmias (atrial fibrillation in 24 patients and paroxysmal supraventricular tachycardia in 27). All the patients, but one, had normal left ventricular function. Dl-sotalol was first choice medication in only three patients. Previously 2 +/- 1.3 antiarrhythmic drugs had been used. METHODS: Retrospective evaluation of therapeutic response (number of clinical recurrences according to a semi-quantitative scale) and secondary effects of dl-sotalol during a minimum follow-up of 18 months. The mean daily dose was 205 +/- 90 mg (80 to 400 mg). RESULTS: In 37% of the patients there were no clinical recurrences of arrhythmia during follow-up. In 37% of the patients there was a significant reduction in recurrences. In 26% there was no change in the number of recurrences. There were no significant differences in response between patients with atrial fibrillation and those with paroxysmal supraventricular tachycardia. Secondary effects occurred in 16% of the patients: symptomatic bradycardia, asthma or sexual dysfunction. No patient had heart failure, torsades de pointes, syncope or death. CONCLUSIONS: From our experience, DL-sotalol seems to be a good therapeutic alternative for the preventive treatment of supraventricular tachyarrhythmias, with a low risk in patients with good ventricular function.

Eosinophilic granuloma of the cervical and thoracic spine in a child.

A case of eosinophilic granuloma affecting a cervical vertebra, thoracic vertebra and pelvis in a child is reported. We present this case because multifocal eosinophilic granuloma lesions of the spine are rare and can present as this case did with both diagnostic and therapeutic problems. Preoperative diagnosis may be made by X-ray, isotope bone scan and needle biopsy, avoiding unnecessary surgical intervention.

Lymphography in clinically suspected lymphoma: a retrospective analysis of 63 cases.

Pedal lymphography was performed for 63 patients with clinical findings (chiefly unexplained pyrexia or splenomegaly) suggestive of lymphoma involving the retroperitoneal nodes. The lymphogram was abnormal in 17 cases. Lymphoma was found in 5, metastatic carcinoma in 3, malignant histiocytes in 1, and benign hyperplasia or fibrolipomatous nodal changes in 4 (histiological tests were not obtained in the other 4). An abnormal lymphogram of the retroperitoneal nodes constitutes an indication for laparotomy; the lymphographic appearance of lymphoma is nonspecific, and histologic confirmation should be sought.