Effects of chlorthalidone and diltiazem on myocardial ischemia in elderly patients with hypertension and coronary artery disease.

OBJECTIVE: Antihypertensive therapy with thiazides decreases coronary events in elderly patients. However, the influence of diuretics on myocardial ischemia has not been fully investigated. The aim of this study was to compare the effect of chlorthalidone and diltiazem on myocardial ischemia. METHODS: Following a randomized, double-blind, crossover protocol, we studied 15 elderly hypertensive patients aged 73.6+/-4.6 years with myocardial ischemia. All patients had angiographically documented coronary artery disease. We measured patients using 48- hour ambulatory electrocardiogram monitoring and exercise testing. After a 2-week period using placebo, patients received chlorthalidone or diltiazem for 4 weeks. RESULTS: Both treatments lowered systolic and diastolic blood pressures. The number of ischemic episodes on ambulatory electrocardiogram recordings was reduced with the use of chlorthalidone (2.5+/-3.8) and diltiazem (3.2+/-4.2) when compared with placebo (7.9+/-8.8; p<0.05). The total duration of ischemic episodes was reduced in both treatments when compared with placebo (chlorthalidone: 19.2+/-31.9min; diltiazem: 19.3+/-29.6min; placebo: 46.1+/-55.3min; p<0.05). CONCLUSION: In elderly hypertensive patients with coronary artery disease, chlorthalidone reduced myocardial ischemia similarly to diltiazem. This result is consistent with epidemiological studies and suggests that reduction of arterial blood pressure with thiazide therapy plays an important role in decreasing myocardial ischemia.

Clinical predictors of prognosis in severe aortic stenosis in unoperated patients > or = 75 years of age.

In elderly patients with severe aortic stenosis, clinical evaluation can dictate decision making. Asymptomatic patients in normal sinus rhythm, without left atrial enlargement and without bundle branch block, can be safely followed clinically, regardless of echocardiographic findings.

[Effect of myocardial revascularization on asymptomatic ischemic episodes]. / Efeito da cirurgia de revascularização miocárdica sobre os episódios isquêmicos assintomáticos.

PURPOSE: To evaluate the effect of coronary artery bypass graft surgery (CABG) on ischemic asymptomatic episodes (IAE). METHODS: Twenty eight males (means age 57.3 +/- 9.6 years) with stable angina and no microcirculation abnormalities, who presented with IAE after medication withdrawal, were studied using ambulatory electrocardiography monitoring. Presence of IEA was analyzed before and 4 months after CABG according to its frequency and heart rate (HR) response. CAGB was considered complete in 75% of the cases. RESULTS: The number or IAE was reduced from 162 (9 symptomatic) in the preoperative period to 4 after surgery (p < 0.05). In two patients with IAE in the postoperative period, coronariography confirmed obstruction of aortocoronary grafts. Analysis of HR at the beginning and peak of IAE suggested as mechanisms both reduced blood flow and increased oxygen consumption by the myocardium. CONCLUSION: CABC eliminated IAE regardless of HR. When IAE is present after surgery, graft occlusion should be suspected.

Efeito da cirurgia de revascularizaçäo miocárdica sobre os episódios isquêmicos assintomáticos / Effect of coronary artery bypass graft surgery on ischemic asymptomatic episodes

OBJETIVO - Avaliar o efeito da cirurgia de revascularizaçäo miocárdica (CRM) sobre episódios isquêmicos assintomáticos (EIA). MÉTODOS - Foram estudados 28 homens, com angina estável (idade média 57,3ñ9,6) anos sem condiçöes relacionadas a alteraçöes de microcirculaçäo e que, após retirada da medicaçäo, apresentaram EIA à eletrocardiografia ambulatorial (ECGA). No pré-operatório e 4 meses após a cirurgia foram analisados os comportamentos dos EIA, segundo sua freqüência, e o de suas freqüências cardíacas (FC). A revascularizaçäo miocárdica foi completa em 75 'por cento' dos casos. RESULTADOS - O número dos EIA foi reduzido de 162 (9 sintomáticos) no pré-operatório para, apenas, 4 no pós-operatório (p<0,05). Nos dois pacientes com EIA no operatório, estudo cinecoronariográfico confirmou obstruçäo de enxertos aortocoronários. A análise das FC no início e pico dos EIA sugeriram envolvimento de mecanismo de reduçÝo de oferta e aumento de consumo de oxigênio pelo miocárdio. CONCLUSÄO - A CRM eliminou os episódio isquêmicos relacionados ou näo ao aumento da FC. Quando os EIA encontram-se presentes após CRM, devemos considerar a possibilidade de oclusäo de enxerto.

Tratamento medicamentoso da insuficiência cardíaca em hospital terciário de Säo Paulo / Heart failure medical treatment in a tertiary hospital of Säo Paulo

OBJETIVO - Verificar como são tratados pacientes com insuficiência cardíaca (IC) em hospital terciário de Säo Paulo. MÉTODOS - Analisados 100 pacientes com IC, em tratamento ambulatorial, com idade média de 56,8 anos, sendo 76 homens. Todos realizaram estudo ecocardiográfico, que identificou diâmetros ventriculares entre 48 e 89mm (média 65,9) e fraçäo de ejeçäo (FE) entre 0,22 e 0,59 (média 0,43). A etiologia da disfunçäo ventricular (DV) foi isquêmica em 42 casos, cardiomiopatia dilatada em 28, secundária à valvopatia em 12, doença de Chagas em 10 e cardiomiopatia hipertensiva em 8. Analisou-se a terapêutica prescrita, se continha inibidores da enzima conversora de angiotensina (IECA) e qual a sua dosagem. Foi analisado, também, se a etiologia ou o grau de DV tinha influência na prescrita. RESULTADOS - Oitenta e sete pacientes receberam IECA, sendo que em 31 a dose foi inferior à preconizada nos grandes estudos. Digoxina foi prescrita em 69 casos, diuréticos em 85 e ácido acetilsalicílico em 33. Dividindo os pacientes os pacientes em dois grupos, com FE maior e menor que 0,45, observamos que, no último, foi maior a prescrição de IECA (91,5 'por cento' vs 80,4 'por cento') e maior o uso de doses adequadas (61 'por cento' vs 48,7 'por cento'). CONCLUSÄO - A maioria dos pacientes foi tratada conforme recomendaçöes atuais, apresentando boa tolerabilidade para IECA, contudo 1/3 deles não usou IECA em dose considerada adequada. Esquemas terapêuticos com betabloqueadores e inibidores da angiotensina II não fizeram parte da prática clínica rotineira.

[Cardiac amyloidosis. A disease with many faces and different prognosis]. / Amilóidose cardíaca. Uma doença de muitas faces e diferentes prognósticos.

PURPOSE: To identify the principal forms of cardiac amiloydosis presentation in a terciary hospital. METHODS: Eight cases with cardiac amyloidosis were identified. Five were women, their ages ranged from 23 to 83 years (mean 62). After a medical history and clinical examination the patients were submitted to complementary tests: electrocardiogram (EKG), echocardiogram (ECHO), scintigraphy with technecium pirophosphate and cardiac biopsy these results allowed the identification of their clinical situation. RESULTS: Seven patients referred dyspnea, 6 were in heart failure, 1 patient had syncope. The EKG identified complete atrioventricular (AV) block in 4 patients, and antero septal inactive area in the other 4. The ECHO showed normal cardiac diameter in all (mean left ventricular diastolic diameter of 46.8) and slight reduction of left ventricular ejection fraction; hypertrophy of the left ventricular septal and posterior walls in all cases, in 7 cases there was a hyper refractile granular sparkling ECHO. Two different groups were identified: one with complete AV block and the second with restrictive cardiomyopathy. The prognosis was different in these two groups. Those with complete AV block evolved better after pacemaker implantation and those with restrictive cardiomyopathy had refractory heart failure and 3 of them died. CONCLUSION: The increased free wall and septal thickness, the slight systolic dysfunction and the infiltration aspect at ECHO allow us to identify the great majority of the cases. Those patients with restrictive cardiomyopathy evolve with refractory heart failure and most of them die in a few months.

Amilóidose cardíaca. Uma doença de muitas faces e diferentes prognósticos / Cardiac amyloidosis. A disease with many faces and different prognoses

OBJETIVO - Avaliar as formas de apresentaçäo da amilóidose cardíaca em hospital terciário. MÉTODOS - Nos últimos 15 anos, foram identificados 8 pacientes com amilóidose, sendo 5 mulheres, com idades entre 23 e 83 (média 62) anos. Após anamnese e exame físico foram submetidos a eletrocardiograma (ECG), ecocardiograma (ECO), estudo com pirosfofato de tecnécio e biópsia endomiocárdica, cujos resultados permitiram caracterizar suas formas clínicas. RESULTADOS - Sete pacientes apresentavam dispnéia aos esforços, 6 quadro de insuficiência cardíaca congestiva (ICC), 1 síncopes. O ECG identificou bloqueio atrioventricular total (BAVT) em 4 casos e área eletricamente inativa ântero-septal em outros 4. O ECG mostrou diâmetros normais em todos e fraçäo de ejeçÝo discretamente reduzida em 6. Hipertrofia do septo e parede posterior em todos, sendo em 7 com aspecto sugestivo de doença de depósito (aspecto granuloso). Os dados clínicos caracterizam dois grupos. um com BAVT e outro com cardiomiopatia restritiva. A evoluçäo foi difrente com melhora clínica após o implante de marcapasso no primeiro grupo e má evoluçäo no grupo com cardiomiopatia restritiva que evoluiu de maneira refratária, 3 falecendo em menos de 6 meses após diagnóstico. CONCLUSÄO - A presença de aumento da espessura das paredes ao ECO, discreta disfunçäo sistólica e aspecto de doença de depósito identifiram a quase totalidade dos casos. Cardiomiopatia restritiva e distúrbio de conduçÝo foram as formas de apresentaçäo, sendo o prognóstico muito reservado nos pacientes com forma restritiva, evoluindo para ICC refratária

[Clinical profile of aged patients with severe aortic stenosis]. / Perfíl clínico de idosos portadores de estenose aórtica severa.

PURPOSE: To evaluate clinical symptoms and echocardiographic findings in elderly patients with severe aortic stenosis and possible gender differences. METHODS: We studied 54 patients, 24 (44.5%) males and 30 (55.5%) females aged 80.7 +/- 5.2 years with severe aortic stenosis. The following variables were analyzed: presence of clinical manifestations (dyspnea, angina, and syncope) and echocardiographic indices (left ventricular [LV] dimensions, ejection fraction [EF], and mass index). RESULTS: Dyspnea was the most frequent symptom with overall prevalence of 44%. EF was lower than 50% in only 2 patients. There were no gender differences in the prevalence of any of the clinical manifestations. Male patients had higher LV volumes (p < 0.05) and lower EF (p = 0.03). CONCLUSION: The data showing dyspnea as the most common clinical manifestation; EF > 50%; lower LV volumes and greater EF in female patients suggest that the adaptive mechanisms to this condition may be different between the two sexes.

[Medical treatment of heart failure at a tertiary hospital of São Paulo]. / Tratamento medicamentoso da insuficiência cardíaca em hospital terciário de São Paulo.

PURPOSE: To study how patients with heart failure (HF) are treated in a tertiary hospital in São Paulo. METHODS: One hundred patients with HF during ambulatory care were analyzed. Seventy-six were men, and the average population age was 56.8 years old. All patients were submitted to echocardiogram, which identified ventricular diameters ranging between 48 and 89 mm (average 65.9) and ejection fraction (EF) between 0.22 and 0.59 (average 0.43). The cause of HF was ischemic in 42 cases, dilated cardiomyopathy in 28, valvular heart disease in 12, Chagas' disease in 10 and systemic hypertension in 8 patients. The prescribed treatment was analyzed, with attention to the prescription and dosage of angiotensin converting enzyme (ACE) inhibitors. We also analyzed whether the cause and/or the degree of HF influenced the treatment chosen. RESULTS: Eighty-seven patients received ACE inhibitors, 31 received doses below those recommended in the large trials. Digoxin was prescribed in 69 cases, diuretics in 85, and aspirin in 33. When dividing the patients according to EF, the group with EF below 0.45 was prescribed more often ACE inhibitors (91.5% vs 80.4%) and had more often usage of adequate doses (61% vs 48.7%). CONCLUSION: In this sample the majority of the patients were treated according to modern recommendations and tolerated well ACE inhibitors, however 1/3 did not receive ACE inhibitors in the recommended doses. Treatment based on betablockers or angiotensin II inhibitors were not routinely employed.

[Risk factors in elderly patients selected by primary care physicians for hypolipemic treatment]. / Fatores de risco em pacientes idosos selecionados por médicos da comunidade para tratamento hipolipemiante.

PURPOSE: To evaluate the influence of age on response to pravastatin treatment in patients treated by community physicians. METHODS: According to age, 873 patients were divided in three groups: group A with ages ranging from 45 to 59 years (n = 55), group B with ages from 60 to 64 years (n = 182) and group C with ages from 65 to 70 years (n = 143). After four weeks only with diet orientation, patients received 10 mg/day of pravastatin for 12 weeks. RESULTS: There was a greater prevalence of risk factors in elderly patients: hypertension (45.7%, 54.4% and 57.1% in groups A, B and C respectively p = 0.0165), diabetes mellitus (9.3%, 17.6% and 25.8% respectively in groups A, B and C p < 0.0001), and previous heart disease (23.1%, 34.3% and 34.7% in groups A, B and C respectively p < 0.001). During the period of diet orientation there was a similar total cholesterol reduction in the three groups (about 10.5%), the reduction reached 30.0% with the introduction of pravastatin for 12 weeks. Low density cholesterol level decreased during the diet period in the three groups (about 10.5%), pravastatin prescription induced further reduction (about 31.7%). The high density cholesterol level (HDL) increased significantly with pravastatin treatment (12.7%). After pravastatin treatment the increase in HDL levels was more significantly among those patients with initial low levels of HDL (< 35 mg/dL) in the three groups. CONCLUSION: In patients selected by community physicians to receive lipid lowering therapy, increased age was associated with greater prevalence of risk factors and heart disease. Regardless of age, there was a good response to pravastatin treatment, however less than half of patients had received treatment prior to the protocol.

[Clinical and Doppler echocardiographic follow-up of elderly patients subjected to aortic balloon valvuloplasty]. / Seguimento clínco e ecodopplercardiográfico de idosos submetidos a valvuloplastia aórtica por cateter-balão.

PURPOSE: To evaluate the evolution of patients with critical aortic stenosis (AS) submitted to balloon aortic valvuloplasty (BAV). PATIENTS AND METHODS: sixteen patients (mean age 74.0 +/- 5.1 years), 11 (68.7%) women. The study periods consisted during the 3 rd (post-1) and 15th month (post-2) after dilatation. RESULTS: The functional class of angina and dyspnea persisted in all patients during period post-1, in 75% of the patients, during period post-2 in relation to intra-hospital evaluation. However, in period post-1, 53% of the patients had significant reduction of aortic valve area, trend which remained in period post-2. Simultaneously, progressive (insignificant) elevation of the left ventricular aortic peak to peak gradient was noticed in the periods post-1 and post-2. Two deaths and two aortic valve replacements occurred during the study. CONCLUSION: BAV is associated to maintenance of functional class improvement obtained immediately after dilatation despite the aortic valve restenosis registered by echodopplercardiography.

[Hemodynamic study at the bedside of patients with acute myocardial infarction over 60 years of age]. / Estudo hemodinâmico à beira do leito em portadores de infarto agudo do miocárdio com mais de 60 anos de idade.

Aiming to study the hemodynamic behavior of the aged during the first 36 hours after acute myocardial infarction (AMI), 41 patients of at least 60 years at age (63.3 +/- 3) were submitted to a bedside hemodynamic study, through a Swan-Ganz catheter. The results obtained for the different variables (right atrial pressure, right ventricular pressure, pulmonary-arterial pressure, pulmonary-capillary, cardiac index, systolic index, left and right ventricular performance, and systemic pulmonary-arterial resistance) were compared to those of 39 individuals with age less than 60 years (49.6 +/- 1.5). It was also considered the electrocardiographic localization of the infarcted area. Eventual differences in the distribution of frequency of the individuals were also investigated, considering the four clinical-hemodynamic groups proposed by Forrester. Upon separate analysis of the hemodynamic variables, the results did not reveal significant differences between the younger and the older. However, by Forrester's classification, it was observed a significantly higher number of aged patients in group III (hypovolemic). Therefore, there was a tendency in the aged to present hypovolemia during the first 36 hours after myocardial infarction. The difficulties to recognize this status clinically and its prognostic importance justify the performance of hemodynamic bedside study in elderly with acute myocardial infarction with hemodynamic instability.

[Efficacy of captopril in the treatment of mild and moderate hypertension in patients over 60 years of age]. / Eficácia do captopril no tratamento da hipertensão arterial leve e moderada de pacientes com idade superior a 60 anos.

The response to the use of converting enzyme inhibitor (captopril) either alone or associated to hydrochlorothiazide was evaluated during three months in 128 patients over 60 years old, with mild (79.7%) and moderate (20.3%) hypertension. Seventy (55%) were female and 58 (45%) male, being 64.8% white, 33.6% non-white and 1.6% asiatic. All patients received initially either a single dose of 25 mg of captopril or twice 12.5 mg, and after 1 month those in which hypertension was maintained 25 mg of hydrochlorothiazide was associated. During this period the analysis of the results showed a significant reduction of systolic and diastolic blood pressure (DP), however, there was a marked reduction during the first month. Thus, DP decreased from 101 +/- 8.8 (control) to 93 +/- 8.7 in the first month, to 89.6 +/- 8.2 in the second and 86 +/- 8.2 in the third, all significant at p less than 0.001. Similar distinction with previous treatment were observed when ranges on DP were analysed in patients receiving isolated or associated captopril. There was a small but significant weight and heart rate fall in patients receiving only captopril. Reduction of side effects was observed in 79% of the patients, as compared to previous treatment there being distinct improvement, while 21% showed no alterations and none showed complications. Therefore, we may conclude that use of captopril in elderly hypertensive patients was efficacious in the control of arterial blood without influence on quality of life.