Takayasu arteritis revisited.

Takayasu arteritis is a large vessel vasculitis with various clinical presentations depending on the territories affected. We report the case of a 47-year-old woman who was diagnosed with Takayasu arteritis following rapid progression of coronary disease. The condition evolved rapidly under corticosteroid therapy, with formation of new arterial stenoses within the carotid and splanchnic circulations. Disease remission was achieved with cyclophosphamide pulses and percutaneous angioplasty of the affected vessels was performed.

Body mass index as a predictor of the presence but not the severity of coronary artery disease evaluated by cardiac computed tomography.

BACKGROUND: The relation between body mass index (BMI) and coronary artery disease (CAD) extension remains controversial. The aim of this study was to evaluate the correlation between BMI and CAD extension documented by coronary computed tomography angiography (CCTA). METHODS AND RESULTS: Prospective registry including 1706 consecutive stable patients that performed CCTA (dual source scanner) for the evaluation of CAD. The population was stratified by BMI: normal 530 (31.1%), overweight 802 (47.0%) and obesity 374 (21.9%). BMI was significantly higher in patients with CAD (27.7 ± 4.3 vs 26.8 ± 4.3 kg/m(2), p < 0.001); these patients were also older, more often male and had higher prevalence of diabetes, hypertension and dyslipidemia. By multivariate analysis (logistic regression) BMI remains an independent predictor of CAD (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.06; p = 0.012). Regarding the severity of CAD, BMI was not significantly different among patients with and without obstructive CAD (27.7 ± 4.3 vs 27.2 ± 4.3 kg/m(2), p = 0.120). In 319 patients (4516 segments; 4077 evaluable), a detailed atherosclerotic burden was evaluated and compared among BMI classes, defined according to the presence of plaque and the degree of stenosis. Obstructive CAD was identified in 16.9% of the patients and 45.1% had non-obstructive CAD. The discriminative threshold for high burden, established by the segment involvement score (SIS), was >5 segments with plaque (15.4% patients). The prevalence of SIS >5 among the BMI classes was: 18.7%, 13.7% and 13.6% for normal, overweight and obesity respectively (p values for the specific classes versus all other patients: 0.241, 0.450 and 0.663). CONCLUSIONS: In this population of stable patients undergoing CCTA for suspected CAD, BMI was an independent predictor of its presence, but was not correlated with the coronary disease severity.

[Non-obstructive coronary artery disease documented by cardiac computed tomography: Discrepancy between atherosclerotic burden and cardiovascular risk]. / Doença coronária não obstrutiva documentada por tomografia computorizada cardíaca: contraste entre a carga aterosclerótica e o risco cardiovascular.

Cardiac computed tomography (CT) documents the presence of coronary artery disease, regardless of the degree of stenosis. The prognostic value of non-obstructive coronary artery disease documented by cardiac CT has recently been validated. However, there are still no clear guidelines on the management of such patients, particularly concerning initiation of more aggressive pharmacological measures for primary prevention. The approach to these patients remains controversial, especially in cases in which there is a discrepancy between cardiovascular risk and the atherosclerotic burden as documented by cardiac CT. The authors describe the case of a patient with a discrepancy between the extent of documented coronary atherosclerosis and that estimated according to pretest probability and cardiovascular risk scores. As this individual had more severe coronary atherosclerosis than expected (calcium score above the 90th percentile and non-obstructive coronary artery disease on cardiac CT) but was a competitive athlete and otherwise asymptomatic and without risk factors or cardiovascular history, with a very low estimated cardiovascular risk, it was difficult to decide on the risks and benefits of pharmacological primary prevention.

Prevalence and predictors of coronary artery disease in patients with a calcium score of zero.

The absence of coronary calcification is associated with an excellent prognosis. However, a calcium score of zero does not exclude the presence of coronary artery disease (CAD) or the possibility of future cardiovascular events. Our aim was to study the prevalence and predictors of coronary artery disease in patients with a calcium score of zero. Prospective registry consisted of 3,012 consecutive patients that underwent cardiac CT (dual source CT). Stable patients referred for evaluation of possible CAD that had a calcium score of zero (n = 864) were selected for this analysis. The variables that were statistically significant were included in a multivariable logistic regression model. From 864 patients with a calcium score of zero, 107 (12.4%) had coronary plaques on the contrast CT (10.8%, n = 93 with nonobstructive CAD and 1.6%, n = 14 with obstructive CAD). By logistic regression analysis, the independent predictors of CAD in this population were age >55 years [odds ratio (OR) 1.63 (1.05-2.52)], hypertension [OR 1.64 (1.05-2.56)] and dyslipidemia [OR 1.54 (1.00-2.36)]. In the presence of these 3 variables, the probability of having coronary plaques was 21%. The absence of coronary artery calcification does not exclude the presence of coronary artery disease, but the prevalence of obstructive disease is very low. In this population, the independent predictors of CAD in the setting of a calcium score of zero were hypertension, dyslipidemia, and age above 55 years. In the presence of these 3 predictors, the probability of having CAD was almost 2 times higher than in the general population.

Are intraventricular gradients a cause of false positive treadmill exercise tests?

BACKGROUND: Treadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations. OBJECTIVES: To determine: 1. the prevalence of IVG in a selected population of false positives on treadmill stress testing; 2. whether this prevalence is different from that described for non-selected populations; 3. whether patient characteristics are related to the presence of IVG; 4. the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure. METHODS AND RESULTS: We evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05). CONCLUSIONS: 1. The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients. 2. This prevalence is significantly higher than that described for non-selected populations. 3. Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disesase/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG. 4. The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.

[Anomalous origin of left coronary artery: a malignant interarterial variant with a benign clinical course]. / Origem anómala da coronária esquerda: variante interarterial maligna com evolução clínica benigna.

Anomalous origin of coronary arteries represents a clinical challenge not only because of the anatomical variability, but also the possible functional consequences, pathophysiological mechanisms involved and the absence of large series in the literature that would provide evidence for clinical and therapeutic orientation. The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile.

Capacidade produtiva local de Tectona grandis em Monte Dourado, Estado do Pará, Brasil / Local productive capacity of Tectona grandis in Monte Dourado, Pará State, Brazil

O trabalho teve como objetivo determinar a capacidade produtiva local da teca em Monte Dourado, Estado do Pará, Brasil, por meio da análise de curvas de índice de sítio. Os dados foram obtidos pela análise de tronco de dez árvores dominantes de um povoamento com 26 anos de idade. Foram ajustados dez modelos de regressão e o critério de seleção obedeceu ao menor erro padrão da estimativa, ao maior coeficiente de determinação ajustado, à significância do teste F e dos coeficientes de regressão e à análise gráfica dos resíduos. As curvas de índice de sítio foram confeccionadas pelo método da curva-guia. O modelo de Spillman apresenta o melhor ajuste, por meio do qual foram geradas três curvas de índice de sítio de 16m a 24m na idade-índice de 26 anos. A região de Monte Dourado, PA, apresenta potencial produtivo para o desenvolvimento da teca.

The study aims to determine the local productive capacity of teak in Monte Dourado, Pará State, Brazil, with the analysis of site index curves. The data were obtained by stem analysis of ten dominant trees in a stand with 26 years of age. Were adjusted ten regression models and the criterion for selection followed the lowest standard error of estimate, the highest adjusted coefficient of determination, the significance of F test and of regression coefficients and graphical analysis of the residuals. The site index curves were built by the guide-curve method. The Spillman model present the best fit, by which were generated three curves of site index from 16m to 24m, at 26 years of index-age. The region of Monte Dourado - PA showed a productive potential for the development of teak.

Playing games with a thrombus: a dangerous match. Paradoxical embolism from a huge central venous cathether thrombus: a case report.

Thromboembolism is a major cause of death in cancer patients. The association between paraneoplastic hypercoagulability of oncological patients and long-term central venous catheters (CVC) may result in CVC associated thrombosis. Patent Foramen Ovale (PFO), especially when associated with atrial septal aneurysm (ASA) is a risk factor for paradoxical embolism. We report a case of paradoxical embolism with stroke in an oncological patient with a huge CVC thrombus playing "ping-pong" with an hypermobile ASA with a PFO. We review the management of hypercoagulability in oncologic patients and discuss the potential role of routine transthoracic echocardiography before the implantation of long term central venous catheters to identify predisposing conditions to paradoxical embolism and select patients for anticoagulant therapy.

Radiation in cardiac CT: predictors of higher dose and its reduction over time.

INTRODUCTION: Cardiac CT provides noninvasive information on cardiac anatomy, particularly in coronary artery disease. However, exposure to radiation has been identified as a limitation of this exam. The aim of this study was to evaluate variations in radiation dose over time and to identify variables associated with use of higher radiation doses. METHODS: A prospective registry of 643 patients who underwent 64-slice dual source cardiac CT scan (Dual source CT--Somaton Definition, Siemens-Medical) during 2007 and 2008 was analyzed. RESULTS: The sample was divided into quartiles according to the chronological order of the exams. There was a progressive reduction in median radiation dose in the quartiles analyzed (Q1: 8.9 [5.9-14.1], Q2: 6.6 [5.5-10.7], Q3: 6.4 [5.3-8.7], Q4: 6.1 [5.2-7.9] mSv), significant when the first quartile was compared with the others (p < 0.05). Along with this reduction, was a progressive increase in the use of a tube voltage of 100 kV (p < 0.001). Predictors of a higher radiation dose were higher body mass index, previous cardiac surgery, atrial fibrillation during acquisition, longer acquisition time and use of a tube voltage of 120 kV. When one or more of these variables were present (one third of the population), the radiation dose was significant higher (12.1 [9.5-14.8] vs. 5.7 [5.0-6.7] mSv, p < 0.001).

Are intraventricular gradients with dobutamine a cause of false positive treadmill stress tests?

An asymptomatic 40-year-old man with no conventional risk factors for coronary artery disease had a positive treadmill stress test based on ECG criteria. Coronary CT angiography showed a small plaque in the left anterior descending artery and dobutamine-atropine stress echocardiography was negative for myocardial ischemia but showed a significant outflow gradient (100 mmHg) during pharmacological stress.

Hypertrophic cardiomyopathy--two atypical forms diagnosed by cardiac CT.

Hypertrophic cardiomyopathy is a relatively common genetic disease (prevalence of 0.2%), with a clinical spectrum that ranges from absence of symptoms to presentation as sudden cardiac death. Atypical forms are a diagnostic challenge and recent cardiac imaging techniques, such as cardiac CT and magnetic resonance imaging, can make an important contribution. We present a review of this disease based on two case reports.

Caseous calcification of the mitral annulus. A review of six cases.

Caseous calcification of the mitral annulus is a rare form of mitral annular calcification, whose etiology is not completely understood and which can lead to an erroneous diagnosis of intracardiac tumor. The authors describe the cases of six patients, five of them female, mean age 74.8 +/- 6.4 years (65-81). Four patients presented with heart failure, two with atrial fibrillation and five with hypertension. Round, echogenic images, 18-26 mm in their largest diameter with a central echolucent area, were identified by transthoracic echocardiography on the lateral and posterior segments of the mitral annulus. Severe mitral regurgitation was also found in four patients. Only three patients with severe mitral regurgitation and heart failure were operated on, and one patient refused surgical treatment. A caseous mass, similar to toothpaste, was obtained from the mitral annulus zone during surgery.

Infective endocarditis complicated by large aortic pseudoaneurysm after cardiac surgery.

A 66-year-old female with Streptococcus viridans aortic and tricuspid infective endocarditis develops, during the course of antibiotic therapy, rupture of a right coronary sinus of Valsalva aneurysm to the right ventricle. An urgent cardiac surgery is preformed with implantation of a mechanical aortic prosthesis and a right coronary sinus plasty. Six months later a huge aortic pseudoaneurysm is diagnosed and she is submitted to a second uneventful surgery. A review is done for the significant features with discussion of diagnosis and therapy.

[Post-partum spontaneous coronary artery dissection. Clinical report]. / Dissecção coronária espontânea pós-parto. A propósito de um caso clínico.

The authors report the clinical case of a 32 years old woman who suffered a spontaneous dissection of the common trunk, anterior descending, intermediary and circumflex coronary arteries, on the 6th post partum day. The diagnosis of acute myocardial infarction was made, through ECG and enzymatic studies and the patient was transferred to a Coronary Unit. Coronary angiography disclosed those lesions and the patient underwent a triple coronary bypass graft, under extracorporeal circulation. The post operative course was uneventful. Eight months after the operation she was found in good condition, free of symptoms and with a normal pattern of life.

Pulmonary embolism associated with a large tricuspid-related mass.

The case of a 43-year-old man with diabetes and alcoholism admitted to the emergency room with shock, fever, pleuritic chest pain and systemic symptoms is presented. Laboratory tests revealed anemia, leukocytosis, thrombocytopenia, high sedimentation rate and D-dimers, hypoxemia and hypocapnea. He also had sinus tachycardia, rSR' in V1 and an opacity on the periphery of the right pulmonary field. Blood and urine cultures were negative, as were serological markers. The echocardiogram showed a large mass adhering to the tricuspid valve, suggestive of myxoma. The patient underwent surgery, and anatomopathological examination of the mass showed it to be a bacterial vegetation, with no agent isolated. It is pointed out that differential diagnosis is difficult between a myxoma with systemic symptomatology associated with a possible pulmonary embolism, and tricuspid endocarditis with negative blood culture associated with a septic pulmonary embolism, which turned out to be the diagnosis in this patient.