Dressler-like syndrome after pulmonary embolism and infarction.

Among 195 patients with pulmonary embolism admitted to our hospital, three men and three women, 16 to 65 years old, developed a pericardial syndrome five to 15 days after the onset of pulmonary embolism and infarction. Other known causes of pericarditis were ruled out by clinical history and ancillary methods. The six patients had a pericardial rub, fever, anemia, leukocytosis, and increasing sedimentation rate; four had a pericardial effusion; two had a pleural effusion. One patient, with coexisting heart disease, died after another episode of pulmonary embolism; in the other five, oral corticosteroids induced complete remission of the pericardial syndrome. This type of pericarditis deserves wider recognition.

Single-dose sublingual nifedipine as the only treatment in hypertensive urgencies and emergencies.

One hundred and eighteen patients with hypertensive urgencies and emergencies and diastolic blood pressure (DBP) at least 120 mm Hg by the cuff method were seen at the Emergency Care Department; none had received calcium channel blockers during the previous twelve hours. Patients with DBP of 120 to 139 mm Hg received 10 mg of sublingual nifedipine; patients with left ventricular hypertrophy or failure, renal disease, hypertensive encephalopathy, angina, papilledema, or a DBP over 140 mm Hg received 20 mg of the drug. The criterion for control was the achievement of a DBP of 100 mm Hg or less within sixty minutes of receiving sublingual nifedipine and maintenance of the effect until discharge. Control was achieved in all patients; a sixty-three-year-old man died of a brain hemorrhage after pulmonary edema and a DBP of 210 had been controlled; the other 117 were discharged to their attending physicians, either as outpatients or to a hospital ward. No patient developed hypotension, clinical or electrocardiographic signs of myocardial ischemia, or clinical signs of neurologic dysfunction. Practical, fast, safe, and dependable control of hypertensive urgencies and emergencies has made sublingual nifedipine the treatment of choice of such patients in the Emergency Care Department.

[The mortality determinants in 93 cases operated on for aortic stenosis]. / Determinantes de mortalidad en 93 casos operados de estenosis aórtica.

We report 93 cases of severe aortic stenosis. We discuss their clinical data, hemodynamic parameters, and surgical outcome. The surgical mortality and variables determining this event evaluated in groups: A (deaths) and B (survivors). Functional class (mean = 2.5 vs 2.0 p less than 0.05) was statistically as determinant for mortality as were also: transaortic gradient (group A mean = 110 +/- 37 mmHg vs group B mean = 82 +/- 31 p less than 0.005), and ejection fraction (group A mean = 55 +/- 13.7 vs group B mean = 64 +/- 14.8 p less than 0.005). Neither time of cardiopulmonary bypass nor aortic clamping were determinants for mortality. Our results are similar to those reported in other groups. Mortality rates, are determined basically by deterioration of left ventricular function, and by the severity of transaortic gradient.

[Atherosclerotic ischemic cardiopathy in patients with dextrocardia in situs viscerum inversus]. / Cardiopatía isquémica aterosclerosa en pacientes con dextrocardia en situs viscerum inversus.

We describe the incidence, clinical, radiologic, electrocardiographic, echocardiographic and angiographic findings of two cases with dextrocardia in situ viscerum inversus with ischaemic heart disease. The first patient had coronary artery saphenous bypass graft and is currently asymptomatic with a negative maximal stress test. The other patient with diabetes mellitus and unfavorable coronary anatomy was not operated and is currently with stable angina on class II of the NYHA. The electrocardiographic, echocardiographic and angiographic strategies are commented.

[A double myocardial rupture (septal and the free wall) due to an infarct. A case report and review of the literature]. / Doble ruptura miocárdica (septal y pared libre) por infarto. Reporte de un caso y revisión de la literatura.

Rupture of the myocardium is often a catastrophic complication of myocardial infarction with a poor prognosis in the short term. The occurrence of more than one myocardial rupture is a rare condition, and has been published in most cases as a necropsy finding. The purpose of this communication is to report one case of double rupture of the myocardium, diagnosed in life; and the clinical and surgical implication of such cases.

[Acute myocardial infarction and pyocholecystitis. Report of a case]. / Infarto agudo del miocardio y piocolecisto. Informe de un caso.

The clinical data of a 43 year old male with acute myocardial infarction and acute abdominal syndrome on the 4th day after the onset of infarction is reported. During abdominal surgery, a gall bladder abscess was found and a cholecystectomy was performed, without abdominal or cardiac complications. This report emphasizes the rare association of these entities and that even in evolving myocardial infarction surgery can be performed with reasonable risk. The collaboration of cardiologist, surgeon and anesthesiologist is suggested.

[Massive pulmonary thromboembolism with left axis deviation and low voltage]. / Tromboembolia pulmonar masiva con desviación del eje eléctrico a la izquierda y bajo voltaje.

The classic electrocardiographic abnormalities observed in massive or submassive thromboembolism in the absence of preexistent cardiac or pulmonary disease are: S1Q3T3 pattern, right axis deviation, "pulmonary" P wave, ST segment depression or elevation, subepicardic ischemia and transient right bundle branch block. Left axis deviation due to pulmonary embolism was first described in 1949; this same finding and the presence of low voltage of the frontal plane owed to pulmonary embolism has been reported occasionally in the last decades, but it has had little diffusion. We report on a patient with no prior cardiac or pulmonary disease who suffered massive pulmonary thromboembolism. Electrocardiographically left axis deviation and low voltage of the horizontal plane attributed to pulmonary thromboembolism was observed. The mechanisms that originate this electrocardiographic changes in pulmonary embolism are unknown. Since the electrocardiogram is aspecific method for the diagnosis of this disorder, and the presence of the mentioned changes originate a greater difficulty in the diagnosis; we consider is important to publish it.

[Early tracheal intubation and mechanical ventilation in the treatment of pulmonary edema secondary to ischemic heart disease]. / Intubación traqueal temprana y ventilación mecánica para el tratamiento del edema pulmonar secundario a cardiopatía isquémica.

Forty patients with overt pulmonary edema secondary to ischemic heart disease were treated in the emergency room with iv ouabain and furosemide; 20 patients in Group A received sublingual nifedipine before undergoing early tracheal intubation and mechanical ventilation with 100% FiO2 during 15 min. and then 50% FiO2; 20 patients in Group B received iv aminophylline, rotating tourniquets and IPPB by mask with 60% FiO2. All patients in Group A were extubated after 66 +/- 10.8 min. in the emergency room; 7 in Group B improved but 13 had to undergo tracheal intubation and mechanical ventilation. Upon arrival at the ICCU all had a Swan-Ganz catheter installed and received comparable therapy for ischemic heart disease. Statistically significant differences in favor of patients in Group A as compared to the 7 improved in B were seen in heart rate, arrhythmias, diastolic blood pressure, mean and wedge pulmonary pressures, systemic resistances, arterial pH and PaO2; when compared to the 13 patients undergoing late tracheal intubation and mechanical ventilation, parameters were more or less similar but improvement appeared later and extubation took place after 1.94 +/- 1.24 days (P less than 0.05). Three patients in Group B died in the emergency room, 3 in Group A and 4 in B died in the ICCU (P less than 0.01). Early tracheal intubation and mechanical ventilation in patients with overt pulmonary edema secondary to ischemic heart disease produce better results due to early improvement in pulmonary and systemic hemodynamics and should be considered in all such patients arriving at the emergency room.

[Calcium antagonists in severe stable post-infarct angina pectoris]. / Antagonistas del calcio en la angina de pecho estable severa post-infarto del miocardio.

In 50 patients with severe stable post-myocardial infarction angina grade III and IV of the N. Y. Heart Association, a calcium antagonist (niphedipine) was used in a double blind study with intercrossing. For the experimental design the same patient was his own control. The following criteria were used: number of bouts of angina, consumption of nitroglycerin pearls to control the angina, excercise test (Bruce technic), at the beginning and at the end of each treatment., Favourable results were observed in 36 of the 50 patients, in relation to the number of anginal crisis with a "p" value equal to 0.0062. In the effort capacity an improvement in relation to the basal conditions was observed with a "p" value less than 0.001. This shows a beneficial action of the drug with possible preferent actions on myocardial circulation.

[Helicoidal ventricular tachycardia caused by amitriptyline. Presentation of a case]. / Taquicardia ventricular helicoidal inducida por amitriptilina. Presentacion de un caso.

We present a case of a psychiatric patient treated with Amitriptyline who developed Stokes-Adams attacks with EKG manifestations of prolonged Q-T and "torsade de pointes".

[The correlation of atrial natriuretic peptide values with those of renin, angiotensin and aldosterone in hypertension patients below and above 50]. / Correlación de valores de péptido natriurético auricular con los de renina, angiotensina y aldosterona en pacientes hipertensos menores y mayores de 50 años.

A comparison of ANP and RAA. In 6 healthy subjects < 50 y, 5 healthy subjects > 50 y, 44 patients with essential hypertension < 50 y, and 41 patients with essential hypertension > 50 y, was performed. ANP values in healthy subjects < 50 y, were means = 44 +/- 7 PG/ml, and means = 87.33 +/- 14 PG/ml in those > 50 y. (P < 0.01). 80% of hypertensives < 50 y, had normal values of ANP (means = 63.8 +/- 10 PG/ml) and 20% high values (means = 131 +/- 6 PG/ml) (P < 0.001). 70% of hypertensives > 50 y, had high ANP values (means = 260 +/- 114 PG/ml) and 30% normal values (means = 75 +/- 5 PG/ml) (P < 0.001). Values for RAA were low or normal in 96% of cases with high ANP values (P < 0.001), and 100% of the cases with high RAA values, had low or normal ANP values. (P < 0.0001). This correlation had an statistically significant value for groups over 50 years (high ANP values, low RAA values) (P < 0.001) and high RAA values with low or normal ANP values in groups below 50 y (P < 0.001). We observed no significant correlation between ANP values and LVH. According to our results, essential hypertensives < 50 y, have low or normal ANP values in the majority of cases (P < 0.001). Essential hypertensives over 50 y. Have high ANP values also in the majority of cases (P < 0.001). As previously reported, an inversely proportional ratio between RAA and ANP was found in our study. The significance of ANP in regulating blood pressure in the elderly is considered.

[Balloon valvuloplasty in stenotic bioprosthesis]. / Valvuloplastía con balón en bioprótesis estenóticas.

The results of balloon valvuloplasty performed on five patients with stenotic bioprosthesis treated in the Hospital de Cardiología Centro Médico Nacional Siglo XXI, are presented. All five bioprosthesis were right sided, two in tricuspid position, one in pulmonary valve position and two in valvulated conduits from right ventricle to pulmonary artery. In all cases a pressure gradient reduction was achieved, an improvement of clinical functional class and heart failure manifestations were obtained. Mansfields balloons were used. One in two patients, and two balloons in three. We had not complications with the procedure. We conclude that balloon valvuloplasty on bioprosthesis is a safe and dependable procedure to be used in right sided bioprosthesis.

[Electric cardioversion in the emergency service. Experience in 1000 cases]. / Cardioversión eléctrica en el servicio de urgencias. Experiencia de 1000 casos.

We describe our experience with 1000 electric cardioversions performed at the emergency ward in the Hospital of Cardiology y Neumology, National Medical Center I.M.S.S. The objectives are: 1. Report our experience. 2. Investigate if digitalis treatment should be discontinued before the procedure. 3. Determine if all patients should be on anticoagulant therapy for elective cardioversion. 4. Indicate the optimal anesthetic drug with minimal side effects. A therapeutic procedure was performed in 73% of our cases and an elective one in the remaining 27%. Patients were grouped as ischemic heart disease 26%, rheumatic heart disease 24%, chronic obstructive pulmonary disease 14%, systemic hypertensive heart disease 13%, without clinical heart disease 6%, preexcitation syndrome 6%, adult congenital heart disease 4%, with implanted pacemaker 2%, pregnancy 2% and diverse myocardial diseases 2%. As a cardiac arrhythmias atrial fibrillation was the main cause 45%. Atrial flutter represented 25%, atrial paroxysmal tachycardia was 21% and ventricular tachycardia 9%. A cardioversion was performed in 43% of patients under digitalis treatment at therapeutic levels, without complications. Atrial flutter reverted to sinus rhythm in 98% of the procedures, and atrial fibrillation in 97%. Elective cardioversion in patients with atrial fibrillation was achieved with energies of 200 joules in 82% of the procedures (P less than 0.001) and in atrial flutter with 100 joules in 89% of the cases (P less than 0.001). The most frequent complications were atrial and junctional premature beats in 41% of the cases. We consider this procedure a safe one, effective at the energy levels described, with no need for discontinuation of digitalis therapy, with no mandatory previous anticoagulant therapy, and with no contraindications on pregnancy or implanted pacemakers.

[Silent myocardial ischemia: a problem in diagnosis and treatment]. / Isquemia miocárdica silenciosa: un problema de diagnóstico y tratamiento.

We tried to establish the incidence of silent myocardial ischemia (SMI) in the general population and also in patients with recognised ischemic heart disease. For this, purpose 2, 375 stress tests (ST) with Bruce protocol were reviewed, 364 were positive and those patients were divided in two groups: group I with SMI during the ST and group II with myocardial ischemia and angina during the ST. Coronary risk factors ergometric behaviour and angiographic factors were analysed. Group I had 263 patients with SMI (71%). Group II had 111 patients with ischemia and angina (29%) P less than 0.05; 90 patients had diabetes mellitus in group I and 19 in group II P less than 0.05. A previous myocardial infarction was registered in 157 patients from group I and 55 from group II P less than 0.05. The remaining coronary risks factors, ergometrics variables and significance and number of diseased coronary vessels were similar in both groups. We conclude that SMI is a frequent event in patients with ischemic heart disease. It represents probably the most frequent event in this disease. Previous myocardial infarction and diabetes mellitus may play an important role in the pathogenesis of SMI. The ST and Holter monitoring are dependable procedures for the identification of SMI and should be always performed specially in patients with high coronary risk factors. Once detecting SMI a therapeutic plan should be considered for medical, angioplastic or surgical procedures even in asymptomatic patients.

[Doppler echocardiography assessment of tricuspid valve prosthesis with normal function and with dysfunction due to obstruction]. / Evaluación mediante ecocardiografía Doppler de las prótesis valvulares tricuspídeas con función normal y con disfunción por obstrucción.

UNLABELLED: In order to know the normal ranges of the maximum velocity and the pressure half-time between normal functioning tricuspid prostheses and malfunctioning tricuspid prostheses due to obstruction, we studied 25 patients with tricuspid prostheses (11 mechanical and 14 biological); they were divided in 2 groups: group I: 14 patients without clinical evidence of malfunction and; group II: 11 patients with malfunction due to obstruction confirmed by catheterization, surgery and/or necropsy. The peak gradient was estimated by the modified Bernoulli equation and the prosthetic valve area by the pressure halftime method. RESULTS: the mean peak velocity in group I was 147 +/- 18 cm/sec versus 165 +/- 16 cm/sec (p NS) in group II. The mean pressure half-time in group I was 124 +/- 20 msec versus 355 +/- 48 msec (p less than 0.001) in group II. CONCLUSIONS: 1. A pressure half-time greater than 200 msec is very suggestive of malfunction due to obstruction (p less than 0.001). 2. There are normo-functioning tricuspid prostheses with prolonged pressure half-time, and the values that divides these groups from those with malfunction is small: 199 and 244 msec, that is why we suggest that every patient has to have his her own echocardiographic control in the immediate postoperative period.

[Radiologic characteristics of cardiogenic pulmonary edema in the elderly]. / Características radiológicas del edema pulmonar cardiogénico en el anciano.

The radiologic appearance of atypical cardiogenic pulmonary edema (ACPE) is presented in 10 cases admitted from 1983 to 1985, with age ranges from 74 to 89, and with diagnosis of ischemic heart disease, with myocardial infarction in 50% of them. Clinically they had asthenia, adynamia and anorexia in 80%, cough and weight loss in 50%. All of them had tachycardia, pulmonary rales and 50% pericardial rub. ECG showed in 80% anterior subepicardial ischemia, 60% posteroinferior subepicardial ischemia, 60% bifascicular block, and 50% left anterior fascicular block. Chest films were interpreted at first as pulmonary fibrosis in 90% of the cases with superior lobe involvement in 50%. Heart enlargement was present in 50%. A chronic lung disease was disclosed on clinical and pulmonary physiological grounds. It is concluded that asthenia, adynamia and anorexia were atypical manifestations of heart failure in the elderly. Silent myocardial infarction was observed in half of our patients and it was complicated with pericardial involvement in 50%. Irregular distribution of fluids in pulmonary edema was attributed to anatomic changes in elder lung. These atypical behaviour of pulmonary edema, has been misinterpreted on radiologic basis with pulmonary infection, tumours, metastasis or fibrosis. Those radiologic changes disappeared or improved in 72 hrs. with treatment of left ventricular failure.

[Tuberculous myocarditis. Presentation of a case and review of the literature]. / Miocarditis tuberculosa. Presentación de un caso y revisión de la literatura.

We report a case of a 22 year-old drug addict man with overt heart failure and cardiomegaly. The patient had no prior history of tuberculosis and not clinical features to suggest this diagnosis. Tuberculosis myocarditis was found at the necropsy. It is important to point out the frequency of this pathology, the uncommon clinical presentation of this case; as well as the lack of immunologic response to the tuberculous bacillus.