Can cardiac computed tomography predict cardiovascular events in asymptomatic type-2 diabetics?: results of a long term follow-up.

BACKGROUND: Doubts remain about atherosclerotic disease and risk stratification of asymptomatic type-2 diabetic patients (T2DP). This study aims to evaluate the usefulness of calcium score (CS) and coronary computed tomography (CT) angiography (CTA) to predict fatal and non fatal cardiovascular events (CVEV) in T2DP. METHODS: Eighty-five consecutive T2DP undergoing CT (Phillips Brilliance, 16-slice) with CS and CTA were prospectively enrolled in a transversal case-control study. Patients were followed for 48 months (range 18 - 68) to assess CVEV: cardiovascular death, acute coronary syndrome, revascularisation and stroke. Potential predictors of CVEV were identified. Predictive models based on clinical features, CTA and CS were created and compared. RESULTS: Performing CT impacted T2DP treatment. Cardiovascular risk was lowered during follow-up but metabolic control remained suboptimal. CVEV occurred in 11.8% T2DP (3.1%/year). CS ≥86.6 was predictor of CVEV over time, with a high negative predictive value, an 80% sensitivity and 74.7% specificity. Although its prognostic value was not independent of the presence/absence of obstructive CAD, adding CS and CTA data to clinical parameters improved the prediction of CVEV: the combined model had the highest AUC (0.888, 95%CI 0.789-0.987, p < 0.001) for the prediction of the study endpoints. CONCLUSIONS: CS showed great value in T2DP risk stratification and its prognostic value was further enhanced by CTA data. Information provided by CT may help predict CVEV in T2DP and potentially improve their outcome.

Atrial fibrillation in acute pulmonary embolism: prognostic considerations.

AIMS: Although it is accepted that atrial fibrillation (AF) may be both the contributing factor and the consequence of pulmonary embolism (PE), data on the prognostic role of AF in patients with acute venous thromboembolism are scarce. Our aim was to study whether AF had a prognostic role in patients with acute PE. METHODS: Retrospective cohort study involving 270 patients admitted for acute PE. Collected data: past medical history, analytic/gasometric parameters, admission ECG and echocardiogram, thoracic CT angiography. Patients followed for 6 months. An analysis was performed in order to clarify whether history of AF, irrespective of its timing, helps predict intrahospital, 1-month and 6-month all-cause mortality. RESULTS: Patients with history of AF, irrespective of its timing (n=57, 21.4%), had higher intrahospital (22.8% vs 13.1%, p=0.052, OR 2.07, 95% CI 0.98 to 4.35), 1-month (35.1% vs 16.9%, p=0.001, OR 3.16, 95% CI 1.61 to 6.21) and 6-month (45.6% vs 17.4%, p<0.001, OR 4.67, 95% CI 2.37 to 9.21) death rates. The prognostic power of AF was independent of age, NT-proBNP values, renal function and admission blood pressure and heart rate and additive to mortality prediction ability of simplified PESI (AF: p=0.021, OR 2.31, CI 95% 1.13 to 4.69; simplified PESI: p=0.002, OR 1.47, CI 95% 1.15 to 1.89). The presence of AF at admission added prognostic value to previous history of AF in terms of 1-month and 6-month all-cause mortality prediction, although it did not increase risk for intrahospital mortality. CONCLUSIONS: The presence of AF, irrespective of its timing, may independently predict mortality in patients with acute PE. These data should be tested and validated in prospective studies using larger cohorts.

Decreased glomerular filtration rate and markers of left atrial stasis in patients with nonvalvular atrial fibrillation.

BACKGROUND: It is currently unknown if the increased risk of stroke in subjects with chronic kidney disease and atrial fibrillation (AF) is due to the presence of left atrial stasis or to any other vascular or systemic conditions. METHODS: This was a retrospective study of 372 subjects undergoing evaluation during an AF episode. The following markers of left atrial stasis were sought on transesophageal echocardiogram: left atrial or left atrial appendage thrombus (LAAT), dense spontaneous echocardiographic contrast (DSEC), and low flow velocities (LFV) in the left atrial appendage. Subgroup comparisons were performed according to the level of estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation as follows: ≥90, 45-89.9, and <45 ml/min/1.73 m2. RESULTS: LAAT was found in 11.6%, DSEC in 29.0%, and LFV in 14.9% of cases. A significant increase in the prevalence of DSEC was observed in the lower categories of eGFR: 37.8% in eGFR <45 ml/min, 30.7% in eGFR 45-89.9 ml/min, and 17.0% in eGFR ≥90 ml/min (p = 0.009; γ for trend = 0.297, p = 0.002). The same was observed when assessing left atrial abnormality, i.e. the presence of at least one of the former transesophageal echocardiogram changes. On multivariate analysis, clinical parameters from CHADS2 (congestive heart failure, hypertension, age ≥75, diabetes mellitus and stroke) and CHA2DS2-VASc (age 65-74, history of vascular disease, and female gender along with the clinical variables from CHADS2) were predictors of transesophageal echocardiogram changes and an additive predictive value was found for eGFR. CONCLUSIONS: Our results suggest an association between compromised renal function as assessed through eGFR and markers of left atrial stasis in patients with AF. The increased risk of stroke in this population may be due to thromboembolism.

Mean platelet volume is associated with the presence of left atrial stasis in patients with non-valvular atrial fibrillation.

BACKGROUND: Mean platelet volume has been associated with stroke in patients with atrial fibrillation. However, its role as a predictor of left atrial stasis, assessed by transesophageal echocardiography, in patients with non-valvular atrial fibrillation has not yet been clarified. METHODS: Single center cross-sectional study comprising 427 patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus before cardioversion. All patients had a complete blood count performed in the 12 hours prior to transesophageal echocardiogram. Markers of left atrial stasis were sought: left atrial appendage thrombus, dense spontaneous echocardiographic contrast and low flow velocities in the left atrial appendage. The presence of at least one of the former markers of left atrial stasis was designated left atrial abnormality. Binary logistic multivariate analysis was used for obtaining models for the prediction of transesophageal echocardiogram endpoints. RESULTS: Left atrial appendage thrombus was found in 12.2%, dense spontaneous echocardiographic contrast in 29.7%, low flow velocities in 15.3% and left atrial abnormality in 34.2%. Mean platelet volume (exp ß = 3.41 p = 0.048) alongside with previous stroke or transient ischemic attack (exp ß = 5.35 p = 0.005) and troponin I (exp ß = 5.07 p = 0.041) were independent predictors of left atrial appendage thrombus. Mean platelet volume was also incorporated in the predictive models of dense spontaneous echocardiographic contrast, low flow velocities and left atrial abnormality, adding predictive value to clinical, echocardiographic and laboratory variables. CONCLUSIONS: These findings suggest that mean platelet volume may be associated with the presence of markers of left atrial stasis, reinforcing a likely cardioembolic mechanism for its association with stroke in patients with non-valvular atrial fibrillation.

Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters.

AIM: Some transoesophageal echocardiogram (TEE) findings are associated with an increased risk of stroke in patients with atrial fibrillation (AF). This study was designed to evaluate and compare the accuracy of CHADS(2) and CHA(2)DS(2)-VASc in the prediction of these findings and test the additive value of transthoracic echocardiogram (TTE)-derived parameters as a possible refinement for these classifications. METHODS AND RESULTS: Cross-sectional study of 405 consecutive patients who underwent TTE and TEE evaluation during AF. Stroke risk assessment was performed using the CHADS(2) and CHA(2)DS(2)-VASc scores, alone and alongside with the addition of two TTE-derived parameters (left atrium area and left ventricle global systolic function). Comparisons regarding the presence of left atrial appendage thrombi (LAA T), dense spontaneous echo contrast (SEC), and left atrial appendage (LAA) low flow velocities (LFV) were performed using receiver operating characteristic curves. In low-risk patients, as assessed through the CHA(2)DS(2)-VASc score and CHADS(2) and CHA(2)DS(2)-VASc scores plus echo parameters, no high-risk features were found on TEE. In subjects classified as low risk using CHADS(2), this figure rose to 10%. No significant differences were found between CHADS(2) and CHA(2)DS(2)-VASc in the prediction of LAA T, dense SEC, and LAA LFV. The addition of TTE-derived parameters to the previous clinical-risk scores resulted in improved prediction of the TEE endpoints. CONCLUSION: These findings suggest that the use of TTE-derived parameters may be a valuable way of refining the available clinical risk schemes for the detection of surrogate markers of stroke. Follow-up studies using clinical endpoints will be necessary to confirm this hypothesis.

[Hypertension in pregnancy: the current state of the art]. / Hipertensão arterial na grávida: o atual estado da arte.

Hypertension complicates 6-8% of pregnancies and includes the following four conditions: hypertension preceding pregnancy or documented before the 20th week of gestation; pre-eclampsia (PE)/eclampsia; chronic hypertension with superimposed pre-eclampsia; and gestational hypertension. The latter is defined as a significant rise in blood pressure after the 20th week of pregnancy in previously normotensive women, to over 140/90 mmHg. When blood pressure remains above 160/110 mmHg, it is considered severe. PE is defined as the presence of proteinuria (> or = 300 mg/24 h) in pregnant women with hypertension. The hypertensive syndromes of pregnancy are among the leading causes of maternal and fetal morbidity and mortality and anti-hypertensive treatment is part of the therapeutic arsenal used to prevent serious complications. Although the role of utero-placental insufficiency due to deficient migration of trophoblasts to the spiral arteries is universally accepted, the pathophysiology of PE remains largely unknown and is the subject of debate. No effective ways of predicting or preventing PE have been found, which highlights the need for further research in this field. This review aims primarily to evaluate recent advances in our understanding of the pathophysiology of gestational hypertension and especially PE, and new ways of predicting PE. Additionally, we present a brief review on the diagnosis, prevention and treatment of PE.

[Glomerular filtration rate: which formula should be used in patients with myocardial infarction?]. / Taxa de filtração glomerular: que fórmula deverá ser usada em doentes com enfarte agudo do miocárdio?

INTRODUCTION: There is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft-Gault [CG] and modification of diet in renal disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk. METHODS: We studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01±13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up. RESULTS: GFR <60ml/min/1.73 m(2) using the MDRD formula was associated with a tendency for more extensive CAD (2.70 affected segments vs. 2.20, p=0.052) and higher two-year mortality risk (p<0.001, OR 3.84, 95% CI 2.04-7.22) and risk for reinfarction (p<0.001, OR 4.09, 95% CI 2.00-8.39), decompensated heart failure (DHF) (p<0.001, OR 3.95, 95% CI 2.04-7.66) and combined cardiovascular endpoints (p=0.001, OR 2.47, 95% CI 1.47-4.17). Using the CG formula, GFR<60ml/min/1.73 m(2) only predicted higher risk for DHF (p=0.016, OR 4.5, 95% CI 1.11-16.57), despite a tendency for more overall combined cardiovascular endpoints (p=0.09, OR 2.84). Both formulas predicted in-hospital mortality. DISCUSSION/CONCLUSIONS: This study confirmed the value of GFR in predicting various cardiovascular endpoints in patients with MI. Compared to the CG formula, the MDRD formula was significantly more accurate in predicting the severity of CAD and two-year CV risk in patients admitted to the ICU with MI.

Severe lactose intolerance in a patient with coronary artery disease and ischemic cardiomyopathy.

A 72-year-old man with severe lactose intolerance was admitted for non-ST-segment elevation myocardial infarction. The coronary angiogram revealed occlusion of the distal third of the first diagonal artery and several non-significant lesions. The pre-discharge echocardiogram revealed moderate left ventricular systolic dysfunction. Discharged on dual antiplatelet therapy, rosuvastatin, perindopril and carvedilol, he was repeatedly readmitted in the following days for abdominal pain/bloating, diarrhea and nausea despite avoiding food products containing lactose. To date, there has been no comprehensive study on the relationship between lactose intolerance and coronary disease, nor has its impact on therapeutics been appropriately addressed. Intolerance to lactose-containing prescription medicines is an extremely rare phenomenon and few strategies are available to overcome this condition, as it has received little attention from the scientific community. Commercial forms of the lactase enzyme and probiotics can limit symptom severity, but different routes of administration, different brands of the same medicine or completely different medicines may be necessary. Some measures were proposed to our patient and, soon afterwards, he was completely asymptomatic in both gastrointestinal and cardiovascular terms.

[Rotational atherectomy in the drug-eluting stent era: a recent single-center experience]. / O ressurgimento da aterectomia rotacional na era dos stents farmacoativos - A experiência de um centro.

INTRODUCTION: Percutaneous coronary intervention (PCI) of heavily calcified lesions is a challenge for the interventional cardiologist and is associated with a high rate of restenosis and target lesion revascularization (TLR). Adequate lesion preparation by rotational atherectomy followed by drug-eluting stent implantation has shown favorable results. OBJECTIVE: To report the recent experience of our center with rotational atherectomy (RA) of complex and heavily calcified coronary lesions. METHODS: We retrospectively analyzed consecutive patients who underwent PCI with RA in our center between January 2009 and December 2010. A total of 42 patients were included, 65% of whom had been previously refused for coronary artery bypass grafting due to unfavorable coronary anatomy or high surgical risk. RA was performed using the standard Boston Scientific Rotablator(®) system. The procedure was performed ad-hoc in 50% of patients and transradial access was used in 35%. Data were collected on immediate post-procedural events and major cardiac events during follow-up - cardiovascular death, myocardial infarction, TLR and recurrent angina. RESULTS: Of 1650 PCIs performed in a 23-month period from January 2009, 42 (2.5%) involved RA, a total of 42 patients (mean age 70.3±10.1 years, 67% male, 55% diabetic), three of whom had left main disease, six had three-vessel disease, 18 had two-vessel disease and the other 15 had single-vessel disease. Of the lesions treated, 71% were >20 mm long and classified in 69% of cases as type C according to the ACC/AHA lesion classification, 4% being chronic total occlusions. The left anterior descending artery was treated in 56% of the procedures. The mean number of burrs used per lesion was 1.3 and a total of 69 stents were implanted, 81% of which were drug-eluting. During follow-up three patients had recurrent angina, one required TLR and two died due to a cardiovascular event. There was significant clinical improvement in 83% of patients. CONCLUSIONS: This study demonstrates that rotational atherectomy followed by stenting in heavily calcified lesions can nowadays be performed with high success rates and few complications, extending the possibility of coronary revascularization to a greater number of patients.

Importance of Manchester Triage in acute myocardial infarction: impact on prognosis.

BACKGROUND: Fast and effective diagnosis of patients with acute myocardial infarction (AMI) in the Emergency Department (ED) is needed. Manchester Triage (MT) is based on identification of the patient's main complaint, establishing, through decision flowcharts, a target-time for first observation. This study aimed to evaluate the impact of MT on short-term mortality in AMI and detect potential improvements, and to analyse high-risk groups: diabetic patients, women and older patients. METHODS: 332 consecutive patients (69.0+13.6 years mean age; 34.9% women) with final diagnosis of AMI were assessed in the ED using MT. Data were analysed according to demographics and risk groups, as well as several AMI parameters, admission duration and intrahospital mortality (IHM). Independent predictors of mortality were determined. RESULTS: 82.8% of patients met the ideal goal of ≤10 min target-time for a first observation (ITTFO). This was higher (95%) in typical presentations ('chest pain'), versus 52% in other flowcharts; p<0.01. Patients ≥70 years old were less frequently screened with ITTFO ≤10 min (76.2% vs 90.0% in those under 70; p=0.001) or the 'chest pain' flowchart (66.9% vs 77.5%; p=0.031). IHM was 13.3%. Triage with ≤10 min ITTFO and the 'chest pain' algorithm seems to predict a lower mortality (0.33 OR; 95% CI 0.17 to 0.63; p=0.0005 and 0.49 OR; 95% CI 0.24 to 1.03; p=0.056). CONCLUSION: MT proved to be an effective system. Patients with typical AMI presentation, ST elevation myocardial infarction and less than 70 years old are protected by MT, with lower ITTFO and better short-term survival.

Carotid stenting for radiation-induced carotid artery stenosis: a challenge?

Endovascular treatment of radiation-induced carotid lesions is challenging and very demanding from a technical standpoint. The authors report the case of a 48-year-old male patient who presented in the emergency department with a non-ST elevation acute coronary syndrome. He had a past history of lung carcinoma treated with radiotherapy. Diagnostic workup included coronary angiography (showing predominantly ostial coronary artery disease) and carotid angiography, which showed a long ulcerated lesion in the right carotid artery. Carotid angioplasty was performed using distal cerebral embolic protection. The post-procedure course was uneventful. At 24 months the patient is well and no major adverse cardiovascular events have been reported. The case presented demonstrates that carotid artery stenting can be safely performed in high risk lesions and highlights the importance of stenting technique and of thorough follow-up.

Screening for warning signs of sudden cardiac death in the young: the SCD-SOS questionnaire.

INTRODUCTION: Sudden cardiac death (SCD) is one of the most common causes of death in the young. It may be preceded by "red flags", but screening for these warning signs is not routinely performed. OBJECTIVE: To test a new questionnaire for fast clinical assessment of possible warning signs of serious heart disease in a young population. METHODS: We studied a population of 1472 university students and hospital employees (mean age 22.3 +/- 5.9 years; maximum age 40 years; 56.5% women), using a rapid-response questionnaire, evaluating major cardiac symptoms, past pathological and family history and medication: the Sudden Cardiac Death-Screening of Risk Factors (SCD-SOS) questionnaire. Descriptive statistical analysis and comparison of quantitative and nominal variables were performed using SPSS version 16.0. RESULTS: Of the questionnaires, 0.3% were blank and 3.5% had 1 to 3 missing answers (of a total of 8); 42.5% had no previous cardiac complaints, 27.8% had previous syncope and 24.5% chest pain; palpitations were reported by 23.5%, cardiac murmur by 5.9%, epilepsy or antiepileptic drugs by 1.6%, cardiovascular medication by 1.4% and family history of cardiac disease by 3.3%. A history of sudden unexplained or cardiovascular death in first- or second-degree family members was reported by 2.0%. Full analysis of the questionnaires identified 69 participants (4.7%) with at least one warning sign indicating need for cardiological evaluation, among whom 17 had two warning signs and three had three. CONCLUSIONS: SCD-SOS detected some cases requiring careful examination by a cardiologist. It could, however, be improved in some respects (characterization of chest pain, palpitations and family history of heart disease), in order to clearly identify possible high-risk patients. Applying this questionnaire together with an ECG may be a better way of risk stratifying this population.

The importance of echocardiography in the diagnosis and treatment of ostium secundum-type atrial septal defect.

Ostium secundum-type atrial septal defect (osASD) is one of the most common congenital heart defects. Treatment of these defects was revolutionized by the introduction of percutaneous closure. Echocardiography has a major role in the evaluation and treatment of this disease. The authors review the role of this imaging technique in diagnosis and in treatment decisions, as well as its advantages in monitoring and follow-up of percutaneous closure. In this context, we present our center's experience with different types of echocardiography, namely transthoracic, transesophageal and intracardiac, in closure of osASD.

Five-year clinical results of coronary angioplasty with drug-eluting stents. National initiative in strategic innovation, iNOS.

INTRODUCTION: The use of drug-eluting stents (DES) is beneficial in patients undergoing percutaneous coronary intervention (PCI) and there is particular interest in long-term follow-up. OBJECTIVE: We aimed to assess and characterize early DES use in Portugal during 2003 and patient follow-up over a 5-year period. We developed a web-based database to collect and organize patient and procedural data from PCI performed in ten cardiovascular interventional centers sharing the same database. METHODS: This was a multicenter retrospective study that included 1833 consecutive angiographically successful coronary angioplasties in which a DES was implanted in 2003. A subgroup of patients with 5-year clinical follow-up after the initial procedure was selected for which there was at least a 90% follow-up rate during one quarter of 2003. Demographic, clinical and angiographic characteristics of the entire population were assessed. In the clinical follow-up cohort, the incidence of major adverse cardiac events (MACE)--death, myocardial infarction and surgical or percutaneous target lesion revascularization--was analyzed by survival curves and logistic regression analysis. RESULTS: Of the total population, 23% were female, and mean age was 62 +/- 11 years (25-92). The main risk factors were hypertension (60.5%), dyslipidemia (42.9%), smoking (45.1%) and diabetes (23.9%, of whom 13.2% were on insulin therapy). There was a history of myocardial infarction, PCI or bypass surgery respectively in 23.1%, 25.1%, and 9.7% of the patients. Multivessel disease was present in 59.9% of patients (mean of 1.86 +/- 0.81 vessels). PCI was performed on average in 1.24 +/- 0.48 lesions, and complete revascularization in 58.8%. A total of 2058 stents were used (mean of 1.62 +/- 0.84) in 1271 patients. The longitudinal substudy included only 320 PCIs, for which follow-up was achieved in 319 (99%; median: 1875 days, P25: 1457 days, P75: 2045 days). Thirty-seven deaths (11.6%) and 61 MACE (19.1%) occurred in this group, with no differences between insulin-treated and other diabetic patients. CONCLUSION: This is the first study to analyze the early Portuguese experience with drug-eluting stents. The clinical results compare favorably with the first published international registries. The on-line platform used was successful in collecting data in a standardized format on the clinical experience of multiple centers.

Natural history of aortic arch aneurysm: the need for new therapeutic approaches.

Aortic arch aneurysms are a therapeutic challenge, as they are usually associated with a high surgical risk and their natural history is poorly understood. The authors present a case report of a 74-year-old man, with widespread atherosclerotic disease and an inoperable aortic arch aneurysm. Despite the severity of his condition, the patient survived for four years. Through regular follow-up, it was possible to document th growth mechanism of the aneurysm and the associated complications. We highlight the lack of information in the literature regarding the evolution and natural history of aneurysms of the aortic arch and the urgent need for new therapeutic strategies, especially a percutaneous approach, which could provide better treatment and outcome for high-risk surgical patients.

Pulmonary hypertension in patients with ostium secundum atrial septal defect--is it related to echocardiographic complexity?

INTRODUCTION: Atrial septal defect (ASD) is one of the most common congenital heart defects. Patients may reach adulthood before being diagnosed and sometimes develop pulmonary hypertension (PH). According to the latest Euro Heart Survey on Congenital Heart Disease, 24.77% of ASD patients develop PH. The reasons for this evolution in only some patients are still unknown. OBJECTIVES: To assess the prevalence of PH in patients with ostium secundum ASD (osASD) in our district and to determine whether the echocardiographic morphology of the defect can be an indicator of evolution to PH. METHODS: The study included 181 consecutive patients, mean age 43.1+/-18.4 years, 65.2% women, with a diagnosis of osASD, referred for transthoracic and transesophageal evaluation in our center from January 2000 to September 2008. We assessed right atrial (RA) and ventricular (RV) dimensions, measured the rims and size of the ASD and determined pulmonary artery systolic pressure (PASP) (RV/RA gradient plus a value corresponding to the degree of inferior vena cava collapse). The type of shunt at the atrial level was assessed with intravenous injection of agitated saline. Statistical analysis was performed using SPSS 15.0. RESULTS: Seventy-seven patients (42.5%) had moderate to severe enlargement of the right heart chambers and 48 (26.5%) had pulmonary hypertension, defined as PASP of over 40 mmHg (equivalent to mean pulmonary artery pressure of 25-30 mmHg). Patients with PH were older (52.8+/-16.9 vs. 39.0+/-17.6 years; p<0.001) and had larger defects (19.7+/-9.6 mm vs. 13.1+/-7.1 mm; p<0.001). The proportion of women was similar in both groups (64.6% in patients with PH vs. 68.75% in those without; p=NS). Most patients with PH had ASDs with more complex shapes on echocardiography. However, some patients with simpler and smaller defects, such as central ASD with a diameter of <5 mm, also developed PH. The prevalence of PH in patients with closed ASDs was much lower: 20.3% vs. 43.75%; p<0.002. CONCLUSIONS: According to these data, development of PH in patients with ASD is frequent and seems to be related to the diameter of the defect. However, patients with smaller and simpler defects may also develop PH. This seems to occur at older ages and not to be gender-dependent. Early ASD closure appears to prevent this.

Aquarium sign in sepsis.

A 91-year-old man appeared in our lab with fever for a transthoracic echocardiography assessment. Highly unusual echo images were found, with a size and movement resembling 'bubbles in an aquarium' in every cardiac chamber, both left and right. The patient died 8 days later, due to a methicillin-resistant Staphylococcus aureus sepsis. These are highly unusual images that should not be confused with microbubbles from contrast agents or radiofrequency ablation, and were previously reported once in association with atrioesophageal fistula.

Echocardiographic assessment of secundum-type atrial septal defects in the adult: role in treatment decisions.

The purpose of this study is to evaluate morphologic patterns of ostium secundum-type atrial septal defects (osASD) in the adult, analyzing their role in treatment decisions. The population was composed of 155 adults (age 43.3 +/- 18.9 years) consecutively diagnosed with osASD in our center, and confirmed by transthoracic and transesophageal echocardiography, between January 2000 and December 2007. Of these, 83 (53.5%) underwent successful percutaneous closure. Surgical closure was used in 31 patients (20.0%). The remaining 42 patients (27.1%) received conservative medical treatment. The mean diameter of the defects was 15.8 +/- 8.5 mm. The prevalence of mitral valve prolapse and severe pulmonary hypertension was also assessed. Based on the criteria in the literature, we detected 14 different morphologic patterns of osASD. There was a central defect in 45/155; 40/155 had a short rim and 20/155 two short rims, 24/155 were multifenestrated and 15/155 PFO-like, and 12/155 had three or more short rims. The different morphologic patterns in each treatment arm, as well as the criteria leading to their inclusion in each, are described. While percutaneously closed defects had a simpler morphology, those that were surgically closed were normally larger and had a more complex shape (with two or more deficient rims or multifenestrated, and thus not suitable for percutaneous closure).

Estimating glomerular filtration rate in acute coronary syndromes: Different equations, different mortality risk prediction.

AIMS: Renal dysfunction is a powerful predictor of adverse outcomes in patients hospitalized for acute coronary syndrome. Three new glomerular filtration rate (GFR) estimating equations recently emerged, based on serum creatinine (CKD-EPIcreat), serum cystatin C (CKD-EPIcyst) or a combination of both (CKD-EPIcreat/cyst), and they are currently recommended to confirm the presence of renal dysfunction. Our aim was to analyse the predictive value of these new estimated GFR (eGFR) equations regarding mid-term mortality in patients with acute coronary syndrome, and compare them with the traditional Modification of Diet in Renal Disease (MDRD-4) formula. METHODS AND RESULTS: 801 patients admitted for acute coronary syndrome (age 67.3±13.3 years, 68.5% male) and followed for 23.6±9.8 months were included. For each equation, patient risk stratification was performed based on eGFR values: high-risk group (eGFR<60ml/min per 1.73m(2)) and low-risk group (eGFR⩾60ml/min per 1.73m(2)). The predictive performances of these equations were compared using area under each receiver operating characteristic curves (AUCs). Overall risk stratification improvement was assessed by the net reclassification improvement index. The incidence of the primary endpoint was 18.1%. The CKD-EPIcyst equation had the highest overall discriminate performance regarding mid-term mortality (AUC 0.782±0.20) and outperformed all other equations (ρ<0.001 in all comparisons). When compared with the MDRD-4 formula, the CKD-EPIcyst equation accurately reclassified a significant percentage of patients into more appropriate risk categories (net reclassification improvement index of 11.9% (p=0.003)). The CKD-EPIcyst equation added prognostic power to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of mid-term mortality. CONCLUSION: The CKD-EPIcyst equation provides a novel and improved method for assessing the mid-term mortality risk in patients admitted for acute coronary syndrome, outperforming the most widely used formula (MDRD-4), and improving the predictive value of the GRACE score. These results reinforce the added value of cystatin C as a risk marker in these patients.

Diagnostic approach to cardiac amyloidosis: A case report. / Amiloidose cardíaca - abordagem diagnóstica, a propósito de um caso clínico.

The authors present a case of systemic amyloidosis with cardiac involvement. We discuss the need for a high level of suspicion to establish a diagnosis, diagnostic techniques and treatment options. Our patient was a 78-year-old man with chronic renal disease and atrial fibrillation admitted with acute decompensated heart failure of unknown cause. The transthoracic echocardiogram revealed severely impaired left ventricular function with phenotypic overlap between hypertrophic and restrictive cardiomyopathy. After an extensive diagnostic workup, which included an abdominal fat pad biopsy, the final diagnosis was amyloidosis.