Bilateral papillary muscle infarction in a chagasic patient.

We report a case of a 59-year-old patient diagnosed with chagasic cardiomyopathy, who manifested sudden heart failure while hospitalized, evolving to death due to cardiogenic and septic shock. Anatomical-pathological studies revealed infarction of the papillary muscles together with histological changes compatible with 48 to 72 hours of evolution. Pulmonary edema was considered the cause of death, probably related to mitral regurgitation of ischemic nature. The cause of the papillary muscle infarction was not elucidated by study of the coronary tree, which presented no signs of recent thrombosis. Explanation for the papillary muscle infarction in this patient may be related to the presence of alterations in microcirculation represented by vasodilation and the consequent phenomenon of "stealing" of blood flow in this territory to the detriment of other areas, or due to the fact that the papillary muscles may represent convergence zones of two distinct coronary circulations.

Chagas' disease and the use of implantable cardioverter-defibrillators in Brazil.

The authors discuss the epidemiology and pathogenesis of Chagas' disease in Brazil, including the use of treatment with a cardioverter-defibrillator in patients with low ejection fraction. Select patients may benefit from resynchronization therapy associated with cardioverter-defibrillator treatment. Electrophysiologic study is indicated in the assessment of the potential utility of an implantable cardioverter-defibrillator.

Impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular infarction.

CONTEXT AND OBJECTIVE: There is uncertainty regarding the risk of major complications in patients with left ventricular (LV) infarction complicated by right ventricular (RV) involvement. The aim of this study was to evaluate the impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular myocardial infarction. DESIGN AND SETTING: Prospective cohort study, at Emergency Care Unit of Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo. METHODS: 183 patients with acute myocardial infarction participated in this study: 145 with LV infarction alone and 38 with both LV and RV infarction. The presence of complications and hospital death were compared between groups. RESULTS: 21% of the patients studied had LV + RV infarction. In this group, involvement of the dorsal and/or inferior wall was predominant on electrocardiogram (p < 0.0001). The frequencies of Killip class IV upon admission and 24 hours later were greater in the LV + RV group, along with electrical and hemodynamic complications, among others, and death. The probability of complications among the LV + RV patients was 9.7 times greater (odds ratio, OR = 9.7468; 95% confidence interval, CI: 2.8673 to 33.1325; p < 0.0001) and probability of death was 5.1 times greater (OR = 5.13; 95% CI: 2.2795 to 11.5510; p = 0.0001), in relation to patients with LV infarction alone. CONCLUSIONS: Patients with LV infarction with RV involvement present increased risk of early morbidity and mortality.

Comparative study of smokers, ex-smokers, and nonsmokers who have experienced myocardial infarction.

OBJECTIVE: To assess the impact of smoking on in-hospital morbidity and mortality in patients who have experienced acute myocardial infarction and to assess the association between smoking and other cardiovascular risk factors and clinical data. METHODS: A prospective cohort study analyzed 121 patients, including 54 smokers, 35 ex-smokers, and 32 nonsmokers. RESULTS: Using the chi-square test (P<0.05), an association between smoking and the risk factors sex, age, and diabetes was documented. Among the morbidity and mortality variables, only acute pulmonary edema showed a statistically significant difference (OR=9.5; 95% CI), which was greater in the ex-smoker group than in the nonsmoker group. CONCLUSION: An association between smoking and some cardiovascular risk factors was observed, but no statistical difference in morbidity and mortality was observed in the groups studied, except for the variable acute pulmonary edema.

[Association of angiotensin converting enzyme polymorphism and echocardiographic measures in young siblings of hypertensive parents]. / Associação do polimorfismo do gene da enzima conversora da angiotensina com dados ecocardiográficos em jovens normotensos filhos de hipertensos.

OBJECTIVES: To evaluate angiotensin converting enzyme gene (ACE) polymorphism with transthoracic bidimensional echocardiogram of normotensive young medical students, siblings of hypertensive parents comparing them with those with normotensive parents. METHOD: We had studied 80 normotensive youngs divided in two groups. Hypertensive parents' normotensive young medical students 40 x Normotensive parents' and normotensive medical students. Exclusion criteria were hypertension, obesity, smoke, use of oral contraceptives, as well as those who use chronically drugs or the presence of any disease. The group has been enrolled between 1994 to 1996. 50 students made transthoracic bidimensional echocardiogram. The statistical analysis was done by "T-student" test. The evaluation of polymorphism ACE gene was studied in 80 people in each step: 1) 5 mL of blood in EDTA tube, 2) extraction of DNA, 3) evaluation of DNA concentration by electrophoresis analyses; 4) Polymerase chain reaction with primer of ACE gene, 5) Analysis of polymorphism ACE gene by electrophoresis 6) Statistical analysis by Chi-square test. RESULTS: The group of students with hypertensive parents presented thicker interventricular septum (7.82 mm +/- 0.69 against 7.38 mm +/- 0.8, p<0.05). On the other hand, we didn't find differences between the groups concerning ACE gene genotype: students with hypertensive parents DD: 42.5%, DI: 37.5%, II: 20% against Students with normotensive parents: DD: 37.5%, DI: 32.5%, II: 30%, (p=0.58), in addition we also did not find differences concerning the alleles Group of hypertensive parents: D: 61.25%, I: 38.75% versus normotensive parents: D: 53.75%, I: 46.25%, p=0.33. We divided these groups into two in relation to the mean thickness of interventricular septum and left ventricular mass and we did not find any difference: in students with hypertensive parents group septum > 7.82 mm: DD: 32%, DI: 24%, II: 20% x septum < 7.82 mm: DD: 8%, DI: 12%, II: 4%, p=0.7) in normotensive parents group septum septum > 7.38 mm: DD: 28%, DI: 12%, II: 12% x septum < 7.38 mm: DD: 16%, DI: 16%, II: 16%, p=0.59). The study of the left ventricular mass in hypertensive parents group mass > 131.52 g: DD: 20.69%, DI: 13.79%, II: 6.9% x mass < 131.52 g DD: 24.24%, DI: 17.24%, II: 17.24%, (p=0.72) in normotensive parents group mass > 117.11 g: DD: 30.43%, DI: 8.7%, II: 8.7% x mass < 117.11 g: DD: 13.04%, DI: 21.74%, II: 17.39%, (p=0.17). CONCLUSION: We found differences between the thickness of the interventricular septum of normotensive students sibling of hypertensive parents and normotensive parents. On the other hand we didn't find any difference between the two groups concerning the ACE gene polymorphism as well as any relation of ACE gene and thickness of interventricular septum and interventricular left ventricular mass.

Atrial fibrillation in the elderly.

This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted.

[Off-pump myocardial revascularization in the elderly: analysis of morbidity and mortality]. / Revascularização do miocárdio sem circulação extracorpórea em idosos: análise da morbidade e mortalidade.

OBJECTIVE: To analyze the in-hospital outcome of elderly patients aged 70 years and older who underwent off-pump coronary artery bypass graft surgery with an intraluminal shunt in urgent, emergent, and elective coronary revascularizations. METHODS: From July 1989 to July 2005, we analyzed 87 patients ranging in age from 70 to 92 years. Of the 87 patients enrolled, 50 (57.5%) patients had unstable angina, with three (3.4%) acute myocardial infarction; thirty-one (35.6%) patients underwent urgent and emergent surgery; thirteen (14.9%) patients had myocardial infarction in less than 30 days, and 34 (39.1%) in more than 30 days. RESULTS: The main postoperative complications were: atrial fibrillation (32.2%), heart failure (12.6%), pneumonia (10.3%), septicemia (3.4%), acute myocardial infarction (2.3%), mediastinitis (1.1%) transient ischemic attack (1.1%), and pneumothorax (1.1%). The mean extubation time was 18.50+/-19.09 hours, the length of stay in the intensive care unit was 2.92+/-2.03 days, and hospital length of stay was 10.55+/-7.16 days. Packed red cells were given to nine (10.34%) patients and none of them was operated due to bleeding. The in-hospital mortality was 4.6%. CONCLUSIONS: In patients over 70 years-old, elective and non-elective off-pump coronary artery bypass grafting with intracoronary shunt showed to be safe and effective, associated with low rates of postoperative complications and mortality in relation to the studied population.

Tabagismo no currículo da Faculdade de Ciências Médicas da Santa Casa de São Paulo / Tobacco education in the curriculum of the Mercy Hospital School of Medicine, São Paulo, Brazil

Este trabalho avalia a inclusão da problemática do tabagismo no currículo da Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP) e investiga o envolvimento de alunos e professores de Medicina e Enfermagem em relação ao assunto. Coordenadores das disciplinas dos dois cursos dessa faculdade foram entrevistados sobre abordagem do tabagismo e engajamento pessoal no assunto. Pedimos que formulassem questões sobre tabagismo discutidas durante o curso. Entrevistamos 120 alunos do curso médico e 80 do curso de Enfermagem, aplicando-lhes as questões formuladas. Alunos dos dois últimos períodos dos dois cursos responderam, ainda, a perguntas sobre o trato com pacientes. Os resultados apontam suficiente carga horária destinada ao assunto, havendo disciplinas com aulas específicas sobre tabagismo e outras que abordam o assunto num contexto mais amplo. Os alunos tiveram êxito nos questionários, ficando claro que o assunto é abordado com competência. A maioria dos professores de Medicina tem contato com pacientes, mas um pequeno número questiona sobre o tabagismo, porém não orienta seus pacientes a abandoná-lo. Uma minoria dos professores de Enfermagem tem contato com pacientes, mas, quando tem, questiona e orienta seus pacientes sobre o assunto. Alunos dos últimos períodos dos dois cursos, na maioria das vezes, questionam sobre tabagismo, porém são inseguros quanto ao seguimento das orientações. Concluímos que os alunos formandos estão preparados para enfrentar os problemas referentes ao tabagismo, mas os professores estão pouco envolvidos.

This study analyzes the inclusion of tobacco use in the curriculum of the São Paulo Mercy Hospital School of Medicine (FCMSCSP) and studies the involvement by medical and nursing students and faculty in this topic. Course coordinators from the two courses were interviewed on the approach to smoking and personal involvement in the issue. We asked them to draft questions on smoking as discussed during their courses. We interviewed 120 medical students and 80 nursing students. Patients from the last two semesters in the two courses were also asked about patient treatment. The findings point to a sufficient number of class hours on the subject, with some disciplines including specific classes on smoking and others approaching it within a broader context. The students answered the questionnaires successfully, demonstrating clearly that the topic is approached competently. Most of the medical school professors have direct contact with patients, but few ask about the smoking habit or orient their patients to quit. Few nursing professors have contact with patients, but when they do they provide patients with appropriate orientation. Most students from the last two semesters usually ask patients about smoking, but they are insecure about how closely their orientation is followed. We conclude that by the end of their undergraduate training students are ready to deal with smoking-related problems, but professors show limited involvement in the issue.

Revascularização do miocárdio sem circulação extracorpórea em idosos: análise da morbidade e mortalidade / Off-pump myocardial revascularization in the elderly: analysis of morbidity and mortality

OBJETIVO: Analisar a evolução intra-hospitalar de doentes com 70 anos de idade ou mais, submetidos a revascularização do miocárdio sem circulação extracorpórea, com uso de shunt intracoronário, operados na urgência, emergência e eletivamente. MÉTODOS: Foram submetidos à cirurgia 87 doentes com idade entre 70 e 92 anos de julho de 1989 a julho de 2005. Dos 87 doentes, 50 (57,5 por cento) eram portadores de angina instável, sendo três (3,4 por cento) na vigência de infarto agudo do miocárdio. Foram operados em caráter de emergência e urgência 31 (35,6 por cento) doentes. De todo o grupo, havia 13 (14,9 por cento) doentes com infarto ocorrido em até 30 dias e 34 (39,1 por cento) com infarto ocorrido há mais de 30 dias. RESULTADOS: As complicações mais freqüentes foram: fibrilação atrial (32,2 por cento), insuficiência cardíaca congestiva (12,6 por cento), broncopneumonia (10,3 por cento), sepse (3,4 por cento), infarto agudo do miocárdio peri-operatório (2,3 por cento), mediastinite (1,1 por cento), acidente isquêmico transitório (1,1 por cento), pneumotórax (1,1 por cento). O tempo médio de intubação foi de 18,50±19,09 horas; permanência em UTI, 2,92±2,03 dias, e hospitalar, 10,55±7,16 dias. Apenas nove (10,3 por cento) doentes receberam concentrado de hemácias no pós-operatório e nenhum foi reoperado por sangramento. A mortalidade hospitalar foi de 4,6 por cento. CONCLUSÃO: Em doentes acima de 70 anos, operados na emergência, urgência e eletivamente, a revascularização do miocárdio sem extracorpórea com shunt intracoronário apresentou adequada evolução pós-operatória e baixos índices de complicações e mortalidade em relação à população estudada.

OBJECTIVE: To analyze the in-hospital outcome of elderly patients aged 70 years and older who underwent off-pump coronary artery bypass graft surgery with an intraluminal shunt in urgent, emergent, and elective coronary revascularizations. METHODS: From July 1989 to July 2005, we analyzed 87 patients ranging in age from 70 to 92 years. Of the 87 patients enrolled, 50 (57.5 percent) patients had unstable angina, with three (3.4 percent) acute myocardial infarction; thirty-one (35.6 percent) patients underwent urgent and emergent surgery; thirteen (14.9 percent) patients had myocardial infarction in less than 30 days, and 34 (39.1 percent) in more than 30 days. RESULTS: The main postoperative complications were: atrial fibrillation (32.2 percent), heart failure (12.6 percent), pneumonia (10.3 percent), septicemia (3.4 percent), acute myocardial infarction (2.3 percent), mediastinitis (1.1 percent) transient ischemic attack (1.1 percent), and pneumothorax (1.1 percent). The mean extubation time was 18.50±19.09 hours, the length of stay in the intensive care unit was 2.92±2.03 days, and hospital length of stay was 10.55±7.16 days. Packed red cells were given to nine (10.34 percent) patients and none of them was operated due to bleeding. The in-hospital mortality was 4,6 percent. CONCLUSIONS: In patients over 70 years-old, elective and non-elective off-pump coronary artery bypass grafting with intracoronary shunt showed to be safe and effective, associated with low rates of postoperative complications and mortality in relation to the studied population.

Impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular infarction / Impacto do envolvimento do ventrículo direito na morbidade e mortalidade hospitalar em pacientes com infarto agudo do ventrículo esquerdo

CONTEXT AND OBJECTIVE: There is uncertainty regarding the risk of major complications in patients with left ventricular (LV) infarction complicated by right ventricular (RV) involvement. The aim of this study was to evaluate the impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular myocardial infarction. DESIGN AND SETTING: Prospective cohort study, at Emergency Care Unit of Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo. METHODS: 183 patients with acute myocardial infarction participated in this study: 145 with LV infarction alone and 38 with both LV and RV infarction. The presence of complications and hospital death were compared between groups. RESULTS: 21 percent of the patients studied had LV + RV infarction. In this group, involvement of the dorsal and/or inferior wall was predominant on electrocardiogram (p < 0.0001). The frequencies of Killip class IV upon admission and 24 hours later were greater in the LV + RV group, along with electrical and hemodynamic complications, among others, and death. The probability of complications among the LV + RV patients was 9.7 times greater (odds ratio, OR = 9.7468; 95 percent confidence interval, CI: 2.8673 to 33.1325; p < 0.0001) and probability of death was 5.1 times greater (OR = 5.13; 95 percent CI: 2.2795 to 11.5510; p = 0.0001), in relation to patients with LV infarction alone. CONCLUSIONS: Patients with LV infarction with RV involvement present increased risk of early morbidity and mortality.

CONTEXTO E OBJETIVO: O risco das principais complicações em pacientes com infarto do ventrículo esquerdo (VE) associado ao comprometimento do ventrículo direito (VD) ainda é incerto. O objetivo deste estudo foi avaliar o impacto do envolvimento do ventrículo direito na morbidade e na mortalidade hospitalar em pacientes com infarto agudo do ventrículo esquerdo. TIPO DE ESTUDO E LOCAL: Estudo prospectivo de coorte, realizado no Serviço de Emergência do Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo. MÉTODOS: Participaram do estudo 183 pacientes com infarto agudo do miocárdio: 145 com infarto do VE e 38 com infarto do VE associado ao VD (VE + VD). Foram comparados entre os grupos a presença das complicações e óbitos no período hospitalar. RESULTADOS: 21 por cento dos pacientes estudados apresentavam infarto VE + VD. Predominou o comprometimento da parede dorsal e/ou inferior (ECG) no grupo com VE + VD (p < 0.0001). A freqüência da classe IV de Killip no momento da admissão e 24 h após foi maior no grupo VE + VD, assim como as complicações elétricas, hemodinâmicas, entre outras, e óbitos. A probabilidade de complicações em pacientes com infarto VE + VD foi 9.7 vezes maior (odds ratio, OR = 9.7468; 95 por cento intervalo de confiança, IC 95 por cento 2.8673 a 33.1325; p < 0.0001) e de óbito 5.1 vezes superior (OR = 5.1313; 95 por cento IC 2.2795 a 11.5510; p = 0.0001) em relação aos pacientes com infarto isolado do VE. CONCLUSÕES: Pacientes com infarto VE com envolvimento do VD apresentam risco aumentado de morbidade e mortalidade precoces.