Mitochondrial and genomic ancestry are associated with etiology of heart failure in Brazilian patients.

There is a high prevalence of heart failure (HF) in the general population, but it is more common in black people. We evaluated the association between genomic ancestry and mitochondrial haplogroups (mt-haplogroups) with HF etiology in 503 Brazilian patients. We elicited Mt-haplogroups by analyzing the control region of mitochondrial DNA, and genomic ancestry, by using 48 autosomal insertion-deletion ancestry informative markers. Hypertensive (28.6%, n=144) and ischemic (28.4%, n=143) etiologies of HF were the most prevalent herein. Our results showed that 233 individuals (46.3%) presented African mitochondrial (mt)-haplogroups, and the major contribution in the genomic ancestry analysis was the European ancestry (57.5% (±22.1%)). African mt-haplogroups were positively associated with a diagnosis of hypertensive cardiomyopathy (odds ratio, OR 1.55, confidence interval, CI 95% 1.04-2.44, P=0.04) when compared with European mt-haplogroups. Regarding the genomic ancestry, the African ancestry variant had higher risks (OR 7.84, 95% CI 2.81-21.91, P<0.001), whereas the European ancestry variant had lower risks (OR 0.14, 95% CI 0.04-5.00, P<0.001) for developing the hypertensive etiology. In addition, European ancestry showed an OR of 4.05 (CI 95% 1.53-10.74, P=0.005), whereas African ancestry showed an OR of 0.17 (CI 95% 0.06-0.48, P=0.001) for developing ischemic etiology. In conclusion, this study supports the importance of using ancestry informative markers and mitochondrial DNA to study the genetics of complex diseases in admixed populations to improve the management, treatment and prevention of these illnesses. Therefore, the ancestry informative markers and mt-haplogroups could provide new biomarkers to be associated with HF etiologies and be used as a premise for more specific management.

The complications of infective endocarditis. A reappraisal in the 1980s.

BACKGROUND: The frequency of complications of infective endocarditis and their influence on the outcome of the patients changed in the antibiotic era. Therefore, we evaluated the complications in a recent large series of patients with infective endocarditis. METHODS: We studied 300 episodes of endocarditis in 287 patients in a tertiary cardiology referral center. Predisposing cardiac conditions were valvular heart disease in 147 episodes, congenital heart disease in 37, other heart diseases in five, and prosthetic heart valves in 69. In 69 episodes, there was no previous heart disease. The infecting microorganisms were streptococci in 147 episodes, Staphylococcus aureus in 59, Staphylococcus epidermidis in 14, gram-negative bacteria in 16, other gram-positive bacteria in eight, and fungi in four. In 52 episodes, blood cultures were negative. Seventy-eight patients (26%) died. Complications were defined as any clinically unfavorable event occurring during treatment. RESULTS: A total of 386 complications occurred in 223 episodes (74%); one complication occurred in 128 episodes (57%), two in 57 (26%), three in 18 (8%), four in 13 (6%), five in three (1%), and six or more in three (1%). The complications were as follows: cardiac, 100 occurrences; neurological, 72; septic, 46; associated with medical treatment, 41; renal, 27; extracranial systemic arterial embolism, 16; septic pulmonary embolism, 26; complications related to surgical treatment, 11; acute prosthetic heart valve insufficiency, six; splenic infarction or abscess, three; cardiac rhythm disturbances, three; and other, 19. The distribution of the complications relative to outcome of the patients revealed that fatality exceeded survival rates for neurologic and septic complications. CONCLUSIONS: Complications may be common in patients with infective endocarditis. Cardiac complications were the most common ones, but fatality rates were higher for neurologic and septic complications. Hence, heart failure was replaced by neurologic and septic complications as the leading causes of death in patients with infective endocarditis.

Bilateral facial pain from cardiac origin. A case report.

A case of a 65-year-old female patient is reported. Her chief complaint was facial pain, so she sought care from her general dental practitioner for evaluation of a suspected temporomandibular disorder, after repeated visits to the emergency department due to excruciating facial pain associated with exertion. The dental examination revealed an edentulous upper and lower jaw. Radiographs of the facial bones revealed no abnormalities. Eventually, she was referred for cardiological evaluation, as her pain radiated to the chest and there was a medical history of myocardial infarction. Cardiac pain may radiate to the face and lead patients to seek dental care. In these settings, dentists may contribute to the diagnosis of ischemic heart disease and refer patients for cardiological evaluation.

Hemochromatosis gene variants in patients with cardiomyopathy.

Iron depletion was suggested to be protective against the development of ischemic heart disease. Population studies have led to conflicting results, and such an association has not been addressed in patients with heart failure due to cardiomyopathy. We studied the distribution of hemochromatosis-related mutations in 319 patients with heart failure due to cardiomyopathy of different etiologies. The genotypic distribution showed a significantly higher prevalence of heterozygotes for the C282Y mutation in patients with ischemic cardiomyopathy than in patients with cardiomyopathy of nonischemic etiologies (p = 0.0036). The frequency of the D63 mutation was not significantly different between ischemic versus nonischemic groups. In multiple logistic regression models adjusted for age, sex, ethnicity, and different degrees of disease progression, there was a strong and significant association of the C282Y mutation with ischemic cardiomyopathy compared with the nonischemic group (odds ratio 6.64, 95% confidence interval 1.71 to 25.73, after adjustment). In our sample, genetic variation in the HFE gene was associated with ischemic cardiomyopathy. Such association merits further study regarding its value as a prognostic marker in patients with ischemic heart disease.

Rupture of posteromedial papillary muscle as a mechanism of death in dilated cardiomyopathy.

The pathogenesis of mitral regurgitation in dilated cardiomyopathy is ascribed to several mechanisms. The authors describe the case of an adult male with idiopathic dilated cardiomyopathy who developed myocardial infarction in the absence of coronary atherosclerosis and died from acute lung edema following rupture of a papillary muscle of the left ventricle. The possibility of coronary embolism could not be ruled out.

Infective endocarditis in the 1980s: experience at a heart hospital.

Three hundred episodes of infective endocarditis (IE) in 287 patients were studied from October 1978 to August 1986. The patients were in the age range of 0.2-78 (mean 30.76 +/- 16.06) years; 185 (68%) occurred in male patients. The etiologic agents were: Streptococci viridans group (93), enterococci (21), streptococci D group, nonenterococci (19), other streptococci (14), Staphylococcus aureus (59), Staphylococcus epidermidis (14), gram-negative bacteria (16), other gram-positive bacteria (16), fungi (4). Etiologic agents were not isolated in 52 (negative cultures). Valvular heart diseases occurred in 231 episodes, congenital heart diseases in 37, other heart diseases in 6. Sixty-nine occurred in patients with prosthetic heart valves. In 69 there was no previous heart disease. Surgical treatment was performed in 102 episodes (37 with prosthetic valve IE and 65 with native valve IE); 22 patients (21%) died, 12 with prosthetic valve and 10 with native valve IE. The in-hospital mortality (medical and surgical patients) was 26% (78 patients). Long-term follow-up of 206 patients up to 7.1 (mean 2.13 +/- 1.68) years revealed that 26 patients died. Thus, IE remains a disease with high mortality and is fatal to a third of the patients, in spite of the progress in therapeutic methods. Its morbidity and mortality continues beyond the microbiological cure.

Extracranial mycotic aneurysms in infective endocarditis.

Nine of 217 (4.15%) patients with infective endocarditis who were followed from October 1978 to February 1984 had extracranial mycotic aneurysms (MA). Age range of patients was 6-43 years (mean of 24.8 years) and 7 were male. Etiologic agents were Streptococcus viridans (3 cases), Staphylococcus aureus (2 cases), Staphylococcus epidermidis (1 case), and Pseudomonas aeruginosa (1 case). Two patients had negative blood cultures. The MA involved the arteries of the limbs (5 cases), thoracic (3 cases), and abdominal (1 case) arteries. The diagnosis was made by means of physical examination (5 cases), chest roentgenogram (2 cases), ultrasound examination (1 case), and aortography (1 case), at hospital admission (2 cases), early or before antibiotic therapy (2 cases), and from two days to six months after finishing antibiotic therapy (5 cases). All but one patient were operated upon due to MA; bleeding occurred in three cases; surgery was an emergency procedure in one case and performed from 8 to 58 days after the diagnosis of the MA in the others. Signs of infection at surgery were found in one case. In the others, further antibiotic therapy was not administered. There were no limb losses in the peripheral MA. Four patients received surgical treatment for endocarditis. There was one in-hospital death and another one 6 months later due to heart failure.

Paroxysmal atrial fibrillation and insidious neck pain.

Paroxysmal atrial fibrillation (AF) is an arrhythmia usually secondary to autonomic imbalance, and it may occur in the absence of any structural heart disease. The case of a patient with paroxysmal AF, in whom the arrhythmia may have been a presenting symptom of a later diagnosed cervical schwannoma, is reported.

Cavitary lesions close to heart valve rings. A necropsy study of 13 cases.

Necropsy reports of 13 patients with 15 cavitary lesions situated close aortic or mitral valve rings were studied in patients who ranged in age from 1 month to 57 (mean 24.9) years; 10 patients were male. Infective endocarditis occurred in 7 patients, rheumatic heart disease in 4, congenital heart diseases in 4, previous valve replacement in 4, and syphilis in 1 patient. Diameters of the cavitary lesions ranged between 1.2 and 10.5 cm; the aortic valve ring was involved in 11 patients; cavitary thrombosis occurred in 2 cases; the orifice communicating the cardiac chamber with the cavitary lesions was situated above the aortic leaflet in 5 lesions, below the aortic leaflet in 4 lesions, and above and below the aortic leaflets in 3 lesions. The mitral valve ring was involved in 3 lesions. Thus, different etiologies may be involved in the pathogenesis of these lesions; positions of the lesion may vary in relation to the valve ring, and the lesions may be a morphological expression of the fragility of the fibrous skeleton of the heart.

Calcific aortic stenosis presenting as acute myocardial infarction.

A previously asymptomatic 38-year-old male with calcific aortic valve stenosis (instantaneous peak-to-peak systolic gradient: 46 mmHg) suffered an acute myocardial infarction. Coronary arteriography revealed an obstruction in a distal branch of the left circumflex artery. Left ventricular angiography demonstrated impairment of contraction of the lateral wall. We suggest that the myocardial infarction was the result of calcific embolism from the calcified aortic valve stenosis and may occur as a first manifestation of the disease.

Perioperative myocardial infarction in a patient with tuberculous constrictive pericarditis in the absence of coronary artery disease.

A 34-year-old man developed severe heart failure due to constrictive pericarditis. Pericardiectomy was carried on and the patient died 12 hours after surgery. Necropsy revealed an extensive hemorrhagic myocardial infarction involving the lateral free wall of the left ventricle in the absence of coronary artery disease. In addition, necropsy revealed tuberculosis as the etiology of constrictive pericarditis. Thus, myocardial infarction may occur in constrictive pericarditis in the setting of pericardiectomy and absence of coronary artery disease.

Acquired ventricular septal defect and tricuspid valve disruption as a complication of infective endocarditis of the aortic valve.

Ventricular septal defect is a rare complication of infective endocarditis. This is a case report of a 48-year-old man with chronic alcoholism without known previous heart disease who developed a ventricular septal defect and a tricuspid valve disruption in the course of a fatal infective endocarditis of the aortic valve.

Compliance with pharmacological treatment in outpatients from a Brazilian cardiology referral center.

To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.

[Infective endocarditis: analysis of 300 episodes]. / Endocardite infecciosa: análise de 300 episódios.

PURPOSE: Study of clinical features and etiologic agents, treatment and mortality of patients with infective endocarditis (IE). PATIENTS AND METHODS: 300 episodes of IE occurring in 288 patients, ages ranged between 0.2 and 78 (mean 30.76) years; 185 (62%) episodes occurred in males. RESULTS: a) etiologic agents: viridans group streptococci in 93 (31%) episodes, enterococci en 21 (7%), group D-non enterococci in 19 (6%) (13 S. bovis), other streptococci in 14 (5%), Staphylococcus aureus in 59 (20%), Staphylococcus epidermidis in 14 (5%), gram-negative bacteria in 16 (5%), gram-positive bacteria other than streptococci and staphylococci and staphylococci in 8 (3%), fungi in 4 (1%). The etiologic agents were not identified in 52 (17%) episodes; b) underlying cardiac diseases: valvular heart disease in 119 (40%) episodes, congenital heart disease in 37 (12%), prosthetic heart valves in 69 (23%), other heart diseases in 6 (2%). There was no evidence of previous heart disease in 69 (23%); c) treatment: surgical treatment was undertaken in 102 (34%) episodes. The frequency of surgical treatment in relation to the etiologic agents ranged between 1% (non-group D streptococcus) and 62% (negative blood cultures). The frequency of operation in relation to underlying heart disease ranged between 17% (other heart diseases), 19% (congenital heart disease) and 54% (prosthetic heart valve); d) mortality: 78 (26%) patients died, 56 (28%) of the 198 submitted to medical treatment and 22 (21%) of the 102 submitted also to surgical treatment. The mortality in the different groups of etiologic agents ranged between 5% (non group D streptococcus) and 62% (gram-positive bacteria other than streptococci ans staphylococci); in relation to the underlying with other heart disease, 19% in valvular heart disease patients, 21% in patients with congenital heart disease, 23% in patients without known heart disease and 43% in patients with prosthetic heart valves. CONCLUSION: The mortality associated with IE remains still high in spite of modern treatment; the mortality is different in relation to the cardiac status before the IE.

[Fatal acute myocardial infarction in a young cocaine addict]. / Infarto agudo do miocárdio fatal em jovem viciado em cocaína.

A 28 year-old male cocaine abuser without coronary atherosclerosis suffered fatal myocardial infarction. Necropsy revealed several myocardial infarctions of different ages. Examination of the coronary arteries revealed fibrointimal thickening of the intimal layer of the coronary arteries.

[Publication trends in quarterly, bimonthly and monthly cycles of publication during the five decades of Brazilian Archives of Cardiology]. / Tendências das publicações nas fases trimestral, bimestral e mensal das cinco décadas dos Arquivos Brasileiros de Cardiologia.

OBJECTIVE: To study trends in selected manuscript characteristics of articles published in the Brazilian Archives of Cardiology from March 1948, to February 1998, in the quarterly, bimonthly and monthly cycles of publication. METHODS: A random sample of 25% of all issues of the journal comprised the study sample: 13 issues (11.5%) from the quarterly, 27 (23,5%) from the bimonthly, and 58 (65%) from the monthly publication cycle. We studied the type of manuscript, number of authors, geographical distribution, language of publication and references. RESULTS: A total of 1204 articles were studied, 90 (7.5%) from the quarterly, 238 (19,8%) from the bimonthly, and 876 (72.8%) from the monthly publication cycle. The most frequent published articles were original contributions (353), reviews (350) and case reports (205). No significant difference occurred in the proportion of original articles, reviews and case reports; the number of authors was higher in the monthly period;a geographical concentration of the contributions occurred (72% from three Brazilian States); manuscripts in languages other than Portuguese decreased. The mean number of Brazilian references cited was less than 4.7 and the mean number of international references cited was greater than 16.7. CONCLUSION: The analysis of the trends over five decades of publication revealed the need for further steps to be taken by the Brazilian Archives of Cardiology, to meet international publication standards for biomedical journals as well as authors' and readers' demands.

[Fatal myocardial infarction in a young patient due to coronary arteritis]. / Infarto do miocárdio fatal em jovem causado por arterite coronária.

A 34 year-old male patient suffered an acute anterior wall infarction at age 32. Myocardial ischemia was demonstrated later by stress testing and thallium myocardial scintigraphy. Coronary arteriography revealed a proximal 90% obstruction of the left anterior descending artery. The patient was submitted to percutaneous transluminal coronary angioplasty. The procedure was unsuccessful as the catheter could not progress through the obstruction. On follow-up, there was less than ideal adherence to medical treatment and the patient complained of occasional atypical non-effort related chest pain. Two years later the patient suffered a large fatal myocardial infarction. Necropsy disclosed that the cause of myocardial infarction was severe coronary arteritis of left circumflex artery with giant cell granulomas.

[Preoperative cardiological evaluation. Report of 255 cases]. / Avaliação cardiológica pré-operatória. Estudo de 255 casos.

PURPOSE: To study preoperative cardiological consultations in a cardiology referral center in a general hospital. METHODS: Two hundred and fifty five patients were studied between June and December 1989; the ages ranged between 16 and 82 (mean 55) years, 120 (47%) were male and 135 (53%) female. A questionnaire was applied by the physicians during consultation. RESULTS: Main symptoms were thoracic pain in 30 (11.8%) cases, dyspnea in 57 (22.4%), palpitations in 13 (5.1%). Symptoms of cardiac disease were absent in 141 (55.3%) patients. On physical examination arterial hypertension was detected in 75 (29.4%) cases and a cardiac murmur in 21 (8.2%). Diagnosis of coronary artery disease was made in 30 (11.8%) cases--13 (5.1%) with history of previous myocardial infarction, aortic valve stenosis in 5 (1.9%), other valvular heart diseases in 14 (5.5%), cardiac arrhythmias in 11 (4.3%). Heart disease was absent in 90 (35.4%) patients. Sixty-five (25.5%) patients were on drug therapy for heart diseases. Consultations were obtained for patients that had been already admitted to the hospital in 171 (67%) cases. Cardiological follow up was recommended to 150 (58.8%) patients. Seven patients died; the cause of the death was related to the primary disease. Contraindication for surgery imposed by cardiological evaluation did not occur. CONCLUSION: In this study, patients with heart disease tolerated the surgical procedures. Preoperative cardiological evaluation added useful data for postoperative care and also for long term follow-up of the patients.

[Fatal active rheumatic disease. Study of 13 necropsy cases]. / Doença reumática ativa fatal. Estudo de 13 casos de necrópsia.

PURPOSE: To study the clinical features of a group of patients with fatal acute rheumatic fever (ARF). PATIENTS AND METHODS: Thirteen patients with ARF, the ages ranged between 4.5 and 25 (mean 14) years. Eight patients were male. Patients were studied in two groups: group A of those 14 year-old or younger (8 cases), and group B of those older than 15 years (5 cases). RESULTS: Clinical presentation was fever and severe heart failure in all patients. In group A, it was the first attack of ARF in 5 patients. The time elapsed between beginning of symptoms and hospital admission ranged between 10 and 90 (mean 40) days. Mitral insufficiency occurred in all patients. The blood leukocyte count was greater than 10000 per mm3 in six cases. Atrioventricular block occurred in one case. Valvular vegetations were detected on echocardiogram in 4 cases. Two patients received antibiotic therapy. Surgical treatment of the valvular heart disease was carried on in one patient. In group B, it was the first ARF attack in 2 cases, the time elapsed between beginning of the symptoms and hospital admission ranged between 4 and 60 (mean 21) days. Leukocyte count greater than 10000 por mm3 occurred in 4 cases. Atrioventricular block was diagnosed in one case. Valvular vegetations on echocardiogram were detected in 2 patients. In two cases, the treatment was antibiotic therapy. Three patients were operated on. CONCLUSION: ARF may still be fatal, even in the first attack or in patients in the third decade of life. Other diagnoses are frequently considered, due to the intense clinical and laboratorial manifestations.

[Endocarditis in heart valve bioprosthesis caused by Cardiobacterium hominis]. / Endocardite em bioprótese valvar cardíaca por Cardiobacterium hominis.

A 36-year-old female patient developed Cardiobacterium hominis endocarditis on a mitral valve prosthesis. The etiologic agent was identified in the seventh day of incubation of the blood cultures specimens. Crystalline penicillin (18.10(6) UI daily) and amikacin (800 mg daily) were administered for 42 days. Surgical treatment for heart failure unresponsive to medical treatment was carried on in the eighteenth day of antibiotic therapy. A bovine pericardium prosthesis was inserted. The patient was discharged and is asymptomatic after seven months.