The involvement of multiple thrombogenic and atherogenic markers in premature coronary artery disease

OBJECTIVE: To examine the association of atherogenic and thrombogenic markers and lymphotoxin-alfa gene mutations with the risk of premature coronary disease. METHODS: This cross-sectional, case-control, age-adjusted study was conducted in 336 patients with premature coronary disease (<50 years old) and 189 healthy controls. The control subjects had normal clinical, resting, and exercise stress electrocardiographic assessments. The coronary disease group patients had either angiographically documented disease (>50% luminal reduction) or a previous myocardial infarction. The laboratory data evaluated included thrombogenic factors (fibrinogen, protein C, protein S, and antithrombin III), atherogenic factors (glucose and lipid profiles, lipoprotein(a), and apolipoproteins AI and B), and lymphotoxin-alfa mutations. Genetic variability of lymphotoxin-alfa was determined by polymerase chain reaction analysis. RESULTS: Coronary disease patients exhibited lower concentrations of HDL-cholesterol and higher levels of glucose, lipoprotein(a), and protein S. The frequencies of AA, AG, and GG lymphotoxin-alfa mutation genotypes were 55.0%, 37.6%, and 7.4% for controls and 42.7%, 46.0%, and 11.3% for coronary disease patients (p = 0.02), respectively. Smoking, dyslipidemia, family history, and lipoprotein(a) and lymphotoxin-alfa mutations in men were independent variables associated with coronary disease. The area under the curve (C-statistic) increased from 0.779 to 0.802 (p<0.05) with the inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors. CONCLUSIONS: The inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors showed an additive but small increase in the risk prediction of premature coronary disease. .

Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short-and long-term results in ischemic cardiomyopathy

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22±5 percent underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40 percent and 60 percent of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95 percent of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7 percent and 15 percent, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4 percent and 13 percent; CHF class III-IV, 8 percent and 16 percent; LVEF,20 percent, 12 percent and 26 percent; LVEF 21-30 percent, 2 percent and 6 percent; gated LVEF exercise/rest .5 percent, ,1 percent and 4 percent; and gated LVEF exercise/rest #5 percent, 17 percent and 38 percent. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84 percent of the patients were in class I/II, LVEF was 45±7 percent, and gated LVEF ex/rest ratio was 13 percent higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in shortand long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients.

Transição epidemiológica da mortalidade por doenças circulatórias no Brasil / Epidemiologic transition in mortality rate from circulatory diseases in Brazil / Transición epidemiológica de la mortalidad por enfermedades circulatorias en Brasil

FUNDAMENTO: As doenças circulatórias (DC) são as principais causas de morte no Brasil, com predomínio das doenças cerebrovasculares (DCbV). Nos países desenvolvidos, predominam as doenças isquêmicas do coração (DIC). OBJETIVO: Analisar a relação entre DCbV/DIC em homens e mulheres a partir de 30 anos. MÉTODOS: As estimativas da população e os dados de mortalidade para DC, DIC e DCbV foram obtidos do Ministério da Saúde para o período entre 1980 e 2005. O risco de morte por DIC e DCbV por 100.000 habitantes e a relação entre DCbV/DIC foram analisados nas faixas etárias decenais a partir de 30 anos. O risco de morte foi ajustado pelo método direto, usando como população padrão a população mundial de 1960. RESULTADOS: Observou-se aumento exponencial do risco de morte por DIC e DCbV, com o aumento da faixa etária. DCbV foi a principal causa de morte no Brasil até 1996, quando passou a predominar a DIC. Foi observada redução de 33,25 por cento no risco de morte por DC na população brasileira. Na região metropolitana de São Paulo, houve uma diminuição de 45,44 por cento, entre 1980 e 2005. A relação DCbV/DIC foi maior nas mulheres mais jovens: de 2,53 em 1980 e 2,04 em 2005 para a população brasileira, e de 2,76 em 1980 e 1,96 em 2005 na região metropolitana de São Paulo, com decréscimo nas faixas etárias subsequentes. Nos homens, a relação DCbV/DIC foi próximo de <1 para todas as faixas etárias. CONCLUSÃO: Observou-se, no Brasil, uma transição do risco de morte por DC, com predomínio atual das DIC.

BACKGROUND: Circulatory diseases (CD) are the major cause of death in Brazil, being cerebrovascular diseases (CVD) predominant. In developed countries ischemic heart diseases (IHD) predominate. OBJECTIVE: The objective of the present study was to investigate the ratio between cerebrovascular diseases/ischemic heart diseases (CVD/IHD) in males and females who were 30 years of age and older. METHODS: Population estimates and mortality data for CD, IHD and CVD were provided by the Ministry of Health for the period between 1980 and 2005. The risk of death from IHD and CVD per 100,000 Brazilians and CVD/IHD ratio were analyzed in 10-year age ranges as of 30 years of age. The risk of death was adjusted by direct method by using 1960 world population as the standard population. RESULTS: It was observed that the risk of death from IHD and CVD increased exponentially as age advanced. CVD was the major cause of death in Brazil until 1996, when IHD took the lead. In the period between 1980 and 2005 a 33.25 percent reduction in death risk from CD was observed in the Brazilian population. In that same period, the metropolitan area of the capital city of São Paulo reported a 45.44 percent reduction. The CVD/IHD ratio was shown to be higher among younger women - from 2.53 in 1980 down to 2.04 in 2005 in the Brazilian population, and from 2.76 in 1980 down to 1.96 in the metropolitan area of the capital city of São Paulo, with decreasing figures for subsequent age ranges. Among males, the CVD/IHD ratio was close to < 1 in all age ranges. CONCLUSION: A transition in death risk from CD could be observed in Brazil, with current predominance of IHD.

FUNDAMENTO: Las enfermedades circulatorias (EC) son las principales causas de muerte en Brasil, con el predominio de las enfermedades cerebrovasculares (ECbV). En los países desarrollados predominan las enfermedades isquémicas del corazón (EIC). OBJETIVO: Analizar la relación entre ECbV/EIC en varones y mujeres a partir de 30 años. MÉTODOS: Se obtuvieron en el Ministério de la Salud las estimaciones de la población y los datos de mortalidad para EC, EIC y ECbV para el periodo entre 1980 y 2005. Se analizaron el riesgo de muerte por EIC y ECbV por 100.000 habitantes y la relación entre ECbV/EIC en los grupos de edad decenales a partir de 30 años. Se ajustó el riesgo de muerte por el método directo, usándose como población estándar la población mundial de 1960. RESULTADOS: Se observó un aumento exponencial del riesgo de muerte por EIC y ECbV, con el aumento del grupo de edad. La ECbV fue la principal causa de muerte en Brasil hasta 1996, cuando pasó a predominar la EIC. Se observó una reducción del 33,25 por ciento en el riesgo de muerte por EC en la población brasileña. En la región metropolitana de São Paulo, hubo una disminución del 45,44 por ciento entre 1980 y 2005. La relación ECbV/EIC fue mayor en las mujeres más jóvenes: del 2,53 por ciento en 1980 y del 2,04 por ciento en 2005 para la población brasileña, y del 2,76 por ciento en 1980 y del 1,96 por ciento en 2005 en la región metropolitana de São Paulo, con reducción en los grupos de edad subsiguientes. En los varones, la relación ECbV/EIC fue cerca de <1 para todas los grupos de edad. CONCLUSIÓN: Se observó en Brasil una transición del riesgo de muerte por EC con predominio actual de las EIC.

Intramyocardial injection of autologous bone marrow cells as an adjunctive therapy to incomplete myocardial revascularization: safety issues

OBJECTIVES: To determine the safety of intramyocardial injection of autologous bone marrow cells in patients undergoing surgical myocardial revascularization (CABG) for severe coronary artery disease. INTRODUCTION: There is little data available regarding the safety profile of autologous bone marrow cells injected during surgical myocardial revascularization. Potential risks include arrythmias, fibrosis in the injected sites and growth of non-cardiac tissues. METHODS: Ten patients (eight men) were enrolled; they were 59±5 years old with limiting angina and were non-optimal candidates for complete CABG. Bone marrow cells (1.3±0.3x10(8)) were obtained prior to surgery, and the lymphomonocytic fraction (CD34+=1.8±0.3 percent) was separated by density gradient centrifugation. During surgery, bone marrow cells were injected in non-grafted areas of ischemic myocardium. During the first year after surgery, the patients underwent laboratory tests, cardiac imaging, and 24-hour ECG monitoring. RESULTS: Injected segments: inferior (n=7), anterior (n=2), septal (n=1), apical (n=1), and lateral (n=1) walls. Except for a transient elevation of C-reactive protein at one month post-surgery (P=0.01), laboratory tests results were within normal ranges; neither complex arrhythmias nor structural abnormalities were detected during follow-up. There was a reduction in functional class of angina from 3.6±0.8 (baseline) to 1.2±0.4 (one year) (P<0.0001). Also, patients had a significant decrease in the ischemic score assessed by magnetic resonance, not only globally from 0.65±0.14 (baseline) to 0.17±0.05 (one year) (P=0.002), but also in the injected areas from 1.11±0.20 (baseline) to 0.34±0.13 (one year) (P=0.0009). CONCLUSIONS: Intramyocardial injection of bone marrow cells combined with CABG appears to be safe. Theoretical concerns with arrhythmias and/or structural abnormalities after cell therapy...

Distribuiçäo dos fatores de risco em pais e irmäos de pacientes com doença arterial coronariana / Distribution of risk factors in parents and siblings of patients with early coronary artery disease

OBJECTIVE: Early coronary artery disease (CAD) is associated with risk factors (RF). Offspring of parents with a RF have a greater prevalence of them. However, the distribution of RF in parents and siblings of patients with early CAD is unknown. METHODS: The study comprised the parents and siblings of 42 patients with early CAD (< 45 years), 29 males. Their mean age was 39.5±3.7 years. The following major RF were analyzed: smoking (> 5 cigarretes/day), hypercholesterolemia (total cholesterol > 200 mg/dL), hypertension (diastolic blood pressure > 90 mmHg), and diabetes (glycemia > 126 mg/dL). RESULTS: Of a total of 102 RF, 4, 3, 2, and 1 were observed in, respectively, 5, 15, 15, and 7 patients with early CAD, the most prevalent being smoking (86 percent) and hypercholesterolemia (83 percent). Diabetes was observed in 15 (36 percent) and hypertension in 16 (38 percent) patients. Smoking was more prevalent in the fathers (76 percent) and hypercholesterolemia in the mothers (30 percent). In 183 siblings, 131 RF were observed (1 patient with the disease had a mean of 4.7 siblings). The prevalences of smoking, hypertension, hypercholesterolemia, and diabetes in the siblings were, respectively, 32 percent, 18 percent, 14 percent, and 9 percent. The incidence of RF was as follows: 72 (39 percent) siblings had 1 RF, 25 (14 percent) siblings had 2 RF, and 3 (2 percent) siblings had 3 RF. In parents and their offspring, smoking was moderately correlated (r=0.43; P=0.02) with CAD. CONCLUSION: Smoking habit of parents is passed on to offspring, and, in association with hypercholesterolemia, it was the major cause of early CAD in offspring. High prevalence of smoking in offspring shows the potential responsibility of parents in the incidence of the disease in offspring

Disfunçäo endotelial e as síndromes coronárias agudas / Endothelial dysfunction and acute coronary syndromes

Revisamos os mecanismos que contribuem para a instabilizaçäo da placa aterosclerótica com conqüente isquemia aguda do miocárdio, manifestando-se clinicamente como angina instável e infarto do miocárdio näo-Q. Sao descritas as interaçöes entre o endotélio, a placa os agentes vasomotores, as plaquetas e as células sanguíneas. Os mecanismos dessa instabilizaçäo säo confrontados com os achado clínicos, angiográficos, e anatomoplatológicos de vários estudos, desde a década de 1970 até a atual, podendo-se propor um raciocínio lógico, que elucida resultados prévios sem explicaçäo convincente bem como a integraçäo dos resultados de estudos experimentais recentes confirmados por pesquisas no ser humano.

Fibrilação atrial aguda na unidade de emergência: qual a droga ideal para rápida reversäo ao ritmo sinusal? / Acute Atrial Fibrillation. Which is the Best Drug for Sinus Rhythm Conversion in the Emergency Room ?

Objetivo - Comparar o tempo e o índice de sucesso para reversäo da fibrilaçäo atrial (FA) aguda, com o uso de amiodarona, procainamida ou quinidina. Métodos - Aleatoriamente, 60 pacientes com FA aguda foram divididos em três grupos, recebendo o grupo quinidina (GQ), constituído de 21 pacientes, digital EV + quinidina até 600mg VO; o grupo procainamida (GP) com 23 pacientes, digital EV + 10mg/kg de procainamida EV e o grupo amiodarona (GA), com 16 pacientes 5mg/kg de amiodarona EV. O período de observaçäo foi de no máximo 4h, através de Holter. Na análise estatíca foi utilizado o teste de x2 com o método de Kruskall-Wallis, considerando-se significativo p<0,05. Resultados - Os três grupos foram similares quanto a idade, sexo e tempo de instalaçäo da FA. A reversäo ocorreu em 71,4 por cento dos casos no GQ, em 47,8 por cento no GP e em 50 por cento no GA, (p>0,05). O tempo para reversäo em minutos foi de 112 + ou - 43 no G!, de 44,1 + ou - 28 no GP, de 20 + ou - 13 no GA, sendo menor e estatisticamente significante no GP e, principalmente, no GA (p= 0,001) em relaçäo ao GQ. Os efeitos colaterais foram mais freqüentes no GP, embora sem significância estatística. Conclusäo - A amiodarona, especialmente na ausência de cardiopatia de base, é uma boa opçäo para maior rapidez na reversäo da FA, enquanto a quinidina propicia maior taxa de reversäo, com menos efeitos colaterais

Relação entre o ECG convencional e a artéria coronária responsável no infarto agudo do miocárdio / The relationship between conventional ECG and the culprit coronary artery in acute myocardial infarct

PURPOSE--To evaluate electrocardiogram (ECG) in detecting acute myocardial infarction (AMI) during the first 12 hours of symptoms and its relationship to the culprit coronary artery. METHODS--We studied 68 patients aged 55.6 (30 to 76) years, 61 males, with AMI confirmed by elevated CKMB isoenzyme and cinecoronariography (CINE). In all of them we obtained two ECG: first (i), with < 12 hours of symptoms and a second, > or = 5 days during evolution. ECG were analyzed in order to disclose up and downward ST-T segments > or = 1 mm, new Q waves > or = 0.04 s and R/S > or = 1 plus downward ST-T segment in leads V1 and V2. Then we have done correlation between these and the culprit coronary lesions at CINE. RESULTS--The culprit coronary lesions were: right coronary artery (RCA) in 16, left circumflex (LC) in 26 and left anterior descending (LAD) in 31 cases. According to the ECG, the RCA determined inferior AMI in all patients and the LC only in 62 por cento of cases. Posterior AMI due to LC was seen in 81 por cento of cases at ECG and, associated with lateral AMI, in 52 por cento . Lone lateral AMI was seen in 5 por cento and true posterior in 14 por cento of cases, all of them due to LC. CONCLUSION--False negative ECG (i) in AMI is in fact due to LC occlusion which, frequently, causes posterior wall more then inferior wall myocardial infarction at ECG

Efeito do tratamento com clortalidona na redução da massa ventricular esquerda de pacientes com hipertensão arterial sistêmica / Effect of Treatment with Chlorthalidone on Reduction of Left Ventricular Mass of Patients with Systemic Arterial Hypertension

PURPOSE--To evaluate the effects of the use of chlorthalidone on left ventricular mass of patients with mild and moderate systemic arterial hypertension (SAH). METHODS--Twenty-nine patients with mild and moderate SAH were studied with mean age of 48.4 years and 16 men. Clinical evaluation, systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR), in supine and standing positions, were obtained before and every 3 weeks, after 2 with placebo, during 12 weeks of treatment with 50mg of chlorthalidone each 48 hours. Laboratory data (hemogram, sodium, potassium, urea creatinine, glucose, hepatic aminotransferases and urinalysis) were done before and at end of study. Echocardiographic study was performed by M-mode before and after 6 and 12 weeks of treatment, and obtained the following data: diastolic diameter (DdLV), diastolic septum (DSTLV) and posterior wall thickness (PWTLV) of left ventricle. The left ventricular mass (LVM) was calculated by the formula: LVM = (DSTLV+PWTLV+DdLVE)3 - (DdLV)3 x 1.05/body surface, in g/m2. RESULTS--A significant reduction of SBP (p < 0.0001), DBP (p < 0.001) in supine and standing positions. HR did not show statistical difference. At echocardiographic study, M-mode, was observed a significant reduction of LVM after 12 weeks of treatment (181 +/- 67 to 156 +/- 34 g/m2, p < 0.01). CONCLUSION--Chlorthalidone was effective to control blood pressure and to reduce LVM of patients with SAH.

Angina instavel: qual a perspectiva para o tratamento farmacologico? / Unstable angina: what is the goal for pharmacological treatment?

Uma analise de varios estudos sobre o prognostico e tratamento farmacologico, exceto anticoagulacao e trombolise, da angina instavel, foi o objetivo desse trabalho. Baseados nos criterios que caracterizam maior risco de infarto agudo do miocardio e mortalidade nesses pacientes, discutiu-se o papel dos nitratos, betabloqueadores, bloqueadores dos canais de calcio e acido acetil salicilico (AAS), os quais podem controlar os sintomas e reduzir esses riscos em quase 90// dos casos. Com base nesses estudos, e em nossa propria experiencia, acreditamos que a associacao de nitratos, betabloqueadores e AAS e a melhor opcao para a estabilizacao dos pacientes com quadro isquemico agudo

Efeito da furosemida endovenosa sobre os parâmetros hemodinämicos e na pressäo coloidosmótica em pacientes com congestäo pulmonar / Intravenous Furosemide Effects Over Hemodynamics Variables and Colloid Osmotic Pressure in Patients with Pulmonary Edema

Objetivo - Avaliar o efeito da furosemida endovenosa sobre os parâmetros hemodinâmicos e na pressão coloidosmótica pulmonar em pacientes com congestão pulmonar. Métodos - Foram avaliados oito pacientes com congestão pulmonar, com idade média de 58,3 ±7,5, sendo 6 do sexo masculino. A monitorização hemodinâmica foi realizada com cateter de Swan-Ganz em artéria pulmonar obtendo-se as pressões médias de átrio direito (PAD), capilar pulmonar (PMCP), em mmHg, e freqüência cardíaca (FC) em bpm. O débito cardíaco (DC) obtido pela técnica da termodiluição. Como parâmetros derivados calculou-se o índice cardíaco (IC) em L/min/m2 e o índice sistólico (IS) em ml. A pressão arterial média (PAM), em mmHg, foi obtida através de cateter em artéria radial. Os pacientes foram tratados com furosemida na dose de 20 mg, via endovenosa, e submetidos a medidas hemodinâmicas antes e após 5, 15, 30, 60 e 120 min. A pressão coloidosmótica pulmonar (PCOP) foi determinada pelo oncômetro de Weil (IL 196). Resultados - Observou-se redução estatisticamente significante das PAD (p = 0,002 e da PMCP (p < 0,0001), FC (p = 0,02), PCOP (p < 0,0001) e de gradiente entre a PMCP-PCOP (p < 0,0001). A queda da PAD e PMCP foram mais significativas nos primeiros 5 minutos e, ao contrário, a PCOP teve uma redução lenta e gradual nos 120 min. O gradiente entre a PMCP-PCOP, inicialmente positivo, permaneceu negativo durante todo o estudo. A PAM, IC, IS e RVS não apresentaram diferenças estatisticamente significantes. Conclusão - A administração de furosemida produz redução nas PAD, PMCP, FC, PCOP e do gradiente entre a PMCP-PCOP, provavelmente devido a redistribuição do excesso de líquidos do interstício para o intravascular e, devido ao predomínio da PCOP, ocorre a reinversão da direção do fluxo de líquidos, que durante o edema pulmonar era do intravascular para o interstício

Purpose - To evaluate the effects of intravenous furosemide over hemodynamics variables and colloid osmotic pressure in patients with pulmonary edema. Methods - Eight patients with pulmonary edema, mean age of 58.3 ± 7.5 years, 6 men, were evaluated. Hemodynamic monitorization was performed by Swan-Ganz catheter in pulmonary artery to obtain RAP and PAWP, in mmHg, and HR, in bpm. Cardiac ouput (CO) was obtained by termodilution method. Cardiac index (CI) in L/min/m2, and systolic index, in ml, arised from variables above. Mean arterial pressure (MAP), in mmHg, patients were treated with 20 mg of intravenous furosemide, and hemodynamic variables were measured before and after 5, 15, 30, 60 and 120 minutes. COP was measured in Weil oncometer (IL 196) at same intervals. Results - A significant reduction of RAP (p=0,002) and PAWP (p<0,0001), HR (p=0,02), COP (p<0,0001) and gradient between PAWPCOP (p<0,0001) were observed. RAP and PAWP reduction was greater in the first five minutes and, otherwise, COP reduction was gradual in 120 min. PAWP-COP gradient inicially positive, stayed negative during all study. MAP, CI, SI and SVR did not show statistical differences. Conclusion - Furosemide administration reduced RAP, PAWP, HR, COP and PAWP-COP gradient, probably by a redistribuition offluid excess in the intersticial to intravascular space, through changes in driving fluid forces, with predominance in colloid osmotic pressure, which reverse fluid from intravascular to intersticial observed in pulmonary edema.

Dissecções agudas da aorta: evoluçäo hospitalar de 186 casos / Acute aortic dissections in hos pital. Outcome of 186 patients

Objetivo - Determinar a evoluçäo hospitalar de pacientes com dissecçäo aguda da aorta. Métodos - Revisamos 186 casos consecutivos, com história de até 14 dias de dissecçäo num período de 6 anos. Adotou-se a classificaçäo de Daily (tipos A e B). Resultados - Tipo A - 127 casos: a) 75 foram operados (37 faleceram); b) 2 receberam tratamento clínico (ambos faleceram); c) 39 faleceram sem tempo hábil para tratamento; d) 11 faleceram sem diagnóstico em vida. A mortalidade total foi de 70%. Tipo B - 59 casos: a) 11 casos complicados foram operados (6 faleceram); b) 40 receberam tratamento clínico (8 faleceram); c) 7 faleceram sem tempo hábil para tratamento; d) um faleceu sem diagnóstico em vida. A mortalidade total foi de 37,2%. Ao todo (tipos A e B) 41,4% dos pacientes sobreviveram, 28,4% faleceram apesar de tratados adequadamente, 24,7% faleceram sem tempo hábil para tratamento e 6,4% faleceram sem diagnóstico em vida. Conclusäo - Dissecçäo aguda da aorta é doença dramática, particularmente a do tipo A, que levou a óbito 41% dos pacientes antes de serem operados. Nesse tipo de dissecçäo, protelar o diagnóstico e a realizaçäo do tratamento cirúrgico pode selecionar pacientes e, de maneira ilusória, revelar razoável sobrevida pós-operatória, enquanto significativo número de pacientes falece no hospital antes de serem operados