Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

Cardiac tamponade in systemic lupus erythematosus. Report of four cases.

OBJECTIVE: To report and assess the incidence of cardiac tamponade in systemic lupus erythematosus as a cardiac manifestation of the disease. METHODS: We reviewed the medical records of 325 patients diagnosed with systemic lupus erythematosus according to the American Rheumatism Association and their complementary laboratory tests compatible with cardiac tamponade. RESULTS: In the 325 medical records reviewed, we found 108 patients with pericardial effusions corresponding to 33.2% of the total and 54% of the patients studied in the active phase of the disease. Clinical assessment and transthoracic echocardiogram allowed the clinical diagnosis of cardiac tamponade in only 4 (1.23%) patients, 3 of whom were females, white, with ages ranging from 25 to 44 years. The pericardial fluid was hemorrhagic or serosanguineous with high levels of FAN and positivity for LE cells. In the treatment, we successfully used pericardiocentesis associated with high doses of corticosteroids. In clinical and laboratory follow-up performed for a period of 3 years, neither recrudescence of the pericardial effusion nor evolution to constriction occurred. CONCLUSION: Even though rare (1.23%), cardiac tamponade in patients with systemic lupus erythematosus has a benign evolution when properly treated, according to our experience.

Natural course of subsequent pregnancy after peripartum cardiomyopathy.

OBJECTIVE: To assess the effect of subsequent pregnancy after peripartum cardiomyopathy (PPCM) on maternal and fetal outcome. METHODS: Prospective study of 34 patients with the diagnosis of PPCM (mean age = 26 years). At the time of first diagnosis 5 were in NYHA functional class (FC) II for heart failure, one in FC III and 28 in FC IV. After clinical treatment, patients were advised to avoid new pregnancies and a follow-up was obtained. RESULTS: There were 12 (35.3%) subsequent pregnancies in patients (pt) aged 19 to 44 years (mean 32), divided into two groups: GI: 6 pts who had normalized their heart size and GII: 6 pts with persistent cardiomegaly. GI had initially mild clinical manifestations (3 were in FC II, 1 in FC II and 2 in FC IV) and complete recovery of cardiac function (FC I). A new pregnancy was well-tolerated in 5 (83.3%); 1 pt presented with preeclampsia, and progressed to FC II. Presently, 5 pt are in FC I and 1 in FC II. GII pts had more severe heart failure at the onset of PPCM (1 pt in FC II and 5 in FC IV); during follow-up, 4 pt were in FC I and 2 in FC II. A new pregnancy was well tolerated in all of them, but the eldest, who had had 2 pregnancies and had a progressive worsening of clinical status, dying 8 years after the last pregnancy and 13 years after the diagnosis of PPCM. The remaining 5 pt are still alive, 3 in FC I and 2 in FC II, with worsening of FC in 1. Subsequent pregnancies occurred 3-7 years after clinical treatment of PPCM and no fetal distress was observed. CONCLUSION: Subsequent pregnancies are well-tolerated after PPCM, but not devoid of risk. No fetal distress was observed. A minimum interval of 3 years after the recovery of function seems to be safe for subsequent pregnancies.

[Apical hypertrophic cardiomyopathy associated with coronary artery disease]. / Cardiomiopatia hipertrófica apical associada a doença arterial coronária.

A fifty-nine year old man, known to have hypertrophic cardiomyopathy, presented worsening of angina. Multivessel coronary artery disease was diagnosed, and he underwent myocardial revascularization (mammary and two safenous grafts were implanted) with good evolution and reduction of left atrium dimension.

[Meningococcemia complicated by myocarditis]. / Meningococcemia complicada por miocardite.

We report a case of a 26-year old man with meningococcemia complicated with myocarditis (ventricular dysfunction and myocardial ischemia), that required treatment for heart failure. Regression of myocardial dysfunction was observed six months after the infection.

Meningococcemia complicada por miocardite / Meningococcemia complicated by myocarditis

Homem de 26 anos com meningococcemia (meningite), complicada por miocardite (disfunçäo ventricular e isquemia miocárdica), requereu tratamento para insuficiência miocárdica, seis meses após o quadro infeccioso

[Significance of alcohol abstinence in alcoholic cardiomyopathy with moderate left ventricular dysfunction]. / O significado da abstinência do alcool na cardiomiopatia alcoólica com disfunção ventricular moderada.

PURPOSE: To evaluate the role of a 12 month alcohol abstinence period in patients with moderate left ventricular dysfunction treated with anticongestive therapy. METHODS: Prospective observational study with 20 patients with alcoholic cardiomyopathy (ACM), 9 (45%) in functional class (FC) II and 11 (55%) in FC III, 16 (80%) men, mostly black (55%), from 35 to 56 (x = 45) years old, heavy alcohol users (> 80 g ethanol for 51 to 112 (x = 88) months. At the beginning, all agreed to participate with psychotherapy and clinical evaluation. After 12 months, they were divided in G-I, formed by those who remained abstemious and G-II of non-abstemious. RESULTS: After 12 months, among the 11 (55%) who remained in psychotherapy, 8 were in G-I, among those who did not 9 (45%), only 2 (22.22%) remained abstemious (G-I). At the end of the evaluation period, both groups had the same number of patients. Comparing them, we observed: a) lower mean systolic and diastolic left ventricular diameters in G-I; b) more hospitalizations in G-II (3); c) more patients with stable or better clinical evaluation in G-I. CONCLUSION: Despite the initial will, only 50% reached abstinence. When it was reached, patients had a better evolution in left ventricular systolic diameter and abstinence should always be tried even in the presence of moderate left ventricular dysfunction.

[High resolution electrocardiogram in frequency domain. Use of statistical techniques of spectral correlation for identification of patients with sustained monomorphic ventricular tachycardia]. / O eletrocardiograma de alta resolução no domínio da freqüência. Utilização de técnicas estatísticas de correlação espectral para identificação de pacientes com taquicardia ventricular monomórfica sustentada.

PURPOSE: To evaluate the diagnostic accuracy of monomorphic ventricular tachycardia (MVT), in patients with structural heart diseases and episodes of sustained MVT, using the signal-averaged ECG (SAECG) in the time (TD) and the frequency domain (FD) with statistical techniques of spectral correlation. METHODS: Twenty seven patients with at least one episode of sustained MVT, 30 patients with structural heart diseases and no evidence of ventricular arrhythmias and 80 subjects with no evidence of heart disease have been studied. SAECG was performed in all patients with the following parameters: duration of the filtered QRS, RMS 40 and LAS40 in TD and the mean and the standard deviation of both signal energy intersegmentar spectral correlation and energy frequency edge track in FD. RESULTS: The sensitivity(S) and positive predict value (PPV) of the SAECG in TD, in FD and combined analysis of both domains were: S = 59.3%, 63.0%, 81.5% and PPV = 80.0%, 81.0%, 84.6%, respectively. CONCLUSION: The combined analysis of SAECG in TD and in FD improves the diagnostic accuracy in patients with S sustained MVT.

Endocardite infecciosa em adolescentes: análise dos fatores de risco de mortalidade intra-hospitalar / Infective endocarditis in adolescents: analysis of risk factors for in-hospital mortality

OBJETIVO - Estudar os aspectos epidemiológicos, clínicos, terapêuticos e evolutivos da endocardite infecciosa (EI) em grupo de paciente com idade entre 12 e 20 (média de 15,5) anos. MÉTODOS - Foram estudados, retrospectivamente, 33 pacientes consecutivos (14 do sexo masculino e 19 do feminino), admitidos com diagnóstico de EI. RESULTADOS - A mortalidade da EI foi de 42 'por cento'. A cardiopatia reumática predominou como condição predisponente (63 'por cento' dos casos), seguida das cardiopatias congênitas (24 'por cento') e próteses cardíacas (12 'por cento'). A maioria dos pacientes (78 'por cento') encontrava-se na admissão em CF III e IV e apresentava mortalidade significativamente maior do que os que se encontravam na CF I e II (p=0,001). Complicaçöes embólicas foram detectadas em 51 'por cento' e determinaram maior mortalidade (p=0,05). O agente etiológico mais isolado foi o Staphylococcus aureus (em 42 'por cento' das hemoculturas positivas), seguido do Staphylococcus viridans (21 'por cento'). A análise multivariada mostrou que a contagem global de leucócitos acima de 10.000/mmü, e a CF referidos na admissão (p=0,001 e p=0,04), e a ocorrência de embolias (p=0,03) eram preditores independentes de mortalidade intra-hospitalar. CONCLUSÄO - A cardiopatia reumática permanece, semelhante à população adulta, como principal fator predisponente da EI nos adolescentes, tendo como principal agente etiológico o S.aureus, semelhante à população pediátrica. A mortalidade é elevada e representam preditores de mortalidade intra-hospitalar a CF na admissão, a ocorrência da fenômenos embólicos e a leucocitose.

O acometimento isquêmico obstrutivo na cardiomiopatia hipertrófica do tipo septal assimétrico com envolvimento da artéria descendente anterior / Obstrutive ischemic involvement of the left anterior descending coronary artery in asymmetrical septal form of hypertrophic cardiomyopathy

OBJETIVO - Avaliar o papel da doença coronária (DAC) com comprometimento da artéria descendente anterior (ADA) na cardiomiopatia hipertrófica (CMH) e sua repercussão na evolução, visto ser controverso o significado da necrose e fibrose do septo interventricular (SIV) nesta cardiomiopatia. MÉTODOS - Entre 158 pacientes com CMH, selecionados 6 (3,79 'por cento') com CMH e DAC com lesão obrigatória de ADA, sendo 4 homens, entre 52 e 70 (x=65,16) anos, 4 com a forma obstrutiva da CMH. O tempo de diagnóstico da CMH foi de 78 a 182 (x=141) meses e da DAC de 1 dia a 106 (x=42) meses. Os pacientes foram acompanhados com avaliaçöes clínicas e exames complementares periódicos. RESULTADOS - A forma de apresentação da DAC foi em 5 com angina instável e um com infarto do miocárdio. A ADA estava comprometida entre 60 a 100 'por cento', sendo em um lesão única e nos 5 restaurantes com lesão em 2 ou mais vasos. Na evolução, 3 foram submetidos a revascularização miocárdica (RM), um associada a miomectomia septal, um a angioplastia e 2 somente a tratamento clínico. No período de observação de 76 a 124 meses após o diagnóstico da DAC, ocorreu um óbito. No fim do estudo observamos redução nos valores médios do SIV de 1,53 para 1,40cm, gradiente de pressão entre o corpo e a via de saída do ventrículo esquerdo (VE) de 56 para 15,75mmHg, com discreto aumento no diâmetro diastólico do VE de 4,55 para 4,85cm e do diâmetro sistólico de 2,83 para 3,13cm, sem alterar a dimensão do átrio esquerdo (4,13cm). CONCLUSÄO - A DAC da ADA é bem tolerada na CMH septal assimétrica, participando do processo fibrótico septal e melhorando o desempenho cardíaco, não representando problema adverso na evolução da CMH

[Is the apical hypertrophic cardiomyopathy seen in one population in Rio de Janeiro city similar to that found in the East?]. / E a cardiomiopatia hipertrófica apical vista em uma amostra na cidade do Rio de Janeiro similar à encontrada no oriente?

PURPOSE: To investigate the differences between clinical aspects and evolution of apical hypertrophic cardiomyopathy (AHCM) seen in Rio de Janeiro and the Oriental form, which was the first described. METHODS: In 156 patients with AHCM diagnosed in our institution, there were 13 (8.34%) with the apical form of the disease, whose clinical settings, diagnostic procedures and evolution were studied. RESULTS: There were 8 males and 5 females, between 19 and 75 years old, all white. Electrocardiogram (EKG) showed giant T waves in precordial leads in 10 (76.92%), echocardiogram (ECHO) demonstrated apical hypertrophy in all, 10 (76.92%) had only in the left ventricle, 2 in right ventricle and one involving both. Cineangiography corroborated ECHO findings. Follow-up ranged from 6 to 294 months (x = 95.4). Two deaths occurred in patients with RV involvement, due to large atria, atrial fibrillation, tricuspid or mitral insufficiency and thromboembolism. Among the survivors, the patient with RV disease has diastolic restriction and the ones with LV involvement, 9 are asymptomatic using either propranolol (8) or amiodarone (1), and one uses no medication. CONCLUSION: A HCM seen in Rio de Janeiro is similar to that found in the Orient (Japan) regarding presentation, diagnosis and evolution; but in 3 patients we have found RV disease, not described in Japan, characterizing a distinct group with a worse evolution.

É a cardiomiopatia hipertrófica apical vista em uma amsotra na cidade do Rio de Janeiro similar à encontrada no oriente? / Is the apical hypertrophic cardiomyopathy seen in one population in Rio de Janeiro city similar to that found in the east?

OBJETIVO - Investigar a existência de diferença na forma de apresentaçäo clínica e evolutica da cardiomiopatia hipertrófica apical (CMHA), vista em uma amostra na cidade do Rio de Janeiro e a observada no oriente, ond foi descrita. MÉTODOS - Entre 156 pacientes com cardiomiopatia hipertrófica diagnosticados em nossa instituiçäo, foram identificados 13 (8,34 por cento) com a forma apical, sendo estudadas as suas manifestaçöes clínicas, os meios de diagnóstico e a sua evoluçäo. RESULTADOS - Eram 8 homens e 5 mulheres, com idades entre 19 a 75 anos, todos da raça branca, a maioria sintomática. O eletrocardiograma revelou ondas T gigantes em precordiais em 10 pacientes (76,92 por cento), o ecocardiograma (ECO), a presença de hipertrofia apical em todos os casos, sendo em 10 (76,92 por cento) restrita a ponta do ventrículo esquerdo (VE), em dois (15,4 por cento) a ponta do ventrículo direito (VD) e, em 1 (7,68 por cento), acometendo ambos os ventrículos. A cineventriculografia confirmou os achados do ECO. A evoluçäo variou de 6 a 264 meses (x=95,4). Ocorreram dois óbitos (15,4 por cento) em pacientes com o comprometimento associado ao VD, devido ao aumento significativo da dimensäo dos átrios, ocorrência de fibrilaçäo atrial, insuficiência valvar mitral e/ou tricúspide e tromboembolismo. Entre os vivos, a paciente com acometimento do VD evoluiu com restriçäo diastólica, e os restantes com lesäo localizada do VE, 9 estäo assintomáticos em uso de propranolol (8) ou amiodarona (1) e um permanece assintomático sem medicaçäo. CONCLUSÄO - A CMHA vista em uma amostra no Rio de Janeiro é similar a encontrada no oriente (Japäo), quanto à apresentacäo, diagnóstico e evoluçäo, porém notamos em 3 pacientes (23,08 por cento) o acometimento da ponta do VD, näo descrito no oriente, mas com péssimo prognóstico evolutivo.

[Depressed electrical atrial activity in hypertrophic and dilated cardiomyopathies. An electrocardiographic, vectorcardiographic and echocardiographic study]. / Atividade elétrica atrial deprimida nas cardiomiopatias hipertrófica e dilatada. Estudo eletro, veto e ecocardiográfico.

PURPOSE: To evaluate the "normal" or low-voltage P wave of the 12-leads conventional electrocardiogram (ECG), in patients with serious electric ventricular disturbances in hypertrophic (HC) and dilated (DC) cardiomyopathies. METHODS: Twenty cases of cardiomyopathies, 11 HC and 9 DC, ages ranging from 23 to 73 (x = 41) years have been studied. The analysis of the P wave was performed with ECG, amplified ECG at 1 mv = 20 mm and speed-paper at 50 mm/sec (ECG2), and the Frank-system vector-cardiogram (VCG). Voltage, delays and shapes of the P wave were evaluated by ECG2 and amplified VCG with gain at 1 mv = 160 mm. All electrical data were correlated with dimension of the left atrium (LA), dimension of left ventricular diastolic diameter (LVDD), dimension of left ventricular systolic diameter (LVSD), interventricular septal thickness (IST), posterior wall thickness ((PWT) and ejection fraction (EF) of the left ventricle of bidimensional echocardiogram (ECHO). RESULTS: Changes in morphologies and delays on the the P wave were best observed only on ECG2 and VCG. The mean voltage of P wave on ECG was 0.1 mv and the mean duration of the P loop on VCG was 133.7 msec in HC and 145.2 msec in DC, with mean terminal delay of 49.2 msec and 46.8 msec, respectively, due to slow atrial depolarization. CONCLUSION: In HC and DC with severe electric ventricular changes, the low-voltage and increased duration of P wave, are attributed to intraatrial-block due to structural changes of the atrial myocardium.

[Apical hypertrophic cardiomyopathy with right ventricular involvement]. / Cardiomiopatia hipertrófica apical acometendo o ventrículo direito.

We report right ventricular involvement in apical hypertrophic cardiomyopathy (HCMP) in two women and one man, aged from 19 to 44 years-old, who presented different signs from those with left ventricular disease (who have good clinical evolution), with signs and symptoms of severe diastolic restriction, showing great atrial enlargement and two with atrial fibrillation and death due to thromboembolism. The right ventricular involvement in apical HCMP leads to a worst prognosis than isolated left ventricular disease, does not have the typical electrocardiographic changes and presents with ventricular restriction and tricuspid regurgitation.

[Evaluation of a cardiac rehabilitation program. Analysis after ten years of follow-up]. / Avaliação de programa de reabilitação cardíaca. Análise após 10 anos de acompanhamento.

PURPOSE: To study the benefits of the cardiac rehabilitation program (CRP) in patients with coronary artery disease (CAD). METHODS: Between 1986 and 1995 we studied 49 patients with CAD, participants of the CRP, 45 (91.83%) of them men. They were compared with a control group of 37 sedentary patients, 33 (89.18%) men. The main parameters analyzed were the duration of exercise, the maximal oxygen consumption (VO2 max), the metabolic equivalent (MET), the functional aerobic impairment (FAI) and the change in the classification of the cardiorespiratory capacity between two graded exercise tests (GTX). RESULTS: There were improvements in all parameters of the GTX analyzed in the two groups. The patients of the CRP presented a better functional capacity than the sedentary patients and, in relation to the duration of exercise, to the VO2 max and to the MET, the differences in the two groups achieved statistical significance (p < 0.05). We did not observe benefits, in relation to the physical conditioning, with a more prolonged permanence of the patients in the program (more than 24 months). There were no cardiovascular complications with the practice of the exercise in the period analyzed. CONCLUSION: The improvement in the duration of exercise, in the VO2 max and in the MET, the more negative variation in the FAI and the improvement in the classification of the cardiorespiratory capacity between the two GTX of the patients of the CRP demonstrate improvement in functional capacity significantly better than sedentary patients. The CRP analyzed was considered a therapeutic method safe and efficient after a coronary event.

[Obstructive ischemic involvement of the anterior descending coronary artery in asymmetrical septal form of hypertrophic cardiomyopathy]. / O acometimento isquêmico obstrutivo na cardiomiopatia hipertrófica do tipo septal assimétrico com envolvimento da artéria descendente anterior.

PURPOSE: The significance of necrosis and fibrosis of the interventricular septum in hypertrophic cardiomyopathy (HCM) is controversial. The purpose of this study was then to evaluate the clinical impact of left anterior descending artery (LAD) disease in HCM. METHODS: Among 158 patients presenting with HCM, 6 (3.79%) had LAD disease. Mean age was 65.16 years (52 to 70), 4 were men and 4 had the obstructive form of HCM. All patients were submitted to complete clinical and laboratory evaluation. Mean time of the diagnosis was 141 months (ranging from 78 to 182) for HCM and 42 months (ranging from one day to 106 months) for LAD disease. RESULTS: Five patients had unstable angina and one had myocardial infarction. LAD disease (60 to 100% coronary narrowing) was present in all patients; one patient had single vessel disease and 5 multivessel disease. During follow-up, 3 patients had coronary artery bypass grafting (CABG), one with associated septal myectomy; one was submitted to coronary angioplasty and 2 were submitted to medical treatment. During a follow-up period ranging from 76 to 124 months after LAD disease diagnosis, one patient died. At the end of the study, a reduction of the thickness of the interventricular septum from 1.53 to 1.40 cm was observed and left ventricular outflow pressure gradient decreased from 56 to 16 mmHg. Left ventricular diastolic diameter increased from 4.55 to 4.85 cm and systolic diameter from 2.83 to 3.13 cm. Left atrium diameter was unchanged. CONCLUSION: LAD disease is well tolerated in the asymmetrical form of HCM and may contribute to septal fibrosis, improving cardiac function. It does not represent an adverse factor in the evolution of HCM.

[Infective endocarditis in adolescents. Analysis of risk factors for hospital mortality]. / Endocardite infecciosa em adolescentes. Análise dos fatores de risco de mortalidade intra-hospitalar.

PURPOSE: To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old (mean 15.5). METHODS: Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied. RESULTS: Infective endocarditis mortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p = 0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm3 and functional class, both at admission (p = 0.01 and p = 0.004, respectively), and the occurrence of embolic complications (p = 0.03) as independent predictors of in-hospital mortality. CONCLUSION: Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S. aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.

[Coronary fistula associated with severe pulmonary stenosis and cianosis]. / Fístula coronariana associada à estenose pulmonar grave e cianose.

A 17 year old male adolescent was admitted to the hospital due to dyspnea and cyanosis, since the age of 6 years. On physical examination, it was found a continuous murmur over the left esternal border at the 4th and 5th intercostal spaces suggesting a coronary fistula. A color-echocardiogram associated with an angiography confirmed the diagnosis of coronary fistula and severe pulmonary stenosis. The functional consequence was a right to left shunt with cyanosis. A surgical repair was performed with closure of the fistula at the point where it drained into the right ventricle plus a pulmonary commissurotomy. The patient had an uneventful recovery.

Fístula coronariana associada à estenose pulmonar grave e cianose / Coronary Fistula Associated with Severe Pulmonary Stenosis and Cianosis

Adolescente do sexo masculino, 17 anos, com queixa de dispnéia e cianose desde os 6 anos, apresentava ao exame fisíco sopro contínuo nos quarto e quinto espaços intercostais esquerdos, sugestivo de fístula coronariana. O eco-color e a angiografia confirmaram a hipótese de fístula coronariana associada a estenose pulmonar valvar grave e shunt direito-esquerdo, o que provocava a cianose. Foi submetido a correçäo cirúrgica para fechamento da fístula ao nível do seu sítio de drenagem e realizaçäo de cosurotomia pulmonar, permanecendo assintomático até o momento.