Exertional chest pain is sometimes more than just coronary atherosclerosis.

CLINICAL CASE: A 64-year-old male, with cardiovascular risk factors and previous history of bilateral carpal tunnel syndrome, presented with exertional retrosternal pain. The resting echocardiogram was unremarkable. A stress echocardiogram with dobutamine revealed hypokinesis of the inferior wall, associated with angina, followed by ventricular tachycardia. The coronary angiography revealed slow flow, a dominant right coronary artery with non-obstructive atherosclerosis and a left anterior descending artery with intermediate lesions in mid and distal segments. The invasive functional evaluation, including fractional flow reserve, thermodilution coronary flow reserve and index of microvascular resistance, led to the diagnosis of microvascular angina, treated with calcium channel blockers and transdermal nitrate, giving symptom relief. EVOLUTION: Three years later he developed complete atrioventricular block and a dual chamber pacemaker was implanted. Shortly after, the patient developed progressive symmetrical tetraparesis, associated with marked muscle atrophy, hand numbness, orthostatic hypotension and dysphagia. The neurology workup led to the diagnosis of familial amyloidotic polyneuropathy, with the Val30Met mutation in the transthyretin gene. The following year he developed congestive heart failure. The echocardiogram showed moderate concentric left ventricular hypertrophy with preserved ejection fraction. A 99mTc-DPD Scintigraphy showed significant myocardial tracer uptake, leading to a diagnosis of TTR amyloid infiltration. DISCUSSION: Patients with exertional angina and microvascular disease should be kept under close surveillance, as they may have systemic disease with cardiac involvement. Carpal tunnel syndrome, in the context of undiagnosed cardiac disease, should trigger suspicion of cardiac amyloidosis.

Atropine in exercise stress echocardiography? Case report.

Stress echocardiography is widely used in the investigation of coronary heart disease. Exercise stress echocardiography offers the advantage of visualizing myocardial motion abnormalities during physiological stress testing. The authors report the use of atropine, as an adjunct to exercise echocardiography, in risk stratification after myocardial infarction.

[Assessment of aortic atherosclerosis with transesophageal echocardiography]. / Avaliação da aterosclerose aórtica por ecocardiografia transesofágica.

OBJECTIVE: To image the thoracic aorta by transesophageal echocardiography (TEE) and study atherosis (morphology and extent of atheroma plaques) and sclerosis (stiffness) and secondarily correlate them with serum lipid levels (cholesterol, HDL, LDL and triglycerides). METHODS: We studied 29 patients (pts) who underwent TEE electively (male 18 pts, age 57.8 +/- 14.6 years). The parameters evaluated were: the stiffness coefficient = ln (PAsist/PAdiast)/(Dsyst/Dmin), and the morphology, location and extent of atheroma plaques. The systolic distension (Dsyst) was the difference between the maximal and the minimal dimensions (Dmin) of the aortic diameter measured by M mode. The lesions were classified in 4 degrees (0-3): 0--normal intima, 1--intimal thickening, 2--atheroma, 3--complicated lesion. Five aortic segments were studied: arch, D1-D4 (descending aorta at 5 cm intervals from the first 25 cm distal of the incisors line). We calculated the individual score = 1 x theta 1/180 + 2 x theta 2/180 + 3 x theta 3/180, theta n represents the angles occupied by the lesions and n (1-3) the severity of atherosis of each lesion. The total atherosis index (TAI) was sigma scores/(n. degree of visualized segments). RESULTS: The arch was not visualized in 3 pts, and the segment D4 was only visualized in 3 pts. TAI mean = 0.82 +/- 0.74, stiffness coefficient mean (SC) = 9.56 +/- 15.072. There were no significant correlations between the lipid levels and the TAI or SC. The only significant positive correlations were: TAI vs age (r = 0.62, p < 0.001) and SC and diastolic blood pressure (BP) (r = 0.42, p < 0.05). CONCLUSIONS: The best visualized segments belong to the descending aorta (25 to 40 cm from the incisors). In this group of patients the lipid levels did not seem to be a preponderant factor in aortic atherosclerosis. The most important factors were age for atherosis and BP for sclerosis.

[Changes in regional wall contractility induced by effort in women with normal coronary angiography --report of a clinical case]. / Alterações da contractilidade segmentar induzidas pelo esforço em mulheres com coronárias angiograficamente normais--caso clínico.

The diagnosis of coronary artery disease in women has been thought to be more difficult than in men, owing to the lower overall prevalence of disease in women, as well as more subtle clinical presentations and unspecific changes in ST segment. The authors report a clinical case of a 61-year old woman, with low cardiovascular risk and history of atypical chest pain and a positive treadmill exercise test on the inferior leads. She did an exercise echocardiogram that revealed severe hypokinesis on the anterior wall and septum with late normalization. The patient was submitted to a coronary angiography that revealed normal arteries. An echocardiogram with hyperventilation was later performed and showed the same ischemic changes as exercise did, on the inferior leads but no regional wall motions abnormalities occurred. The patient is currently asymptomatic under calcium antagonist treatment.

[Plasma total anti-oxidant status in young survivors of myocardial infarction]. / Estado anti-oxidante total do plasma em doentes jovens com enfarte do miocárdio.

UNLABELLED: Free oxygen radicals are involved in the endothelial lesion process which leads to the formation of the atheroma plaque and thrombosis. There is some evidence that antioxidant therapy may be beneficial in coronary heart disease prevention. Our objective was to study the plasma total anti-oxidant status in young survivors of acute myocardial infarction. POPULATION: 23 patients, mean age 35.2 years (22-40) admitted for acute myocardial infarction from January 1995 to June 1998 (20 males). RISK FACTORS: Tobacco smoking 22/23, systemic arterial hypertension 4/23, hypercholesterolemia 17/23, positive family history for coronary heart disease 5 patients, previous history of angina 4 patients, none of these patients had diabetes mellitus. The location of the infarct was anterior in 12 patients, inferior in 10 patients and non-Q wave in one patient. Blood samples were drawn after overnight fasting and the plasma total antioxidant status (TAS) was determined by a colorymethric method (Trolox equivalent). The mean time elapsed since the acute myocardial infarction until sample collection was 16.5 +/- 10.7 months. RESULTS: 18 patients had low TAS values, mean 1.23 +/- 0.11 mmol/L (below the reference values: 1.3-1.77 mmol/L). CONCLUSIONS: In this group of patients, the plasma total antioxidant capacity was globally decreased, which may constitute a risk factor for coronary heart disease.

[Direct coronary angioplasty versus thrombolysis in the acute phase of myocardial infarction--inpatient outcome]. / Angioplastia coronária directa versus trombólise na fase aguda do enfarte do miocárdio--evolução intra-hospitalar.

Both thrombolysis and percutaneous transluminal coronary angioplasty (PTCA) are effective methods for the treatment of acute myocardial infarction (AMI). In our centre we perform primary PTCA during the available schedule of the hemodynamics laboratory. In this article we compare the predischarge evolution of patients submitted to each therapeutic procedure. From January 1996 to June 1997, 298 patients were admitted with the diagnosis of AMI. Eighty-four patients (28%) were thrombolysed (TB group) and 30 patients (10%) underwent primary PTCA (PTCA group). There were no significant differences among the two groups concerning demographic characteristics: age (61 +/- 13--TB and 59 +/- 12 years--PTCA); sex (male 81%--TB; 83%--PTCA), risk factors and previous cardiac history. The mean time since the onset of symptoms until arrival at the hospital was 156 +/- 156 minutes for TB and 202 +/- 210 minutes for PTCA (p < 0.02). The delay since admission until the beginning of treatment was 100 +/- 88 minutes for TB and 119 +/- 142 minutes for PTCA. The primary success rate of PTCA was 94% and there were no complications during the procedure. During the hospital stay, 12 patients developed post-infarction angina in the TB group and two patients in the PTCA group; in 15 patients of the TB group a revascularization procedure was performed (surgery in 5 and PTCA in 10 patients); one patient suffered reinfarction in the TB group. Two patients of the TB group (2.4%) had intracranial hemorrhage; the in-hospital mortality was 9.5% in the TB group and 3.3% in the PTCA (p < 0.001). The mean in-hospital stay was 11 +/- 5.6 in the TB group and 7.8 +/- 2.5 days in the PTCA group (p = 0.055). In our experience, primary PTCA in AMI appeared to be a safe procedure with lower occurrence of coronary events and hemorrhagic complication, with an earlier hospital discharge when compared to thrombolysis.

[Is the stress test useful in the detection of post-angioplasty restenosis?]. / Será a prova de esforço útil na detecção de reestenose pós-angioplastia?

Restetenosis is still the greatest limitation of coronary angioplasty (PTCA). The systematic use of ergometry (PE) with the objective of identifying restenosis is controversial and, namely, the ACC/AHA does not recommend its routine use. Our objective was to conduct a retrospective study of the use of PE when performed late (3 to 6 months) for the detection of restenosis. As a protocol, our group performed "late" PE on all the patients without contraindications, the patients with positive ergometry or CCS class II-IV angor submitted to angiographic control. Between January 1996 and July 1997, 121 patients (pts) were submitted to PTCA. Our study population was composed of patients submitted to complete revascularisation with follow-up in our centre: 59 pts (49%) with an average age of 58 +/- 12 years, 82% male. Eighty-three percent of the pts had revascularisation in a context of unstable angina, 10% in the acute phase of myocardial infarction and 7% due to chronic angina. Stents were implanted in 42% of the pts. In the follow-up after six months, 7 pts complained of CCS class II or III angor. The ergometry showed positive electrocardiographic criteria in 11 pts (18.6%). All pts with angor had positive PE. All these pts were submitted to angiographic control; restenosis (residual stenosis equal to or above 50%) was observed in all the patients who complained of angor (100% positive predictive value); restenosis occurred in 9 pts with positive ergometry (82% positive predictive value). In asymptomatic pts, PE indicated 2 pts with restenosis (2/59-3.4%) and two false positive (2/11-18%). At six months, PE detected 22% of the pts with restenosis. In conclusion, complete post-revascularisation angor due to coronary angioplasty has a higher positive predictive value than ergometry. However, the stress test, performed systematically, can identify an additional percentage of pts with restenosis with an acceptable percentage of false positives.

[Abciximab (ReoPro) in primary angioplasty]. / Uso de abciximab (ReoPro) na angioplastia primária.

UNLABELLED: The aim of the study was to evaluate the efficacy and safety of abciximab (ReoPro) in primary percutaneous transluminal coronary angioplasty (P.T.C.A.) in patients with myocardial infarction (M.I.). From June 96 to October 97, 16 patients with a mean age of 58 +/- 12 years, 86% males, with myocardial infarction (less than 12 hours of pain) were treated with ReoPro during P.T.C.A. The infarction was anterior in seven patients (44%), inferior in eight patients (50%) and non-Q wave in one patient (6%). Nine patients (47%) had a previous history of angina or myocardial infarction. The mean time from onset of symptoms to hospital arrival was 306 +/- 370 min and the mean time between hospital admission and the beginning of the procedure was 79 +/- 86 min. P.T.C.A. was performed on the anterior descending artery and right coronary in 44% and 56%, respectively. The success rate was 94%. Stents were used in 31%. In patients with angiographic success, we obtained TIMI III flow in 14 patients and TIMI II in one patient. No complications arose during P.C.T.A; no significant changes in platelets or hemoglobin were observed after the procedure. In this group of patients, one case of hematoma was found at the site of puncture with no need for transfusion. During hospitalization, no major coronary events were found. During the follow-up of 10.5 +/- 4.9 months, one patient died after non cardiac surgery and one patient was submitted to coronary artery bypass graft; there was no reinfarction nor new P.T.C.A. CONCLUSIONS: In our experience with ReoPro during direct angioplasty, we obtained good immediate and long term results, with no significant bleeding complications.