Cholesterol lowering with statins reduces exercise-induced myocardial ischemia in hypercholesterolemic patients with coronary artery disease.

Coronary flow reserve is mainly influenced by the combination of luminal stenosis and vascular dilation capacity. Thus, after statin treatment, the reduction of ischemic threshold in patients submitted to exercise testing could be intensely influenced by angiographic severity. In this study, we verify the effect of statin treatment on exercise-induced myocardial ischemia in hypercholesterolemic patients with a broad range of coronary angiographic severities. Patients with 2 consecutive positive exercise tests, coronary stenosis > or =70%, total cholesterol > or =300 mg/dl, and triglycerides < or =200 mg/dl were randomly assigned to a 16-week treatment period with either diet alone (n = 39) or diet plus statins (simavastatin, n = 31 and pravastatin, n = 10). Statin-treated patients had a significant variation in total cholesterol (-46% vs -2.7%; p <0.01), low-density lipoprotein cholesterol (-58% vs 0.8%; p <0.01), and high-density cholesterol (+28% vs -6%; p <0.05) in comparison with the diet-only group. After 16 weeks of treatment, 36 patients (92%) in the diet group still had positive exercise tests, whereas only 7 patients (15%) of the statin group had a positive test (p <0.01). The proportion of positive tests was significantly reduced in subgroups of patients with 1-, 2-, or 3-vessel disease. Regarding the severity of coronary stenosis, the proportion of positive tests was significantly reduced in patients with stenosis between 70% and 90% and in patients with stenosis > or =90%. Moreover, the proportion of positive tests tended to decrease to a greater extent in patients with mild coronary disease. In conclusion, cholesterol-lowering treatment with statins reduces exercise-induced myocardial ischemia in hypercholesterolemic patients with mild or severe epicardial coronary stenosis.

Low-dose aprotinin in heart valve reoperations.

BACKGROUND AND AIM OF THE STUDY: Aprotinin is effective in promoting hemostasis, notably in cardiac surgery with cardiopulmonary bypass. Its efficacy has been shown in coronary bypass graft operations. However, few reports exist of aprotinin use in valve operations, and in those studies only the full dose was used. Thus, our aim was to evaluate the effects of low-dose aprotinin in patients undergoing heart valve reoperation. METHODS: Eighteen patients having reoperative valve surgery received 10(6) KIU aprotinin after induction of anesthesia, and a further 10(6) KIU in the pump prime. A group of 18 similar patients who were operated on but did not receive aprotinin were used as controls. RESULTS: A significant reduction in postoperative blood loss (approximately 470 ml) occurred in patients receiving aprotinin. These patients also presented less postoperative bleeding than untreated patients in 70.4% of cases. No adverse effects of the drug were noted, except for one case of allergic reaction. CONCLUSION: The systematic use of low-dose aprotinin should be considered in valve reoperation, except in cases of re-exposure to the drug, or allergic reaction.

Effect of spironolactone on ventricular arrhythmias in congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy.

Epidemiologic studies have shown an important increase in the high mortality of patients with congestive heart failure (CHF) despite optimal medical management. Ventricular arrhythmia was recognized as the most common cause of death in this population. Electrolyte imbalance, myocardial fibrosis, left ventricular dysfunction, and inappropriate neurohumoral activation are presumed responsible for sudden cardiac death. In this study, we focused on the deleterious effects of the overproduction of aldosterone that occurs in patients with CHF. Secondary hyperaldersteronism can be part of several factors thought to be responsible for sudden cardiac death. We randomized 35 patients (32 men, aged 48 +/- 9 years) with systolic dysfunction (ejection fraction 33 +/- 5%) and New York Heart Association class III CHF secondary to dilated or ischemic cardiomyopathy into 2 groups. The treatment group received spironolactone, an aldosterone receptor antagonist, along with standard medical management using furosemide, angiotensin-converting enzyme inhibitors, and digoxin. The control group received only the standard medical treatment. Holter monitoring was used to assess the severity of ventricular arrhythmia. After 20 weeks, patients who received spironolactone had a reduced hourly frequency of ventricular premature complexes (VPCs) (65 +/- 18 VPCs/hour at week 0 and 17 +/- 9 VPCs/hour at week 16) and episodes of nonsustained ventricular tachycardia (VT) (3.0 +/- 0.8 episodes of VT/24-hour period at week 0, and 0.6 +/- 0.3 VT/24-hour period at week 16). During monitored treadmill exercise, a significant improvement in ventricular arrhythmia was found in the group receiving spironolactone (39 +/- 10 VPCs at week 0, and 6 +/- 2 VPCs at week 16). These findings suggest that aldosterone may contribute to the incidence of ventricular arrhythmia in patients with CHF, and spironolactone helps reduce this complication.

[Myocardial ischemia with stable angina pectoris: clinico-ergometric evaluation after the use of diltiazem]. / Isquemia miocárdica com angina do peito estável: avaliação clínico-ergométrica após uso de diltiazem.

PURPOSE: To evaluate the efficacy of diltiazem versus placebo in patients with stable angina. METHODS: Eight-seven angina pectoris patients, mean age of 57 +/- 9, 82 white and 79 male were evaluated in a randomized, double-blind trial of two groups of patients diltiazem and placebo, 3 to 4 tablets a day (diltiazem 180 to 240 mg daily). The patients were evaluated after laboratory tests and clinical-ergometric examinations. A coronary arteriography was performed on study entry. RESULTS: The average of anginal attacks, number of weekly sublingual nitrate, heart rate, systolic and diastolic pressure at rest and at the end of diltiazem period were significantly lower (p < 0.05) regarding same periods on placebo. The percentage of depression for ST-segment was lower for diltiazem when compared with placebo (p < 0.05) and the percentage of patients that reach higher stages in the ergometric test was significantly better for diltiazem. Heart rate and systolic plus diastolic pressures after exercise did not differ in both groups. CONCLUSION: Diltiazem reduced the clinical and electrocardiographical aspects and raises the effort tolerance during the ergometric test in patients with stable angina.

Anestesia e síndrome de Down / Anesthesia and Down`s syndrome

Os autores apresentam uma revisäo sobre a síndrome de Down, sua classificaçäo genética, características e o diagnóstico. As principais alteraçöes cardiopulmonares, digestivas, hematológicas e endócrinas säo descritas. Chamam ainda a atençäo para os aspectos imunológicos e enzimáticos da síndrome e os principais problemas relacionados a drogas e técnicas anestésicas

Estudo comparativo entre a metoclopramida e o droperidol no controle de náuseas e vômitos na operaçäo cesariana em gestantes submetidas a bloqueio subaracnóideo / A comparative study between metoclopramide and droperidol in the control of nauses and vomit in patients subjected to spinal blockade during cesarean section

Os autores realizaram um estudo comparativo para avaliar a eficácia do droperidol e metaclopramida no controle das náuseas e vômitos peroperatórios em gestantes submetidas a cesariana sob bloqueio subaracnóideo. As gestantes foram divididas em três grupos (I, II e III), de acordo com o agente profilático, utilizado. No grupo I foi utilizado o droperidol (5mg) e no grupo II metoclopramida (10 mg), ambos por via venosa. O grupo III foi o controle. O droperidol e a metoclopramida foram utilizados após a retirada co concepto. No que se refere a qualidade e ao nível do bloqueio sensitivo, bem como a intensidade do bloqueio motor, näo houve diferenças relevantes nos grupos estudados. Com relaçäo a pressäo arterial e freqüência cardíaca houve, após a utilizaçäo do droperidol (grupo I), uma tendência a hipotensäo arterial e taquicardia quando comparadas aos grupos II (metoclopramida) e III (controle). Estas alteraçöes foram transitórias e de no máximo 20% em relaçäo aos valores basais, näo sendo utilizada qualquer terapêutica. No que se refere a incidência de náuseas e vômitos no peroperatório houve diminuiçäo significativa estatisticamente quando comparamos os grupos I (droperidol) e II (metoclopramida) com o grupo III (controle), entretanto näo houve diferença estatisticamente significativa quando comparados os grupos I (droperidol) e II (metoclcopramida) entre si. Os autores concluem que tanto o droperidol como a metoclopramida, nesse estudo, diminuíram intensamente a incidência de náuseas e vomitos em gestantes submetidas a cesariana, sob bloqueio subaracnóideo, podendo ser utilizada com segurança neste tipo de pacientes

Alteraçöes cardiovasculares com a associaçäo bloqueio subaracnóideo e sedaçäo com quetamina em pacientes pediátricos / Cardiovascular changes of intravenous ketamine associated with spinal block in pediatric patients

Os autores realizaram um estudo em 30 pacientes pediátricos, submetidos a cirurgia de abdômen inferior e extremidades, nos quais foram avaliadas as alteraçöes cardiovasculares (pressäo arterial, freqüência e ritmo cardíacos) com bloqueio subaracnóideo e sedaçäo com quetamina. Ao chegar a sala de cirurgia, foram injetadas, por via venosa, quetamina (2 mg.Kg -1) e atropina (0,02 mg.Kg-1). Apos os pacientes adormecerem foi injetada, no espaço subracnóideo, lidocaína 5% na dose de 3 mg.Kg-1 com L3-L4. Näo houve alteraçöes no ritmo cardíaco2. Ocorreu aumento da pressäo arterial, na maioria dos pacientes, porém nunca superiores a 30 mmHg (3,9 KPa). Após a realizaçäo do bloqueio, houve tendência a estabilidade da pressäo arterial, que se acentuou progressivamente até o final da cirurgia. A freqüência cardíaca aumentou, porém, em valores nunca superiores a 30 bpm, quando comparados aos valores basais. Esta taquicardia teve sua intensidade diminuída após o bloqueio subaracnóideo, estabilizando-se ao final da cirurgia. Os autores concluíram que a associaçäo bloqueio subaracnóideo e sedaçäo com quetamina proporcionou boa estabilidade cardiovascular, podendo ser utilizada com segurança em pacientes pediátricos

Estudo comparativo entre o fentanil e o diazepam na profilaxia das mioclonias produzidas pelo etomidato / Comparative study between fentanyl and diazepam in the prophylaxis of myoclonias produced by etomidate

Realizou-se um estudo comparativo entre o fentanil e o diazepam para avaliar suas eficácias na profilaxia das mioclonias produzidas pelo etomidato. Foram estudadas 45 pacientes submetidas a curetagem uterina pós-abortamento ou semiótica, cuja faixa etária variou de 17 a 63 anos, o peso de 49-83 kg e divididas ao acaso em três grupos (I, II e III). No grupo I foi empregado o sulfato de atropina (0,5mg) e etomidato (0,2 mg.Kg**-1), venoso. No grupo II e III foram empregadas as mesmas substâncias preceditas de diazepam 10 mg (grupo II) e fentanil 100 microng (Grupo III), 120 antes da induçäo. Foram avaliados os seguintes parâmetros: presença e intensidade das mioclonias e necessidade de doses suplementares de etomidato. Em nosso estudo houve uma diminuiçäo näo estatisticamente significativa, na freqüência e intensidade das mioclonias, quando comparados os Grupos II (diazepam) e grupo III (fentanil profilático), com o grupo I (controle). Näo houve diferenças significativas nos três grupos estudados, no que se refere à necessidade de doses suplementares de etomidato

Placebo-controlled study of lisinopril in congestive heart failure: a multicentre study.

A double-blind randomised, parallel, placebo-controlled study was performed in patients with congestive heart failure, at 13 centres in 10 countries, to assess the efficacy and safety of lisinopril, a new angiotensin-converting enzyme inhibitor. After a 2-week run-in period, 130 patients receiving digoxin and/or diuretics were randomised to 12 weeks of treatment with lisinopril 5 mg daily (87 patients) or with placebo (43 patients), with an option to increase lisinopril dosage to 10 or 20 mg. Patients treated with lisinopril improved significantly more than placebo-treated patients (p less than 0.05) for all clinical parameters except oedema and paroxysmal nocturnal dyspnoea. Left ventricular ejection fraction rose by 8% in lisinopril patients compared to 2% in the placebo group, while the cardiothoracic ratio and echocardiographic end systolic diameter fell in the lisinopril group (p less than 0.01) but not in the placebo group. Exercise duration was greater in the lisinopril group at all timepoints, and the increase in exercise duration at 12 weeks was greater by more than 2 min in the lisinopril group as compared to the placebo group (p less than 0.01). Changes in clinical and noninvasive parameters such as the New York Heart Association status, were well correlated with changes in exercise duration. Four patients in the lisinopril group and three in the placebo group died in this study, and there were 31 adverse clinical experiences in the 87 lisinopril-treated patients compared to 13 in the 43 placebo-treated patients. We conclude that lisinopril in doses of 2.5-20 mg/day is well tolerated and effective in patients with heart failure who are receiving digitalis and diuretics.

Emprego da quetamina na induçäo das anestesias com intubaçäo nasotraqueal às cegas / Use of ketamine in induction anesthesia with blind nasotracheal intubation

Os autores relatam um estudo realizado com o emprego do cloridrato de quetamina, em pacientes portadores de anquilose da articulaçäo têmporo-mandibular, submetidos a cirurgia corretiva, que necessitaram de intubaçäo nasotraqueal às cegas, em virtude da intensa imobilidade articular. O estudo teve como objetivos utilizar uma técnica que proporcionasse sedaçäo, amnésia e analgesia prolongadas durante as manobras de intubaçäo, ausência de depressäo respiratória ou cardiovascular bem como facilitar o cirurgiäo e proporcionar conforto ao paciente em caso de ser necessária traqueostomia. A intubaçäo nasotraqueal às cegas foi realizada satisfatoriamente em 11 pacientes (91,6%). Em um paciente (8,4%) foi necessária traqueostomia. Houve em 33,3% dos pacientes uma discreta estimulaçäo do sistema respiratório, näo prejudicando as manobras de intubaçäo traqueal. A quetamina determinou estimulaçäo do sistema cardiovascular, de curta duraçäo, traduzido por aumento da pressäo arterial e freqüência cardíaca. Näo ocorreram alteraçöes de ritmo cardíaco. Näo foram observados em nossos pacientes agitaçäo, dor, desconforto, memorizaçäo ou alucinaçöes. Os autores concluem que o cloridrato de quetamina representa uma opçäo em pacientes portadores de anquilose da articulaçäo têmporo-mandibular, que necessitam de intubaçäo nasotraqueal; às cegas, os quais säo bastante instáveis emocionalmente, näo tolerando bem manobras prolongadas e desconfortáveis como a intubaçäo retrógrada

Tratamento da hipertensão arterial com dose única diária de guanfacina / Treatment of arterial hypertension with a single daily dose of guanfacine

Foram estudados 52 pacientes portadores de hipertensao arterial leve ou moderada (pressao diastolica ate 115 mm Hg), com guanfacina, em dose unica. Em todos foi afastada disfuncao renal ou outra doenca concomitante. Apos 2 semanas de placebo, iniciou-se medicacao na dose de 0,5 mg por dia ao deitar, aumentando-se progressivamente quando necessario, a cada duas semanas, ate o maximo de 3 mg por dia. Os pacientes foram seguidos por 10 semanas.Terminaram o estudo 47 pacientes conseguindo-se normalizacao da pressao arterial diastolica (< igual 90 mm Hg) em 39 (83%). Nos demais, (17%), houve diminuicao da mesma.A dose media ideal sitou-se entre 1 e 2 mg.Em apenas um caso, foi necessaria a suspensao do tratamento por efeito colateral (intensa sonolencia). Os demais efeitos colaterais foram de intensidade leve ou moderada, sendo boca seca e sonolencia os mais frequentes (53% e 28%, respectivamente). Conclui-se que a guanfacina, como monoterapia, representa mais uma opcao para o tratamento de pacientes com hipertensao arterial leve ou moderada