[Of medicine and arts: the poet, he and the other]. / Da medicina e das belas letras: Mário de Sá-Carneiro, o poeta, ele e o outro.

The poet Mário de Sá-Carneiro, who commited suicide in Paris, in 1916, had had an appointment with the neurologist Egas Moniz, in Lisbon, two years before. After listenning to what he had to say, Moniz tells him that he identifies his symptons, curiously, with expressions of a poem he had read in the literary magazin Orfeu. This magazin wanted, in a provocative way, to announce a literature that was breaking with the past. Sá-Carneiro told him that he was the author of the poem. On reading it, Egas Moniz, had suspected that his author was a squizofrenic. In this article the literary and poetical work of Sá-Carneiro is analised, identifying it, as a whole, with the demonstrations that depict squizofrenia.

Role of myocardial ischemia and left ventricular wall motion abnormalities as contributory factors in the genesis of exercise-induced ST-segment elevation in Q-wave myocardial infarction.

In patients with a previous myocardial infarction, controversy exists regarding the significance of postexercise ST-segment elevation in the infarct-related leads. Although usually admitted to be a sign of left ventricular dysfunction or myocardial aneurysm, other studies however have related this finding to transient myocardial ischemia and to the presence of jeopardized but viable myocardium in the infarct area. The aim of the present study was to assess the significance of postexercise ST-segment elevation in Q-wave leads as a marker of transmural ischemia or left ventricular dysfunction in 36 consecutive patients, 16 with exercise-induced ST-segment elevation in infarct-related leads. Patients were evaluated by treadmill exercise testing, coronary angiography and ventriculography, thallium-201 tomographic scintigraphy and radionuclide ventriculography within 3 months of the first myocardial infarction. Sixteen patients (group I) had exercise-induced ST segment elevation and 20 (group II) postexercise inversion, no change or pseudonormalization of the T wave in infarct-related leads. The study showed no difference in infarct-related artery, vessel disease or luminal diameter stenosis in groups I and II. The overall agreement between ST shifts and myocardial perfusion in the infarct area was 30.56% with a kappa coefficient of -0.33 (p = NS). The overall agreement between ST shifts and wall motion abnormalities was 69.44% with a kappa coefficient of 0.39 (p < 0.01), stress-induced ST-segment elevation being associated with severe wall contractile disorders in 85% of the patients. In conclusion stress-induced ST-segment elevation in Q wave leads, although not a marker of wall motion abnormalities, is associated with akinesia or dyskinesia of the left ventricular wall.

Post-exercise electrocardiographic alterations, ST-segment elevation and QTc changes in patients with recent myocardial infarction.

UNLABELLED: Stress-induced ST-segment elevation and a prolongation or no change of the QTc ratio (corrected QT interval for heart rate) at maximal exercise in the infarct leads have been associated with the presence of residual myocardial ischemia in the infarct zone. The aim of this study was to test the agreement between stress-induced ST-segment elevation and post-exercise QTc changes in infarct leads, in 36 consecutive patients, studied by coronariography, radionuclide ventriculography and thallium-201 scintigraphy, within 3 months of the acute myocardial infarction. Sixteen patients (Group I) had exercise-induced ST-segment elevation in the infarct leads and 20 did not (Group II). The study showed no significant difference between severity of vessel disease and occlusion, prevalence of the infarct related artery or left ventricular dysfunction in Group I and II. No agreement between ST-segment shifts and myocardial perfusion in the infarct zone was found. Resting wall motion abnormalities were more severe in Group I than in Group II (p < 0.01). In the total of the 36 patients there was no agreement between ST-segment shifts and QTc-variations. The study showed agreement between QTc changes and myocardial perfusion in the infarct area (K = 0.64) (p < 0.001). CONCLUSION: This study showed no relation between post-exercise ST elevation and post-exercise QTc variations in Q wave leads. QTc variations at the end of exercise in the infarct related leads identified residual ischemia. Exercise ST segment elevation, although not a marker of ischemia, is associated with more severe wall motion abnormalities in the infarct zone.

Comparison between dobutamine echocardiography and thallium-201 scintigraphy in detecting residual stenosis, ischemia, and necrosis in patients with prior myocardial infarction.

BACKGROUND: Following the first attempts to detect myocardial ischemia with two-dimensional echocardiography stress testing, pharmacologic stress using dobutamine infusion has become an alternative to echocardiography exercise testing for evaluation of coronary artery disease. It has been shown that stress echocardiography has a diagnostic accuracy similar to that of an exercise thallium test. Other studies, however, indicated that radionuclide myocardial perfusion imaging was more sensitive than exercise or pharmacologic stress echocardiography for detection of ischemia or jeopardized myocardium. HYPOTHESIS: The aim of the present study was to determine the ability of dobutamine stress echocardiography in comparison with thallium-201 scintigraphy to identify multivessel disease and the presence of myocardial scar and ischemia in 60 consecutive patients who suffered a first myocardial infarction (MI). METHODS: Patients were evaluated by coronary angiography and ventriculography, thallium-201 (201TI) tomographic scintigraphy, and dobutamine echocardiography within 3 months of a first MI. Forty-seven had Q-wave MI and 13 had non-Q-wave MI. Eleven patients were excluded from final analysis-7 because of failure to achieve target heart rate in spite of the use of atropine, and 4 because of high blood pressure following the infusion of dobutamine. RESULTS: Dobutamine echocardiography showed an overall sensitivity of 43% for detection of coronary artery lesions of 50-74% diameter stenosis and 201TI scintigraphy showed a sensitivity of 71%. For detection of lesions of > or = 75% diameter stenosis, dobutamine echocardiography showed a sensitivity of 52% and 201TI a sensitivity of 70%. Overall agreement between wall motion and myocardial perfusion for detection of necrosis and/or ischemia in the infarct area was 40.4% with a kappa coefficient of 0.09 (p = 0.13). For detection of ischemic myocardium outside the infarct zone, overall agreement was 78.6% with a kappa coefficient of 0.49 (p < 0.0001). CONCLUSION: Dobutamine echocardiography results showed a lower sensitivity than myocardial perfusion images in predicting multivessel coronary artery disease, and there was poor agreement between both methods in identifying necrosis or ischemia.

[Coronary artery disease, myocardial perfusion and ventricular function in Q-wave and non-Q-wave myocardial infarcts]. / Doença arterial coronária, perfusão miocárdica e função ventricular em enfartes do miocárdio com onda Q e sem onda Q.

Controversy remains in considering non-Q wave myocardial infarction (NQMI) a distinct pathophysiological entity of Q wave myocardial infarction (QMI). In order to analyze the severity of coronary artery disease, extension of myocardial scar or myocardial ischemia and ventricular function, 78 consecutive patients with QMI and 32 with NQMI, mean age 55.4 +/- 8.5, not submitted to thrombolytic therapy, were studied. Coronary angiography, exercise thallium scintigraphy and radionuclide ventriculography were performed in all at least within 3 months of a prior myocardial infarction. In the present study the occurrence of QMI was significantly more frequent in older patients than NQMI. There was no prevalence of occlusion either in the right, left circumflex or left anterior descending coronary arteries in both groups. Ejection fraction, degree of occlusion and presence of collateral circulation showed an equal prevalence in QMI and NQMI patients. A higher incidence of multivessel disease was found in NQMI that had less necrosis than QMI patients. The prevalence of exercise induced thallium-201 redistribution defects within the infarct zone was substantially higher and involved more scar segments in NQMI patients. Physiological and clinical consequences of coronary thrombosis depends on the size and the number of diseased arteries, the approach the pathophysiologic consequences of coronary disease in terms of fractal structure has been suggested. A pronounced heterogeneity in regional myocardial blood flow in a fractal branching arterial network may be responsible for the pathophysiologic differences of coronary thrombosis between Q-wave and non Q-wave infarction.

Minimal residual coronary obstructions in patients who suffered a first myocardial infarction. A prospective study comparing coronary angiography and exercise thallium scintigraphy.

The purpose of the present study was to correlate the presence of minimal coronary obstruction (< or = 50%) assessed by coronary angiography with the presence of myocardial scar and ischemia detected by thallium-201 myocardial perfusion imaging. The study included 83 consecutive patients (74 men and 9 women) with a mean age 55.4 +/- 8.5 years who suffered a first myocardial infarction and did not undergo thrombolytic therapy. In all patients, coronary angiography, left ventriculography, and exercise thallium-201 tomographic scintigraphy were performed within 3 to 5 months of the myocardial infarction. Coronary arteriograms showed minimal residual obstructions in 37 (45%) patients. Of a total of 54 patients with < or = 50% obstruction, 18 showed persistent defects and 22 reversible defects on thallium scintigrams. The present study showing estimated angiographic stenosis of < or = 50% as being responsible either for myocardial scar or myocardial ischemia on postexercise thallium scintigrams leads us to conclude that percent value of stenosis does not accurately predict the pathophysiologic significance of coronary atherosclerotic lesions in patients who suffer a myocardial infarction. After a first myocardial infarction, coronary angiographies and thallium-201 scintigrams are complementary for an optimal treatment strategy for selected subsets of patients.

Postexercise changes of the QTc interval in patients with recent myocardial infarction.

A lack of the QTc ratio decrease at maximal exercise is considered as an index of exercise-induced ischemia in patients with coronary artery disease. The authors studied 51 patients with recent myocardial infarction in order to evaluate the QTc changes with exercise in assessing the presence of remaining ischemic myocardium. All patients were submitted to exercise stress tests, coronary angiographies, and exercise thallium 201 scintigraphies within 3-5 months of the myocardial infarction. Of the patients studied, 18 showed one-vessel disease and 33 showed multivessel disease. All vessels were classified as patent or occluded. In all patients with reversible thallium 201 defects both at distance and in the infarct zone, the QTc interval following exercise either showed a prolongation or no change from the resting electrocardiogram. In patients with only fixed perfusion defects, the QTc shortened at the end of the test. This study showed a low sensitivity and specificity for inducible ST-segment depression compared with the delayed redistribution on the postexercise thallium 201 scintigram. QTc variations at the end of exercise electrocardiograms are valuable as a noninvasive, low-cost identification of residual ischemic myocardium in patients after myocardial infarction.

[Significance exercise-induced ST elevation in patients with myocardial infarction]. / Significado do supradesnivelamento ST de esforço em doentes com enfarte do miocárdio.

In 52 patients with previous myocardial infraction, 49 men and 3 women (mean age 56 +/- 7.1 years) the significance of ST-segment elevation during the stress-test, was evaluated. Of the 52 patients 15 (29%) showed St-segment elevation and 37(71%), showed no alteration of the ST-segment. Extension of coronary disease, degree of obstruction, wall motion abnormalities and the presence of residual ischemia were evaluated by coronary angiography, technetium-99M pyrophosphate imaging and exercise TL-201 scintigraphy. From the results of the study one may conclude that, in patients with previous myocardial infraction exercise, ST-segment elevation is a consequence of sub-occlusion of the left anterior descending coronary artery with severe ventricular dysfunction either in patients with one or multiple vessel disease.

[Diagnosis of ischemic cardiopathy in ambulatory care patients. Multivariate analysis of clinical and electrocardiographic data]. / Diagnóstico de cardiopatia isquémica no doente ambulatório. Análise multivariada de dados clínicos e electrocardiográficos.

This study was done on 113 subjects, 93 men and 20 women, whose ages ranged between 32 and 70 years (average 52.9 years). Males varied between 35 and 70 years (average 53.7) and females between 32 and 67 years (average 49.5). Our objective is: to give an account of the different discriminatory methods with mixed data usually used in medical applications, to apply these methods to all the subjects studied with the purpose of comparing their performance and, to develop a protocol for diagnosing coronary artery disease by noninvasive tests. All the subjects were referred for evaluation of chest pain, and were submitted to an exercise test on an ergometric bicycle, selective coronary angiography and left ventriculography. Patients with prior myocardial infarction, cardiomyopathy, valvular or congenital disease, mitral valve prolapse or intraventricular conduction defect were excluded. Subjects were classified as having coronary artery disease and not having coronary artery disease according to the coronarographic results. We used four clinical variables (age, sex, risk factor and chest pain) and five variables obtained from the stress test (ST depression, appearance of chest pain, appearance of arrhythmias, variations in blood pressure and R wave changes). For the analysis of this set of data we use well known univariate statistical methods, such as chi-squared test, F-test and t-test, and the following multivariate statistical methods: Fisher, Quadratic and Logistic, discriminant methods. To study the relative importance of the different variables in the discrimination of the individuals, we performed a stepwise linear discriminant analysis over the 113 subjects. Of the 9 variables tested R-wave was of little value and excluded.(ABSTRACT TRUNCATED AT 250 WORDS)

[Equilibrium radionuclide angiography in patients with previous myocardial infarct. Correlation with electrocardiogram and coronarography]. / Angiografia de radionuclídos de equílibrio em doentes com enfarte do miocárdio prévio. Correlação com o electrocardiograma e a coronariografia.

Fifty five patients with previous myocardial infarction (MI), 47 male and 8 female, mean age 55.5 +/- 8.9 years, have been studied in order to correlate the alterations found on the equilibrium (gated) radionuclide angiogram (RNA) with the location of the MI on the electrocardiogram of the obstructive lesions on coronary angiographies. Of the 55 patients studied, 22% showed no regional wall motion abnormalities (WMA). Both MI with and without Q wave may show WMA, which are significatively more frequent in patients with anterior MI on the ECG and with occlusive lesions (greater than 90%) on coronariographies. Regional localization of the WMA on the RNA does not identify the localization of the obstructive lesions. Hypokinesia was the most frequent type of WMA found both with occlusive (greater than 90%) and sub-occlusive (greater than 75%) lesions. Low values of the ejection fraction (less than 45%) were found in the presence of WMA and occlusive artery lesions.

[Immunosuppression therapy in peripartum myocardiopathy]. / Terapêutica imunosupressora na miocardiopatia periparto.

The dramatic clinical recuperation of a thirty years old, Caucasian female, with peripartum cardiomyopathy, treated with azathioprine and prednisolone, is described. The maintenance of the same degree of ventricular dilatation and fractional shortening (14%) on serial echocardiograms inspite of complete regression of cardiac congestion was the most intriguing feature of this clinical case.

[Silent ischemia in patients with previous myocardial infarct. Correlation of Holter and coronarography]. / Isquémia silenciosa em doentes com prévio enfarte de miocárdio correlação entre Holter e coronariografia.

OBJECTIVE: Our objective was to determine the presence of silent myocardial ischemia and the degree of coronary obstructions. DESIGN: Successively patients with myocardial infarction. SETTING: Patients admitted to the coronary intensive care, later followed in a specialised out-patients consultation. PATIENTS: 62 patients with previous myocardial infarction. INTERVENTIONS: All the patients were submitted to Holter-monitoring and coronary angiography. RESULTS: Silent ischemia was present in 14 (22,6%) of the patients. Seven of these (50%) had 3 vessels disease, 2 (14,3%) had 2 vessels disease, and 5 (35,7%) had 1 vessel disease. Twelve of the patients (86%) had occlusive lesions (greater than 90%), localised in 11 (79%) in the third proximal segment of the artery. CONCLUSIONS: Our results showed that the presence of silent myocardial ischemia was predominantly associated with 3 vessels disease, and with lesions of more than 90% of occlusion, localised in the 1/3 proximal of the vessel. Patients with previous myocardial infarction and silent ischemia may belong to a subgroup with surgical indication. And so, Holter studies in these patients should be followed by angiographic studies for localization of the obstructive lesions.

Postexercise electrocardiographic and clinical changes in patients with sick sinus syndrome.

Forty patients with sick sinus syndrome, 15 women and 25 men with a mean age of 53.83 +/- 13.34 years, were studied using a maximal graded bicycle stress test. None of the patients were using a pacemaker or being treated with drugs that would interfere with the sinus node function; one patient had family myocardiopathy and eight suffered from essential hypertension. All patients, including those suffering from very marked bradycardia (less than 40 beats/min) responded to the increased effort with increased heart rate. The exercise test was stopped in 22 patients (55%) after the appearance of clinical signs and in 4 (10%) after ST-segment depression greater than 1 mm. Eight (20%) finished the stress test after reaching the maximal heart rate according to age, due to an increase in sinus rate. The exercise produced or increased extrasystoles in five patients (12.5%), but only one was forced to suspend the test. The Q-T interval, corrected for heart rate according to Bazett's formula (QTc), was measured on the resting ECG before the start of the test and on the ECG recorded immediately following the end of the exercise in all patients, except one with atrial fibrillation. In 24 patients (60%), a QTc mean increase of 0.040 +/- 0.022 sec was observed at the end of the stress test. Fourteen (35%) had the usual shortening due to the increase in heart rate. One patient showed no variation of the QTc. A lengthening of the QTc at the end of the exercise in more than half of the patients was the most intriguing electrocardiographic change.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac alterations in ankylosing spondylitis.

Forty patients, 30 men and 10 women with an average age of 38.47 +/- 11.07 years, suffering from ankylosing spondylitis and attending a Rheumatology Outpatient Clinic, were evaluated for cardiovascular involvement. The evaluation was based on patients' clinical observation, electrocardiography, echocardiography, and chest x-ray. More than a simple review, this study was undertaken with the aim of arriving at a better clinical definition of the cardiovascular manifestations found in ankylosing spondylitis. In fact, of the 40 patients, 8 (20%) had systemic hypertension for which an explanation could not be found, 4 of whom were less than forty-five years old; the echocardiogram showed mitral valve prolapse in 4 patients (10%), 2 of them with a systolic murmur and other 2 with a protosystolic click on auscultation. More significant than the changes in conduction was the finding of a sinus bradycardia in 9 patients (22.5%), and a PR interval below 120 msec in 3 patients (7.5%). The authors conclude that the extension of cardiovascular changes in ankylosing spondylitis is more vast than usually acknowledged.