Hemodynamic and tissue oxygenation responses to exercise and beta-adrenergic blockade in patients with hyperthyroidism.

BACKGROUND: Exercise-induced dyspnea is a frequent feature in patients with hyperthyroidism. HYPOTHESIS: Data from clinical studies to elucidate the origin of this symptom are lacking. In the current study, we examined the hemodynamic and oxygenation responses to exercise and beta-adrenergic blockade in patients with hyperthyroidism and their relationship with dyspnea. METHODS: Hemodynamic studies were performed under resting conditions and after isotonic exercise in 15 patients with hyperthyroidism and 11 control subjects. Exercise was applied using a bicycle ergometer, with progressive loads. In the hyperthyroid group, measurements were repeated at rest and during supine exercise after administering 15 mg of intravenous metoprolol. RESULTS: End-diastolic pulmonary artery pressure and cardiac index were higher in the hyperthyroid group than in controls (18.6 +/- 5.3 vs. 11.2 +/- 4.9 mmHg; p = 0.02, and 6.0 +/- 1.7 vs. 2.8 +/- 0.5 l/min/m2; p = 0.0001, respectively). After exercise, there was an increase in end-diastolic pulmonary artery pressure in the hyperthyroid group (18.6 +/- 5.3 to 25.5 +/- 9.9 mmHg; p = 0.02), revealing impaired cardiocirculatory reserve. Pulmonary arteriolar resistance increased significantly in parallel with end-diastolic pulmonary artery pressure after drug administration, suggesting an inadequate cardiovascular response after beta blockade in patients with hyperthyroidism. CONCLUSION: We observed that functional left ventricular reserve is impaired in patients with hyperthyroidism, suggesting an explanation for the frequent symptom of dyspnea and impaired exercise tolerance. Moreover, we also suggest that beta-adrenergic blockade may adversely affect cardiovascular function in patients with hyperthyroidism.

Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial.

OBJECTIVES: This prospective, randomized, placebo-controlled, double-blind clinical trial was performed to analyze the effect of atorvastatin compared with placebo on the occurrence of a 6-month composite of cardiovascular events after vascular surgery. Cardiovascular complications are the most important cause of perioperative morbidity and mortality among patients undergoing vascular surgery. Statin therapy may reduce perioperative cardiac events through stabilization of coronary plaques. METHODS: One hundred patients were randomly assigned to receive 20 mg atorvastatin or placebo once a day for 45 days, irrespective of their serum cholesterol concentration. Vascular surgery was performed on average 30 days after randomization, and patients were prospectively followed up over 6 months. The cardiovascular events studied were death from cardiac cause, nonfatal myocardial infarction, unstable angina, and stroke. RESULTS: Fifty patients received atorvastatin, and 50 received placebo. During the 6-month follow-up primary end points occurred in 17 patients, 4 in the atorvastatin group and 13 in the placebo group. The incidence of cardiac events was more than three times higher with placebo (26.0%) compared with atorvastatin (8.0%; P =.031). The risk for an event was compared between the groups with the Kaplan-Meier method, as event-free survival after vascular surgery. Patients given atorvastatin exhibited a significant decrease in the rate of cardiac events, compared with the placebo group, within 6 months after vascular surgery (P =.018). CONCLUSION: Short-term treatment with atorvastatin significantly reduces the incidence of major adverse cardiovascular events after vascular surgery.

[Electrocardiographic abnormalities and cardiovascular risk factors for ischemic heart disease in an adult population from São Paulo, Brazil]. / Alterações eletrocardiográficas e sua relação com os fatores de risco para doença isquêmica do coração em população da área metropolitana de São Paulo.

OBJECTIVE: Ischemic heart disease is associated with high rates of mortality and it is the most prevalent among cardiovascular diseases. It is a multifactorial disease, and its prevention depends on control of risk factors. Resting electrocardiogram can be used to detect manifestations of ischemic heart disease, since some electrocardiographic abnormalities are indicative of coronary disease in asymptomatic subjects. The aim of the study was to analyze the relationship between electrocardiographic abnormalities and risk factors for ischemic heart disease in an adult population from the metropolitan area of São Paulo. METHODS: A cross-sectional study was carried out in an adult population (age 20 years and over) from Cotia, near São Paulo, southeastern of Brazil. The study population comprised 1067 subjects. The subjects were interviewed using a questionnaire. The variables studied were: gender, age, smoking behaviour, physical activity, body mass index, waist-to-hip ratio, blood pressure, diabetes mellitus, blood lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides) and electrocardiographic abnormalities. Electrocardiographic abnormalities were grouped according to the classification: ST-T changes, left ventricular hypertrophy and abnormalities non related to ischemic myocardial disease or without abnormalities. RESULTS: The population was relatively -young (79% younger than 50 years, mean age 39.8 +/- 13.2 years old), and 59.3% were female. The resting electrocardiogram showed ST-T changes in 9.5% of the subjects and left ventricular hypertrophy in 3.3%. Female gender, age over 65 years for women and 55 years for men, diabetes, hypertension, total cholesterol >/= 200 mg/dl, LDL-cholesterol >/=130 mg/dl, Triglycerides >/=200 mg/dl, body mass index >/= 25 Kg/m2 and abnormal waist-to-hip ratio, were positively related to ST-T changes. Male gender, diabetes, hypertension and smoking behaviour were positively related to left ventricular hypertrophy. In the presence of ST-T changes on the ECG, we observed an odds ratio of 3.54 for the diagnosis of systolic hypertension an of 1.83 for total cholesterol >/= 200 mg/dl. In the presence of left ventricular hypertrophy on the ECG, we found an odds ratio of 5.92 for systolic hypertension diagnosis. Among the three most important risk factors correlated to electrocardiographic abnormalities indicative of myocardial ischemia, two can be controlled by nutritional intervention (hypertension and total cholesterol >/= 200 mg/dl). This findings suggest the importance of its early detection. Future studies should determine the predictive value of the electrocardiogram, a simple and inexpensive method, suggesting the presence of cardiovascular risk factors in epidemiological and nutritional studies.

Alteraçöes eletrocardiográficas e sua relaçäo com os fatores de risco para doença isquêmica do coraçäo em populaçäo da área metropolitana de Säo Paulo / Electrocardiographic abnormalities and cardiovascular risk factors for ischemic heart disease in an adult population from Säo Paulo, Brazil

OBJETIVO: A doença isquêmica do coraçäo apresenta altas taxas de mortalidade e é a mais prevalente entre as doenças cardiovasculares. É uma doença multifatorial, cuja prevençäo depende do controle dos fatores de risco. O eletrocardiograma de repouso pode ser utilizado para detectar manifestaçöes da doença isquêmica do coraçäo quando o indivíduo ainda é assintomático. O objetivo do estudo foi o de analisar a relaçäo entre as anormalidades eletrocardiográficas e os fatores de risco para doença isquêmica do coraçäo em uma populaçäo adulta residente na área metropolitana de Säo Paulo. MÉTODOS: Realizou-se um estudo transversal com populaçäo do município de Cotia (SP). A amostra constou de 1067 indivíduos com idade acima de 20 anos, de ambos os sexos. Os dados foram obtidos por meio de entrevista com utilizaçäo de um questionário padronizado. As variáveis estudadas foram: sexo, idade, tabagismo, atividade física, índice de massa corpórea, relaçäo cintura/quadril, pressäo arterial, diabetes melito, dislipidemia (colesterol total, LDL-colesterol, HDL-colesterol e triglicérides) e alteraçöes eletrocardiográficas. As alteraçöes eletrocardiográficas foram agrupadas em três categorias: alteraçöes de repolarizaçäo ventricular (ARV), sobrecarga do ventrículo esquerdo (SVE) e alteraçöes näo relacionadas à isquemia miocárdia ou sem alteraçöes (NRI). RESULTADOS: A populaçäo de estudo era predominantemente jovem, sendo 79 por cento abaixo de 50 anos, com idade de 39,8 anos ± 13,2 anos. Cerca de 59,3 por cento dos indivíduos eram do sexo feminino. O eletrocardiograma mostrou que 9,5 por cento da populaçäo apresentava ARV e 3,3 por cento apresentava SVE. O sexo feminino, a idade de risco (acima de 65 anos para mulheres e acima de 55 anos para homens), a presença de diabetes, hipertensäo arterial, colesterol total ³ a 200 mg/dl, LDL-colesterol ³ a 130 mg/dl, triglicérides acima de 200 mg/dl, índice de massa corpórea indicativo de sobrepeso ou obesidade (³25 Kg/m2),relaçäo cintura/quadril alterada correlacionaram-se positivamente com ARV. O sexo masculino, diabetes, hipertensäo arterial e o tabagismo foram correlacionados positivamente com SVE. Na presença de ARV no ECG encontramos uma razäo de chance de 3,54 para a ocorrência do diagnóstico de hipertensäo sistólica e de 1,83 para colesterol total ³ a 200 mg/dl. Na presença de SVE no ECG, a razäo de chance para a ocorrência do diagnóstico de hipertensäo sistólica observada foi de 5,92...

Hyperlipidemia related to the use of HIV-protease inhibitors: natural history and results of treatment with fenofibrate

Hyperlipidemia has been frequently recorded as a side effect of treating HIV patients with protease inhibitors (PI). This study was initiated to analyze the modifications on blood lipids in HIV-patients receiving PI and the safety and efficacy of the treatment with fenofibrate. Total (TC) and HDL-cholesterol, triglycerides (TG), and CD(4)(+) T-cell counts were measured in 30 HAART-naive patients (Group I) before and after PI introduction. In a second phase of the study, the effects of fenofibrate on lipids, CPK, CD(4)(+), and viral load were determined in 13 patients (Group II) with elevated TC or TG. In Group I, 60 of the patients showed TC or TG elevations. Average increments of 31 and 146 in TC and TG respectively (p<0.0006 and p<0.0001) were observed. In Group II, fenofibrate treatment was associated with decrements of 6.6 (TC) and 45.7 (TG) (p=0.07 and 0.0002) and no modifications on CPK, CD(4)(+), and viral load. In conclusion, hyperlipidemia is common during the treatment of HIV with protease inhibitors, and fenofibrate appears to be an effective and safe choice for its treatment.

Análise crítica dos métodos de monitorizaçäo hemodinâmica em terapia intensiva / Critical analysis of hemodynamic monitoring methods on intensive care unit

Para um grupo específico de pacientes da Unidade de Terapia Intensiva com instabilidade hemodinâmica, a monitorizaçäo deve incluir a obtençäo do débito cardíaco e outros parâmetros que interferem na funçäo cardíaca: pressäo de enchimento ventricular esequerdo e resisténcia vascular sistêmica. Desde 1970, o cateter de Swan-Granz vem proporcionando melhor conhecimento dos fenômenos fisiopatológicos envolvidos no choque e orientando a terapêutica adequada. Hoje, com o cateter de artéria pulmonar, säo possíveis a medida contínua do débito cardíaco e a melhor avaliaçäo da funcäo do ventrículo direito. A controvérsia gerada pela indefiniçäo quanto aos reais benefícios do uso do cateter de Swan-Ganz tem estimulado ampla discussäo na literatura sobre o potencial dos diferentes métodos näo-invasivos de monitorizaçäo do débito cardíaco, resultado do avanço tecnológico. Ainda que näo possam ser considerados substitutos do método clássico invasivo, a bioimpedância torácica, o Doppler-ecocardiograma transesofágico, a análise pletismográfica do pulso e a medida do CO2 expirado proporcionam excelente avaliaçäo contínua da tendência do desempenho cardíaco e podem contribuir para a seleçäo dos pacientes que väo se beneficiar da monitorizaçäo invasiva.

Aneurisma subvalvar mitral de ventrículo esquerdo / Mitral subvalvular aneurysm of the left ventricle

A 21-year-old white man presented with cardiogenic shock and refractory pulmonary congestion. At the transthoracic echocardiogram a subvalvar left ventricular aneurysm of the inferior wall with severe mitral regurgitation was observed. The outcome was favorable after surgical correction of the mitral regurgitation and of the subvalvar aneurysm. We emphasize that, whenever possible, valvar repair is better than mitral replacement, since annulus tissue fragility causes suturing of the mitral prosthesis to be difficult.

Falência hepática aguda secundária a choque cardiogênico em portadores de insuficiência cardíaca congestiva / Acute Liver Failure Cardiogenic Shock in Patients with Congestive Heart Failure

Fulminant hepatic failure is a complication of severe cardiocirculatory failure, with high morbidity and mortality, and is frequently misdiagnosed as fulminant viral hepatitis. We report three cases of patients with chronic severe heart failure who developed cardiogenic shock complicated by elevation of aminotransferase levels above 1,000 soon after the most severe episode of hypotension. All the three patients presented regression of hepatic enzymes 72h after admission. Two patients developed hepatic encephalopathy and renal failure. One underwent the implantation of an artificial left ventricle, followed by orthotopic heart transplantation. One died of systemic multiple organ failure, after he had showed improvement on his hepatic profile, and one was sent to the ward, after 15 days with marked improvement on his clinical status and no signs of hepatic disease

Toxicidade pelo tiocianato decorrente do uso prolongado de nitroprussiato de sódio na insuficiência cardíaca grave / Thiocyanate toxicity arising from prolonged use of sodium nitroprusside in severe heart failure

PURPOSE--To evaluate the toxicity of thiocyanate induced by the infusion of sodium nitroprusside in patients with severe congestive failure. METHODS--We studied 23 patients with congestive heart failure, in class IV (NYHA) under continuous infusion of sodium nitroprusside with doses varying between 0.5 and 5.5 micrograms/kg/min. Clinical evaluation, thiocyanate serum dosage and laboratorial evaluation of renal, hepatic and pulmonary functions were done. RESULTS--Seventeen patients (74 per cent) presented toxic levels of thiocyanate (over 10 micrograms/ml), with the average of 29.9 +/- 4.4 micrograms/ml. Only renal function was related to the presence of intoxication. Clinical evaluation was not accurate to diagnose the thiocyanate toxicity in the patients. CONCLUSION--Sodium nitroprusside is potentially toxic, especially when the renal function is abnormal. Thiocyanate dosage is useful in diagnosing nitroprusside induced toxicity and then it contributes to an adequate treatment and prevention of clinical toxicity