[Constrictive pericarditis: an early diagnosis?]. / Pericardite constritiva: um diagnóstico precoce?

The authors report a case study of a 73-year-old male, with signs of right-sided heart failure with 6 months of evolution. It was constrictive pericarditis, without radiologic, echocardiographic and magnetic resonance imaging manifestations, diagnosed on the basis of the clinical situation and hemodynamic evaluation during cardiac catheterization. The authors suggest that the lack of imagiologic manifestations might have been the result of an early diagnosis, before the development of the classic picture. Pericardiectomy, performed with success, was followed by resolution of the heart failure. It was not possible, histologically, to draw conclusions about the etiology. The development of mitral regurgitation after pericardiectomy has enriched this case with an unusual, but previously described, complication of this type of surgery.

[Primary mesothelioma of the pericardium: a clinical case]. / Mesotelioma primário do pericárdio: um caso clínico.

We describe a 33-years-old male patient, presenting with progressive right heart failure. After evaluation, the hypothesis of effusive-constrictive pericarditis was considered. Medical therapy was initiated with no clinical benefit. On the 15th day after admission he was proposed for surgical intervention. The intraoperatory examination revealed a thick pericardium adhering to the epicardium without a clear separation between them. Complete resection was technically impossible. The postoperative course evolved with worsening heart failure and development of renal failure requiring hemodialysis. A diagnosis of primary pericardial mesothelioma was made after histological evaluation. The patient died 8 days after surgery despite all efforts at hemodynamic compensation. Despite its rarity, this diagnosis should be considered in cases with rapid evolution of constrictive or effusive-constrictive pericarditis. The prognosis for pericardial mesothelioma is poor due to its late diagnosis, the difficulty of surgical excision and poor response to radio- or chemotherapy.

[The prognostic significance of late potentials in patients with chronic coronary disease]. / Significado prognóstico dos potenciais tardios em doentes com doença coronária crónica.

OBJECTIVE: The prognostic value of late potentials (LP) in the subacute phase of myocardial infarction (MI) is well known, but its prognostic value in long-standing coronary disease (LSCD) has not yet been established. In a population with LSCD we searched for a relation between the presence of LP in signal-averaged ECG (SAECG) performed before cardiac catheterization, and the incidence of cardiac events. METHODS: Based on our department's casuistics, we selected 50 consecutive patients with coronary disease confirmed by an angiogram and LP, and a control group without LP, in SAECG. We selected 91 men and nine women with an average age of 59 +/- 8 years. None of the patients had had ischemic events or revascularization procedures, in the 3 month period before catheterization. The follow-up was made between the time of the SAECG and the last medical visit. The events recorded were: ventricular arrhythmia, cardiac death, coronary angioplasty, coronary artery by-pass graft, MI or unstable angina. RESULTS: During a follow-up period of 20.1 +/- 8 months, we found no statistically significant difference between the two groups, regarding the incidence of such events. However, there was a higher incidence of ventricular arrhythmic events in the group with LP (four patients with ventricular tachycardia against none in the control group). All patients with ventricular tachycardia had had a previous MI. CONCLUSIONS: In this study, the presence of LP in SAECG did not have the same prognostic value found in the subacute phase of MI, but a higher incidence of arrhythmic events was observed in the group with LP and a previous MI.

[Infectious endocarditis caused by Q fever. Apropos of a clinical case]. / Endocardite infecciosa a febre Q. A propósito de um caso clínico.

Endocarditis is a rare, but some times fatal, complication of Q fever. Its diagnosis is difficult and it is based on non-specific cardiac findings and a high title of phase I antibodies. The treatment is based on tetracyclines alone or in combination with cotrimoxazole, for long periods of time. The therapeutic efficacy is evaluated by the measurement of phase I antibodies, every three months. The relapses are frequent despite the long period of antibiotic therapy. We report what is probably the first case of Q fever prosthesis endocarditis in Portugal, as a complication following an acute episode of Q fever.

[Experience with dl-sotalol in the treatment of supraventricular arrhythmia]. / Experiência com dl-sotalol na terapêutica de arritmias supraventriculares.

OBJECTIVES: To review the results of our experience with oral dl-sotalol for preventive treatment of supraventricular tachyarrhythmias (atrial fibrillation and paroxysmal supraventricular tachycardia). POPULATION: 51 patients, 28 female and 23 male, mean age 46.2 +/- 14.4 years, from outpatient arrhythmology clinics of our institution, with recurrent supraventricular tachyarrhythmias (atrial fibrillation in 24 patients and paroxysmal supraventricular tachycardia in 27). All the patients, but one, had normal left ventricular function. Dl-sotalol was first choice medication in only three patients. Previously 2 +/- 1.3 antiarrhythmic drugs had been used. METHODS: Retrospective evaluation of therapeutic response (number of clinical recurrences according to a semi-quantitative scale) and secondary effects of dl-sotalol during a minimum follow-up of 18 months. The mean daily dose was 205 +/- 90 mg (80 to 400 mg). RESULTS: In 37% of the patients there were no clinical recurrences of arrhythmia during follow-up. In 37% of the patients there was a significant reduction in recurrences. In 26% there was no change in the number of recurrences. There were no significant differences in response between patients with atrial fibrillation and those with paroxysmal supraventricular tachycardia. Secondary effects occurred in 16% of the patients: symptomatic bradycardia, asthma or sexual dysfunction. No patient had heart failure, torsades de pointes, syncope or death. CONCLUSIONS: From our experience, DL-sotalol seems to be a good therapeutic alternative for the preventive treatment of supraventricular tachyarrhythmias, with a low risk in patients with good ventricular function.

[Coronary disease in women --risk factors, diagnostic and therapeutic approaches]. / Doença coronária na mulher--factores de risco, atitudes diagnósticas e terapêuticas.

OBJECTIVE: To characterize and evaluate the prognosis of coronary artery disease in women. SETTING: Hospital with referral for cardiac catheterization, since 1982. PATIENTS: We studied post-menopause patients, not under hormonal replacement therapy, to whom coronary artery disease (CAD) was diagnosed by coronary angiography in the first 5 years of activity of our centre. Patients should have at least five years of follow-up (Group W-84 patients). METHODS: Risk factors for CAD were studied in Group W, and compared with a group of male patients with CAD and a group of women without CAD, that underwent coronary arteriography in the same period of time. RESULTS: Most risk factors for CAD were more prevalent in women with CAD, with special focus on hyperlipidaemia and hypertension. Cigarette smoking was more frequent in men. At the time of coronary arteriography, most patients were in NYHA class I-II and CCS class 3-4. On follow-up 68 patients were revascularized (bypass graft on most). At five years, five patients died and most survivors were a NYHA class I-II and CCS class 1-2. Patients with multivessel disease (MVD), were older, more symptomatic and with more risk factors than patients with single vessel disease (SVD). Follow-up was on medical treatment 17% of the patients and included revascularization procedures in 83% of MVD patient's disease and 77% of patients with SVD patients. Cardiac events (unstable angina, myocardial infarction, admission for cardiac failure) occurred in 49% of MVD and 32% of SVD patients, and distribution of CCS and NYHA classes at 5 years were similar in both subgroups. CONCLUSIONS: The present study characterize the group of women with CAD as having a high prevalence of risk factors, with a large proportion of multivessel disease and high rates of revascularization. Prognosis at five years was favourable in this group. Multivessel disease was associated with presence of more risk factors and increased clinical severity before catheterization, but at five years the prognostic was similar to single disease, therapeutic options, notably the high rate of revascularization, could account for these results.

[The 3-year prognosis of patients with suspected coronary disease and a normal myocardial scintigraphy with thallium-dipyridamole]. / Prognóstico aos 3 anos de doentes com suspeita de doença das coronárias e cintigrafia miocárdica com tálio-dipiridamol normal.

OBJECTIVES: To assess the 3-year prognosis of patients with suspected coronary artery disease and a normal dipyridamole-thallium scintigram. POPULATION: 43 patients, 16 male and 27 female, mean age 55.8 +/- 9.2 years with suspected coronary artery disease. Forty-two patients had anginal complaints. There was a previous positive treadmill exercise test in 14 patients. All the patients had a normal dipyridamole-thallium SPECT. METHODS: Dipyridamole was infused at a rate of 0.56 mg/kg in 4 minutes followed by 3 minutes of low-level cycloergometer exercise. Two mCi of thallium-201 were injected 3 minutes after the end of dipyridamole infusion. Stress and redistribution SPECT acquisitions were performed respectively 5-10 minutes and 4 hours after thallium-201 injection. The cardiac events during a 3-year follow-up were analysed. RESULTS: No patient had unstable angina, PTCA, CABG or death. One patient suffered an inferior myocardial infarction 28 months after the scintigraphy. The event rate was 0.78% per patient per year. CONCLUSION: Three-year prognosis in patients with suspected coronary artery disease after a normal dipyridamole thallium SPECT is excellent approaching that of the general population.

[The maximum heart rate in the exercise test: the 220-age formula or Sheffield's table?]. / Frequência cardíaca máxima na prova de esforço: 220-idade ou tabela de Sheffield?

OBJECTIVE: To determine in the maximum cardiac rate in exercise test of apparently healthy individuals may be more properly estimated through 220-age formula (Astrand) or the Sheffield table. DESIGN: Retrospective analysis of clinical history and exercises test of apparently healthy individuals submitted to cardiac check-up. PARTICIPANTS: Sequential sampling of 170 healthy individuals submitted to cardiac check-up between April 1988 and September 1992. MATERIAL AND METHODS: Comparison of maximum cardiac rate of individuals studied by the protocols of Bruce and modified Bruce, in interrupted exercise test by fatigue, and with the estimated values by the formulae: 220-age versus Sheffield table. RESULTS: The maximum cardiac heart rate is similar with both protocols. This parameter in normal individuals is better predicted by the 220-age formula. CONCLUSIONS: The theoretic maximum cardiac heart rate determined by 220-age formula should be recommended for a healthy, and for this reason the Sheffield table has been excluded from our clinical practice.

[Predictive value of coronarography in the localization of arterial lesions responsible for future infarcts of the myocardium]. / Valor preditor da coronariografia na localização da lesão arterial responsável por futuro enfarte do miocárdio.

OBJECTIVES: To evaluate the capability of coronary angiography, when performed in stable conditions, to predict which arterial segment will be responsible for future acute myocardial infarction. POPULATION: 17 patients (15 men and 2 woman), mean age 52 +/- 12 years, who suffered a myocardial infarction (AMI), and had been previously submitted to coronary angiography. After the myocardial infarction all the patients had a new angiography. METHODS: The coronary angiographies performed before and after the AMI were compared, by simultaneous visualization of the films, and the segment related to the AMI was determined with the help of ECG and ventriculography. Among the arterial segments with in the coronary angiography performed before the AMI and who were found to be related with it, three Groups were considered: A-with no angiographic lesion; B-with less then 70% lesion; C-with a lesion equal or superior to 70% (angiographically significant). RESULTS: In nine patients the arterial segment related to AMI belonged to group A. In four patients it belonged to group B and in four to C. Segments with angiographically significant lesions were responsible for AMI in less then one fourth of the patients. CONCLUSIONS: Coronary angiography, when performed in stable conditions, has a low predictive value to determine the localization of the arterial segment related to future AMI.

[Does the modified Bruce protocol induce physiological stress equal to that of the Bruce protocol?]. / O protocolo de Bruce modificado induz stress fisiológico igual ao do protocolo de Bruce?

OBJECTIVE: To determine if the physiological stress induced by the modification of Bruce protocol used in our hospital is equivalent to the original protocol. DESIGN: Retrospective analysis of clinical history, physical examination and stress test of apparently healthy individuals submitted to cardiac check up. SETTING: Outpatient private cardiological clinical. PARTICIPANTS: Sequential sampling of 80 individuals apparently healthy, submitted to cardiac check-up between April 1988 and September 1992. MATERIAL AND METHODS: Comparison of heart rate, blood pressure and double product progression, as well as time of exercise of individuals studied by the Bruce protocol (group A: n = 51) with the same data of individuals tested by the modified Bruce protocol (group B: n = 29). MEASUREMENTS AND MAIN RESULTS: The first stage of group A protocol provokes a superior physiologic stress than group B protocol, since there are bigger increments on heart rate (28.8 +/- 9.9 vs. 20.2 +/- 11.2 bpm; p < 0.01), blood pressure (27.0 +/- 11.3 vs. 14.3 +/- 11.4 mmHg; p < 0.0001) and, consequently, higher double products. In submaximal stages with the same speed and grade on the treadmill the hemodynamical stress is similar in both groups. At peak exercise, group A attains higher values on systolic blood pressure (197.1 +/- 9.5 vs. 188.8 +/- 10.4 mmHg; p < 0.001), double product (34330.4 +/- 2191.8 vs. 33060.9 +/- 2049.8; p = 0.01) and corrected exercise time also higher than estimated (929 +/- 91 vs. 818 +/- 94 sec; p = 0.02). It could be found that more individuals on group A (76% vs. 48%; p = 0.02) could complete the stage of 6.8 Km/h x 16% (stage IV on Bruce protocol and V on modified Bruce protocol. CONCLUSIONS: Modified Bruce protocol has a lighter initial increment, but decreases moderately the capacity of peak exercise due to peripheral fatigue secondary to the first stage of low intensity. Bruce protocol has a higher initial increment but permits to attain higher peak exercise intensities. Bruce protocol seems more adequate to individuals with good physical capacity and the modified Bruce protocol to individuals moderately limited in their functional capacity due to bad physical fitness or illness.