Prognostic factors of rheumatic mitral stenosis during pregnancy and puerperium.

OBJECTIVE: To identify characteristics associated with complications during pregnancy and puerperium in patients with rheumatic mitral stenosis. METHODS: Forty-one pregnant women (forty-five pregnancies) with mitral stenosis, followed-up from 1991 to 1999 were retrospectively evaluated. PREDICTOR VARIABLES: the mitral valve area (MVA), measured by echocardiogram, and functional class (FC) before pregnancy (NYHA criteria). Maternal events: progression of heart failure, need for cardiac surgery or balloon mitral valvulotomy, death, and thromboembolism. Fetal/neonatal events: abortion, fetal or neonatal death, prematurity or low birth weight (<2,500 g), and extended stay in the nursery or hospitalization in newborn ICU. RESULTS: The mean +/- SD of age of the patients was 28.8+/-4.6 years. The eventful and uneventful patients were similar in age and percentage of first pregnancies. As compared with the level 1 MVA, the relative risk (RR) of maternal events was 5.5 (95% confidence interval (CI) =0.8-39.7) for level 2 MVA and 11.4 (95% CI=1.7-74.5) for level 3 MVA. The prepregnancy FC (FC > or = II and III versus I) was also associated with risk for maternal events (RR=2.7; 95% CI=1.4-5.3).MVA and FC were not importantly associated with these events, although a smaller frequency of fetal/neonatal events was observed in patients who had undergone balloon valvulotomy. CONCLUSION: In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but are not associated with fetal/neonatal events. Balloon mitral valvulotomy could have contributed to reducing the risks of fetal/neonatal events in the more symptomatic patients who had to undergo this procedure during pregnancy.

[Efficacy and tolerance of the bisoprolol/hydrochlorothiazide combination in arterial hypertension]. / Eficácia e tolerabilidade da associação bisoprolol/ hidroclorotiazida na hipertensão arterial.

PURPOSE: Multicenter, open and non-controlled study to evaluated the efficacy and the tolerability of a low-dose combination of two anti-hypertensive agents: a cardioselective beta-blocker, bisoprolol (2.5 and 5.0 mg) with 6.25 mg of hydrochlorothiazide. METHODS: One hundred and six patients in the stage I and stage II of the systemic hypertension (mild to moderate) were given the bisoprolol/hydrochlorothiazide combination once daily and the diastolic and systolic blood pressures were monitored during the 8-week trial. RESULTS: The bisoprolol/hydrochlorothiazide combination reduced the initial mean values of systolic and diastolic blood pressures, respectively, from the 157.4 mmHg and 98.8 mmHg to 137.3 mmHg and 87.4 mmHg. At the end of the treatment period, 61% of the patients normalized blood pressure values (< 90 mmHg) and 22.9% of them had responded to the treatment, resulting in a total response rate (normalized + responsive) of 83.9% of cases. Adverse events were described only in 18.9% of the patients and dizziness and headache were the most common. There were no clinically significant changes on plasma levels of potassium, uric acid, glucose, or in the lipid profile. CONCLUSION: The combination of low dosages of bisoprolol and hydrochlorothiazide may be considered an effective, well tolerated and rational alternative for the initial treatment of the patients with mild to moderate hypertension.

[Temporal QT dispersion in patients with systemic blood hypertension]. / Dispersão temporal do QT em pacientes com hipertensão arterial sistêmica.

PURPOSE: To evaluate QT dispersion in hypertensive patients, with and without left ventricular hypertrophy, and compare with normal persons. METHODS: Thirty eight patients (21 male and 17 female, age 55 +/- 15 years) underwent echocardiography and simultaneous 12 lead, vertically aligned, electrocardiogram at 50 mm/s speed. No patient was on antiarrhythmic therapy. There were 19 non-hypertensive patients that constituted the control group (G-I). Group II was constituted by the other 19 patients, who were hypertensives. This group was further divided in group II-A (9 patients without left ventricular hypertrophy) and group II-B (10 patients with left ventricular hypertrophy). QT dispersion was obtained by the difference between the longest and the shortest QT registered. RESULTS: QT dispersion was significantly increased on hypertensive patients, both with and without left ventricular hypertrophy, when compared to controls (G-I 31 +/- 9 ms, G-II 52 +/- 15 ms. P < 0.0001; G-IIa 46 +/- 10 ms and G-IIb 56 +/- 18 ms X G-I, p < 0.0005). In hypertensive patients, there was no statistically significant difference between group II-A and group II-B. CONCLUSION: We conclude that QT dispersion is significantly increased on hypertensive patients when compared to non-hypertensive individuals and that such increase, occurs before left ventricular hypertrophy develops. These findings suggest that, in hypertensive patients, electrical changes in left ventricular myocardium can precede structural and morphological abnormalities. Such findings offer new insights into the mechanisms related to enhanced mortality among hypertensive patients.

Dispersäo temporal do QT em pacientes com hipertensäo arterial sistêmica / QT dispersion in patients with hypertension

OBJETIVO - Avaliar a medida da dispersäo do QT (DQT) em portadores de hipertensäo arterial sistêmica, com e sem hipertrofia ventricular esquerda (HVE) e comparar com indivíduos normais. MÉTODOS - Foram submetidos a ecocardiograma e eletrocardiograma (ECG) de 12 derivaçöes simultâneas, alinhadas, na velocidade de 50mm/s, 38 pacientes (21 homens e 17 mulheres, com idade média 55ñ15 anos). Nenhum deles estava em uso de antiarrítmicos. Dezenove eram näo hipertensos constituindo o grupo controle (G-I); 19 hipertensos (GII), sendo 9 sem HVE (índice de massa 96ñ33g/m²=GIIa) e 10 portadores de HVE (índice de massa 163ñ33 g/m²=GIIb). A DQT foi obtida pela subtraçäo entre o mior e o menor QT medidos nas 12 derivaçöes, obtendo-se a média de 3 batimentos consecutivos. RESULTADOS - A DQT foi maior nos indivíduos hipertensos com ou sem HVE, quando comparada com indivíduos controles (G-I31ñ9ms, G-II52ñ15ms, P<0,001; G-IIa 46ñ10ms e G-IIb 56ñ18ms X G-I, p<0,0005). Entretanto, quando comparamos entre si os indivíduos hipertensos com e sem hipertrofia ventricular esquerda, apesar de ter havido diferença em valores absolutos quando testado estatisticamente, essa diferença näo foi identificada. CONCLUSÄO - A DQT é significativamente maior nos indivíduos hipertensos e estas modificaçöes ocorrem antes do aparecimento de HVE, sugerindo que alteraçöes elétricas do miocárdio podem preceder alteraçöes morfológicas e estruturais. Estes achados podem servir como subsídios para a compreensäo dos mecanismos relacionados à maior mortalidade dos hipertensos

Purpose - To evaluate QT dispersion in hypertensive patients, with and without left ventricular hypertrophy, and compare with normal persons. Methods - Thirty eight patients (21 male and 17 female, age 55±15 years) underwent echocardiography and simultaneous 12 lead, vertically aligned, electrocardiogram at 50mm/s speed. No patient was on antiarrythmic therapy. There were 19 non-hypertensive patients that constituted the control group (G-I). Group II was constituted by the other 19 patients, who were hypertensives. This group was further divided in group II-A (9 patients without left ventricular hypertrophy) and group II-B (10 patients with left ventricular hypertrophy). QT dispersion was obtained by the difference between the longest and the shortest QT registered. Results - QT dispersion was significantly increased on hypertensive patients, both with and without left ventricular hypertrophy, when compared to controls (G-I 31±9 ms, G-II 52±15ms, P<0.0001; G-IIa 46±10ms and GIIb 56±18ms X G-I, p<0.0005). In hypertensive patients, there was no statistically significant difference between group II-A and group II-B. Conclusion - We conclude that QT dispersion is significantly increased on hypertensive patients when compared to non-hypertensive individuals and that such increase, occurs before left ventricular hypertrophy develops. These findings suggest that, in hypertensive patients, electrical changes in left ventricular myocardium can precede structural and morphological abnormalities. Such findings offer new insights into the mechanisms related to enhanced mortality among hypertensive patients

Left ventricular end-diastolic pressure response to atrial pacing in idiopathic mitral valve prolapse.

The response of several parameters of left ventricular function to right atrial pacing was compared in 21 patients with idiopathic mitral valve prolapse and 10 normal patients. An inability to appropriately lower left ventricular end-diastolic pressure with increasing rates was demonstrated in the mitral valve prolapse group. This abnormality was not related to mitral regurgitation or factors other than ventricular performance per se.

Propranolol in mitral stenosis during sinus rhythm.

Patients with early symptomatic mitral stenosis usually suffer from pulmonary congestion on the basis of left atrial and pulmonary venous hypertension. They are often in sinus rhythm, and cardiac output is usually well maintained. Symptoms occur most often when heart rate, cardiac output, or both are increased. In this study, intravenous propranolol administered to patients with pure mitral stenosis in sinus rhythm resulted in significant reductions in mitral diastolic gradient (-7.1 mm. Hg +/- 1.6 SED), mean pulmonary wedge pressure (--6.9 mm. Hg +/- 1.2) and mean pulmonary artery pressures (--9.0 mm. Hg +/- 1.2). This was due to simultaneous reduction of heart rate (--13.0 beats/minute +/- 2.6 and cardiac output (--0.5 L./minute +/- 0.2). A small associated reduction of left ventricular systolic pressure (--5.1 mm. Hg +/- 2.6) was not accompanied by adverse clinical effects. A potential role for propranolol in medical management of pure mitral stenosis in the presence of sinus rhythm is suggested.

Sustained haemodynamic action of nitroglycerin ointment.

Intravenous vasodilators have been shown to improve the haemodynamic status of patients in congestive heart failure. However, neither intravenous nor sublingual preparations are suitable for chronic administration or use in ambulatory patients. In this study, nitroglycerin ointment bas administered to 11 patients in congestive heart failure. Mean pulmonary wedge and arterial pressures, as well as systemic blood pressures and heart rate were then monitored for 2 to 5 hours and compared with baseline values. Pulmonary wedge and arterial pressures, as well as systemic systolic arterial pressure, decreased significantly at 15 minutes after application and remained depressed for up to 5 hours. Systemic diastolic pressures fell significantly at 30 minutes and also remained significantly reduced for up to 5 hours. Thus, nitroglycerin ointment may be suitable for chronic vasodilator therapy of congestive heart failure.

Electrocardiographic detection of left atrial enlargement. Correlation of P wave with left atrial dimension by echocardiography.

The validity of various electrocardiographic P wave measurements was tested in 48 patients by comparing them to left atrial dimensions determined by echocardiography (echo), a proved method of left atrial size estimation. Of all the measurements considered, only the width of the P wave (PW), the P terminal force in lead V1 (PV1), and the PW/PR segment ratio (PW/PR) showed statistically significant correlations with left atrial size measurements by echo, with r values of 0-746, 0-491, and 0-479, respectively. The results indicated that P widths in excess of 105 ms were present in all the patients who had left atria equal to or greater than 3-8 cm by echo and in 11 per cent of patients without atrial enlargement (false positives), and that when measurements were less than 105 ms left atrial enlargement was unlikely.

Appraisal of sinus node artery disease.

The relationship of depressed sinus node function to coronary artery disease (CAD) was evaluated. The sinus node artery (SNA) was easily identified in all of 80 unselected normal coronary arteriograms. Angiographic disease of, or significant obstruction proximal to, the SNA was seen in 21% of 80 unselected CAD patients. Heart rate and sinoatrial recovery times (SART) were obtained in 50 consecutive unmedicated patients prior to arteriography. There was no difference between the SART of 23 CAD patients free of SNA involvement (1092 msec +/- 55 sem) and 18 normals (1070 +/- 40 msec). Nine patients with SNA involvement had shorter SART (941 +/- 52 MSEC) than normals (P less than 0.05) or other CAD patients (NS). Similar results were obtained for heart rate. No patient with SNA involvement had a prolonged SART or sick sinus syndrom (SSS). six of the 50 patients studied were symptomatic with SSS. Five of these SSS patients had CAD but none had angiographic evidence of SNA involvement. Obstructions involving the SNA were common in CAD but were not associated with altered heart rate or SART. Patients with SSS exhibited no angiographic evidence of SNA involvement. Therefore, it is unlikely that SSS is related to CAD of the SNA.