Do cardiologists at a university hospital adopt the guidelines for the treatment of heart failure?

OBJECTIVE: To verify whether the guidelines for the treatment of heart failure have been adopted at a university hospital. The guidelines recommend the following: use of angiotensin-converting enzyme inhibitors for all patients with systolic ventricular dysfunction, use of digitalis and diuretics for symptomatic patients, use of beta-blockers for patients in functional classes II or III, use of spironolactone for patients in functional classes III or IV. METHODS: We analyzed the prescriptions of 199 patients. All these patients had ejection fraction (EF)

Chagas' heart disease: evolutive evaluation of electrocardiographic and echocardiographic parameters in patients with the indeterminate form.

OBJECTIVE: To identify and associate potential electrocardiographic and echocardiographic changes in patients with the indeterminate form of Chagas' disease during long-term follow-up. METHODS: One hundred sixty patients underwent standard electrocardiography and two-dimensional guided M-mode echocardiography for left ventricular ejection fraction determination. Patients were followed up for 98.6+/-30.4 months, undergoing repeat electrocardiographic studies at 6-month intervals and echocardiographic studies at 12-month intervals. RESULTS: Based on the electrocardiographic findings, the patients were divided into group I, 125 patients (78.6%) with normal electrocardiograms throughout follow-up, and group II, 34 patients (21.3%) who developed electrocardiographic changes. Group II was further divided into group IIA (9 patients, 5.6%) with permanent electrocardiographic changes, group IIB (14 patients, 8.8%) with transitory electrocardiographic changes, and group IIC (11 patients, 6.9%) with changes appearing only on the final electrocardiogram. Left ventricular ejection fractions remained normal in the entire population studied and did not differ among groups. CONCLUSION: The indeterminate form of Chagas' disease clearly represents a benign condition with a favorable long-term prognosis. Although some patients develop electrocardiographic changes, left ventricular systolic function is well preserved.

Peripheral arterial embolism. Report of hospitalized cases.

OBJECTIVE: We analyzed the frequency of peripheral embolisms, the underlying heart disease,triggering factors, the sites of the emboli, and evolution of the patients. METHODS: We analyzed 29 cases of peripheral arterial embolism out of a total of 20,211 hospitalizations in a cardiology center in the city of São Paulo. The age was 51.89+/-18.66 years, and 15 were males. RESULTS: Embolism in the right lower limb occurred in 18 patients (62.0%),in the left lower 11(37.9%) and right upper 3 (10.3%) limbs, and in the left arm (1). Four patients had embolism in two limbs. The heart disease, mitral valvar heart disease (9 patients - 31.0%); infective endocarditis (7- 24.1%); dilated cardiomyopathy (6 - 20.6%); ischemic coronary heart disease (6 patients - 20.6%); and one patient with cor pulmonale. Atrial fibrillation was observed in 20 patients (68.9%), chronic in 12 patients (41.3% ) and acute in 8 (27. 5%). All patients with mitral valvar heart disease had atrial fibrillation, chronic in 8 patients (88.8%); patients with cardiomyopathy and coronary heart disease, 4 in each group had atrial fibrillation, acute in 60% of the patients. Patients with infective endocarditis, 3 had staphylococcus and 2 Gram-negative bacteria. In the follow-up, 2 patients (6.8%) required limbs amputation, and 5 (17.2%) died due to embolism. CONCLUSION: Most of the time, embolism does not cause permanent complications. Our data highlight the importance of anticoagulation for patients acute atrial fibrillation in myocardial dysfunction and for patients with chronic atrial fibrillation in cases of mitral valvar heart disease to prevent peripheral embolism.

[Coronary risk factors in children of young coronary artery disease patients]. / Fatores de risco para doença arterial coronariana em crianças e adolescentes filhos de coronariopatas jovens.

PURPOSE: To determine whether children and adolescents, whose fathers have established coronary artery disease (CAD), have increased prevalence of coronary risk factors (RF). METHODS: The frequencies of abnormal values of lipid variables, glucose, blood pressure, obesity index (calculated through Newen-Goldstein index), smoking and electrocardiographic alterations (ECG), were assessed in 280 descendents of young revascularized patients (< 55 years). The study population was divided in two groups according to age, respectively GA (2 to 12 years) and GB (12 to 19 years). Eventual influences of age, gender, obesity and smoking on lipid variable were evaluated through variance analysis. RESULTS: Of the study population, 48.2% and 44.6% had total cholesterol (TC) and LDL-C respectively above the desirable values; 21.7% and 26.1% had values similar to adults under increased risk. Triglyceridemia (TG) > 200mg/dl was found in 1.4% of the sample and lower values of HDL-C in 16.8%. Overweight and obesity were observed in 13.1% and 20.0% of the patients and influenced TG levels in GB. Smoking occurred in 10.4%; hypertension in 3 cases and none had abnormal glucose levels or ECG. CONCLUSION: Healthy children of fathers with established CAD, exhibit a high frequency of altered lipid profile and increased body weight. The results suggest the need for early identification of RF in offspring of young CAD patients, thus emphasizing changes in risk profile and improving lifestyle.

Fatores de risco para doença arterial coronariana em crianças e adolescentes filhos de coronariopatia jovens / Coronary risk factors in children of young coronary artery disease patients

Objetivo - verificar a prevalência dos fatores de risco (FR) em crianças e adolescentes filhos de coronariopatas. Métodos - em 280 filhos de coronariopatas jovens (< 55 anos), submetidos à cirurgia de revascularizaçäo miocárdica, foi determinada a frequência de desvios dos valores considerados ideiais para a faixa etária da colesterolemia total-CT, trigliceridemia-TG, HDL-C e LDL-C, glicemia, da pressäo arterial (PA), do peso corpóreo (através do índice de Newen-Goldstein-ING). Foram também verificas as frequências do hábito de fumar, e de alteraçöes eletrocardiográficas. Crianças de 2 a 12 anos formaram o grupo GA e adolescentes de 12 a 19 anos formaram o grupo GB. Eventuais associaçöes entre o FR e a influência dos fatores idade, sexo, peso corpóreo e tabagismo sobre as variáveis lipídicas também foram estudadas. Resultados - no conjunto estudado, 48,2 por cento e 44,6 por cento apresentaram respectivamente valores de CT e LDL-Cacima dos considerados ideais, sendo que 21,7 por cento e 26,1 por eto apresentavam valores indicativos de risco também para adultos. TG acima de 200 mg/dl ocorreur em 1,4 por cento da amostra e valores diminuídos de HDL-C em 16,8 por cento. O sobrepeso e obesidade estiveram presentes, respectivamente, em 13,1 por cento e 20,0 por cento (12,9 por cento e 31,4 por cento em GA e 13,2 por cento e 15,8 por cento em GB) e influenciaram os níveis de TG. Tabagismo ocorreu em 10,4 por cento; houve somente 3 casos de hipertensäo arterial. Näo foram encontradas anormalidades da liemia e nem alteraçöes eletrocardiográficas. Conclusäo - a investigaçäo reitera a necessidade de particular atençäo preventiva nos filhos de coronariopatas jovens, considerando a levada frequência de desvios do metabolismo lipídoco e de aumento do peso corpóreo (sobrepeso e obesidade)

Purpose - To determine whether children and adolescents, whose fathers have established coronary artery disease (CAD), have increased prevalence of coronary rishfactors (RF). Methods - The frequencies of abnormal values of lipid variables, glucose, blood pressure, obesity index (calculated through Newen-Goldstein index), smoking and electrocardiographic alterations (ECG), were assessed in 280 descendents of young revascularized patients (<55 years). The study population was divided in two groups according to age, respectivelly GA (2 to 12 years) and GB (12 to 19 years). Eventual influences ofage, gender, obesity and smoking on lipid variable were evaluated through variance analysis. Results - Of the study population, 48.2% and 44.6% had total cholesterol (TC) and LDL-C respectively above the desirable values; 21.7% and 26.1% had values similar to adults under increased risk. Triglyceridemia (TG) >200mg/dl was found in 1.4% of the sample and lower values of HDL-C in 16.8%. Overweight and obesity were observed in 13.1% and 20.0% of the patients and influenced TG levels in GB. Smoking occurred in 10.4%; hypertension in 3 cases and none had abnormal glucose levels or ECG. Conclusion - Healthy children of fathers with established CAD, exhibit a high freqüency of altered lipid profile and increased body weight. The results suggest the need for early identification of RF in offspring of young CAD patients, thus emphasizing changes in risk profile and improving lifestyle

Aplicaçäo do exercício físico em portadores de insuficiência cardíaca congestiva / Exercising in patients with congestive heart failure

Pacientes com insuficiência cardíaca congestiva das mais diversas etiologias têm se beneficiado com programa de reabilitaçäo supervisionado. Considera-se hoje que o exercício físico é um método secundário de pevençäo e tratamento da insuficiência cardíaca congestiva. Vários estudos, nesses casos, têm demonstrado melhora da qualidade de vida.

Capacidade física em idosos submetidos a programa de condicionamento físico / Physical capacity in elderly subjects engaged in an exercise training program

No presente trabalho, säo relatados resultados obtidos a partir de avaliaçäo ergométrica e cardiorrespiratória ao exercício (ergoespirométrica), em idosos, sadios ou portadores de doença cardiovascular, incluídos em programa de condicionamento físico em nosso Serviço. Nossa experiência tem confirmado que um programa de atividade física regular supervisionada, mesmo quando iniciado em idade avançada, pode trazer benefícios para indivíduos sadios ou näo, independentemente do sexo. A adoçäo de hábitose vida ativa atenua a reduçäo da capacidade física associada a idade ou doençae, portanto, pode melhorar a qualidade de vida nessa populaçäo. A heterogeneidade de comportamento do idoso implica a necessidade de individualizaçäo de condutas. Assim, a avaliaçäo da capacidade física ao início e no decorrer do treinamento físico tem-se mostrado essencial para adequaçäo da prescriçäo da intensidade de exercício. Ademais, individualizaçäo do tratamento parece ser ponto importante para a permanência nos prograade reabilitaçäo. A prescriçäo de treinamento físico baseada na resposta cronotrópica, ou seja, na reserva de frequência cardíaca ou na frequência cardíaca máxima, exibe limitaçöes, podendo superestimar a capacidade funcional de indivíduos jovens e idosos. A popularizaçäo de avaliaçäo cardiorrespiratória ao exercício pode proporcionar a realizaçäo rotineira de prescriçäo de treinamento físico baseada näo apenas na frequência cardíaca, mas principalmente no estresse metabólico causado pelo exercício, torano os programas mais preciosos e adequados. Apesar dos benefícios aqui demostrados, em diversas condiçöes, altos índices de desistência e obsenteísmo enfatizam a importância de conscientizar o idoso e o profissional de saúde quanto à necessidade de adoçäo e/ou manutençäo de um estilo de vida ativo.

[Magnetic resonance imaging in chronic Chagas cardiopathy. Correlation with endomyocardial biopsy findings]. / Imagem por ressonância magnética na cardiopatia chagásica crônica. Correlação com biopsia endomiocárdica.

PURPOSE: To study the correlation between magnetic resonance imaging of the heart and right ventricle endomyocardial biopsy results in chronic Chagas' heart disease. METHODS: Ten patients with Chagas' disease, mean age 47 +/- 7 years, all males, in congestive heart failure with New York Heart Association class II (2 patients), III (6) and IV (2) were studied. Mean left ventricular ejection fraction was at echocardiogram 36 +/- 6%. The patients were submitted to right ventricular endomyocardial biopsy and magnetic resonance imaging of the heart. The results of this group were compared with a control group of patients with idiopathic dilated cardiomyopathy, with mean age of 46 +/- 10 years and left ventricular ejection fraction of 30 +/- 4%, in heart failure with functional class II (1 patient), III (5) and IV (1). RESULTS: All patients with Chagas' heart disease presented an increase in magnetic ressonance imaging signal of the heart after gadolinium use. The septal signal intensity changed from 0.87 +/- 0.06 to 1.54 +/- 0.16 (p < 0.001). In the control group the mean septal signal intensity was 0.93 +/- 0.07 before and 0.89 +/- 0.06 after the gadolinium (p = ns). Eight patients of the Chagas' disease group had biopsy proven myocarditis and two had borderline myocarditis. However, only one patient of the control group had diagnosis of borderline myocarditis. CONCLUSION: Myocarditis is frequently found in Chagas' heart disease patients and who unlike controls present a significant increase in myocardial signal intensity after gadolinium infusion. The magnetic resonance imaging of the heart seems a promising alternative method for the diagnosis of an inflammatory process in Chagas' heart disease.

Survival improvement with dynamic cardiomyoplasty in patients with dilated cardiomyopathy.

Surgical support to the failing heart has been investigated in the treatment of severe myocardial failure. Dynamic cardiomyoplasty was indicated in 32 patients with dilated or chagasic cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximum medical therapy. Fifteen patients were operated on, and 17 refused the surgical treatment and were maintained by clinical means. With an average follow-up period of 12.3 months, actuarial survival rates for cardiomyoplasty patients were 86.6% at 6 months, 78.7% at 1 year, and 65.6% at 2 years of follow-up, whereas patients under medical therapy presented survival rates of 58.8%, 41.1%, and 27.4% at the same periods, respectively (p = 0.03). Furthermore, five of the 11 surviving patients of the cardiomyoplasty group are in NYHA class I, five in class II, and one in class III. At 6 months of cardiomyoplasty follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.1 +/- 3.9% to 26.8 +/- 7.5% (p less than 0.01). Cardiopulmonary exercise testing showed that maximum oxygen consumption during treadmill testing improved from 14.7 +/- 3.9 to 18.3 +/- 3.9 ml/kg/min (p = 0.01). At 1 year of follow-up, these data remained essentially unchanged. In conclusion, dynamic cardiomyoplasty reverses congestive heart failure and improves the long-term survival of patients with severe cardiomyopathies.

Latissimus dorsi cardiomyoplasty in the treatment of patients with dilated cardiomyopathy.

Stimulated skeletal muscle grafts have been proposed as a means to reinforce ventricular wall in the treatment of severe myocardial failure. Latissimus dorsi cardiomyoplasty was performed in 11 patients with advanced heart failure due to cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximal medical therapy. There were no operative deaths. Eight patients were followed for a mean of 10.8 months. Two patients remain in muscle conditioning protocol. One patient died with latissimus dorsi ischemia and congestive heart failure. Four of the eight patients in long-term follow-up are in NYHA class I, three in class II, and one in class III. At 3 months of follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.5 +/- 3.6% to 26.8 +/- 8.1% (p less than 0.01). Doppler-echocardiography demonstrated that left ventricular segmental wall shortening improved from 11.3 +/- 2.5% to 16.5 +/- 3.9% (p less than 0.01) and left ventricular stroke volume from 22.9 +/- 4.6 to 33.1 +/- 10 ml (p less than 0.01). Cardiopulmonary exercise test showed that maximal oxygen consumption during treadmill test increased from 14.8 +/- 3.7 to 18.2 +/- 3.3 ml/kg.min (p less than 0.05). At 6 months of follow-up, all the above values remained essentially unchanged. Furthermore, nonsustained ventricular tachycardia was abolished without specific medical therapy in four patients. Thus, cardiomyoplasty improves left ventricular function, reverses congestive heart failure, and may improve long-term survival in severe cardiomyopathies.

Histopathological criteria of myocarditis--a study based on normal heart, chagasic heart and dilated cardiomyopathy.

This work is a detailed study of the relevance of three sets of criteria to define myocarditis: Dallas meeting criterion, Edwards criterion and Dallas meeting criterion modified by the authors. Two groups were evaluated: normal autopsied hearts and endomyocardial biopsy from chronic chagasic patients at high risk of having myocarditis. Furthermore, endomyocardial biopsies from patients with dilated cardiomyopathy (DCM) were also evaluated. Applying the Edwards criterion, incidences of myocarditis in normal and chagasic hearts were 0% and 67% while with Dallas meeting criterion they were 0% and 42% and using our criterion the incidences were 0% and 92% respectively. In endomyocardial biopsies from DCM patients, the incidence of myocarditis was 7% with Edwards criterion, 22% with Dallas meeting and 33% with the authors own criterion. The authors concluded that their criterion, which defines myocarditis as the presence of inflammatory mononuclear cells enclosing more than 2 lymphocytes/400X aggregated to the cardiac fiber sarcolemma, is the most appropriate criterion of the three. Myocarditis was found in 33% of the 27 endomyocardial biopsy specimens from patients with DCM.