Role of anthropometric indexes and blood pressure as determinants of left ventricular mass and geometry in adolescents. The Rio de Janeiro Study.

To evaluate left ventricular structural changes and their relationship to blood pressure and anthropometric indexes, we examined by echocardiography 108 adolescents aged 13 to 19 years. Subjects were divided into three groups according to blood pressure tracking during three moments of observation: group 1 (n = 27), > or = 95th percentile; group 2 (n = 37), < or = 50th percentile; and group 3 (n = 44), blood pressure not stable in the original percentile. Left ventricular mass index and the prevalence of altered left ventricular geometry were greater in group 1 (P < .05 and P < .02, respectively). Of all the anthropometric indexes, body surface area showed the best correlation with left ventricular mass (P < .00001). Left ventricular mass also correlated with systolic and diastolic pressures (P < .00001 and P < .003, respectively). Ventricular septal and posterior wall thicknesses and left ventricular diastolic diameter showed good correlations with body surface area (P < .00001). These variables also correlated with systolic pressure (P < .001). In a multiple regression model when body surface area was controlled, systolic pressure did not correlate significantly with left ventricular mass. In a similar model systolic pressure maintained a significant correlation with ventricular septal and posterior wall (P < .00001) thicknesses but not with left ventricular diastolic diameter (P > .05). We conclude that left ventricular structural changes can occur early after initial abnormalities of blood pressure. Considering that body surface area and systolic pressure were the best predictors of left ventricular alterations in adolescents, the usual way of correcting left ventricular mass by body surface area should be reviewed.

Monocyte procoagulant activity induced by concanavalin A is decreased in a population of chronic chagasic patients.

1. The ability of peripheral blood mononuclear cells (PBMC) from Chagas' disease patients to induce monocyte procoagulant activity (PCA) in response to concanavalin A (Con A) and to a Con A induced lymphokine was studied. 2. In spite of the variability of PCA levels among both chagasic patients and normal controls, statistical analysis of the data permitted us to draw the following general conclusions. 3. The Con A-induced monocyte PCA measured in 17 assays of 15 chagasic patients was significantly lower than the PCA response of 18 normal controls or of 11 patients with non-chagasic myocardiopathies. 4. The response of PBMC from chagasic patients to lymphokine was also lower than that observed for normal controls. 5. These results suggest that monocytes from chagasic patients are deficient for the generation of PCA which is an in vitro correlate of the delayed-type hypersensitivity reaction.

[Thromboembolism in patients with apical lesion caused by chronic chagasic cardiopathy]. / O tromboembolismo em pacientes com lesão apical da cardiopatia chagásica crónica.

The thromboembolism in patients with apical lesion of the chronic Chagas' heart disease diagnosticated by left cineventriculography are present in this study. The series comprises 32 females and 23 males between the ages of 22 and 69 years, all presenting cardiovascular symptoms, 20 in cardiac failure (10 with left ventricular failure and 10 in congestive heart failure). Heart size was normal in 35 instances and 20 showed cardiomegaly on chest X-ray examinations (slight in 8, moderate in 6 and marked in 6). The following morphological aspects of the apical lesions were observed: mammillary-23 (41.82%); digital-18 (32.73%) and semilunar-14 (25.45%). In 8 cases (14.54%) intraventricular thrombi were detected and 10 these were associated with discinetic areas. Seventeen episodes of thromboembolism occurred in 14 (24.45%) patients including 7 to the brain, 9 to the lung and 1 to the iliac right artery, mostly in patients with heart failure. Eight were women and 6 were men, varying between 30 and 62 years of age, the morphological aspects of the apical lesion were semilunar in 8 and mammillary in 6. Cardiac pacemakers were implanted in 8 cases due to complete A-V block in 6, to sinus node disfunction in 1, and to sinus arrest in 1. In 4 cases (28.57%) intraventricular thrombi were detected, in 3 occasioned thromboembolism to the brain. Thrombo-embolic phenomena occurred in the 11 nonsurvivors. The most frequent cause of death was heart failure in 8 followed by cerebro-vascular attacks in 3, after a follow-up period of 19 to 176 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of high-risk valvular endocarditis]. / Tratamento cirúrgico da endocardite valvular de alto risco.

The authors have studied the short and long term results of surgical treatment of acute phase of infectious endocarditis in a group of 33 high risk patients with valvular heart disease. The age varied from 2 to 68 years; 18 patients were male and 22 were of the white race. The aortic valve was most frequently involved (18/54.5%), followed by the mitral valve (13/39.3%) and tricuspid valve (2/6.0%). Twenty four patients (72.7%) were in functional class III and seven (21%) in functional class IV. The noninvasive studies in those patients revealed 13 cases (39.4%) with normal cardiac size. The ECG was abnormal in 27 cases (81.8%) mostly with left atrial and ventricular hypertrophy. The echocardiogram revealed the presence of vegetations in 27 patients (81.8%) and blood cultures were positive in 22 cases (66.6%). All patients were treated with antibiotics. The pathologic analysis revealed the presence of vegetations in 94% and structural alterations in 16.5%. Twenty-one patients had heart valve replacement with mechanical prosthesis (63.6%), 11(33.3%) had bioprosthesis and one had tricuspid excision without replacement (3.0%). The hospital mortality was 12% and the late mortality 3%. Three deaths occurred in patients who had prolonged clinical treatment (more than 65 days) and one patient died of severe fungal endocarditis. The follow-up of the remaining 26 patients varied from 01 to 448 weeks (mean 183) demonstrating important clinical improvement and a normally functioning valve prostheses. All patients are in functional class I and II. The analysis of our data indicates that surgical treatments is the best option for high risk endocarditis and should be undertaken earlier in all patients in this risk group.

[Echocardiography in the evaluation of cardiac involvement in seronegative spondylo-arthropathies]. / El ecocardiograma en la evaluación del compromiso cardiáco en las espondiloartropatías seronegativas.

To evaluate the involvement of the heart in patients with seronegative spondyloarthropathies by echodopplercardiography, 35 patients including 20 with ankylosing spondylitis, 10 with Reiter's syndrome and 5 with psoriatic arthritis (21 men and 14 women, with ages ranging from 17-68 years and averaging 38.5) were studied. Most were asymptomatic with respect to the cardiovascular system (65.71%) and 12 oligosymptomatic with palpitations as their main complaint. Each patient had an echocardiogram and electrocardiogram. A two-dimensional echocardiogram demonstrated alterations in 19 patients (54.29%), 28.58% asymptomatic and 25.71% symptomatic. This study revealed most of lesions (17/19-84.47%) followed by the Dopplerechocardiography (10/19-52.63%) and the one-dimensional echocardiography (9/19-47.36%). Abnormal aortic valves were found in 10 patients, in 7 thickenning and in 3 calcifications. The mitral valve was involved in 11 patients, in 8 thickenning, in 1 calcification and in 2 valve prolapse. In ankylosing spondylitis aortic valve disease was found in 8 patients. Dopplerechocardiography evidenced the presence of aortic regurgitation in 4 patients and mitral insufficiency in 3. The Q-T interval was increased in 19 patients, there was one first degree auriculoventricular block, one right branch block and one sinus bradicardia. Thus the echocardiogram is an excellent noninvasive method to disclose cardiac disturbances in patients with seronegative spondyloarthropaties.

[Apical and inferior mammillary aneurysm in chronic Chagas cardiomyopathy]. / Aneurismas mamilares apical e inferior na cardiopatia chagásica crônica.

A 66 year-old woman with chronic Chagas's heart disease, presented palpitations, dizziness and chest pain. The His bundle electrograms revealed sick sinus syndrome. The left cineventriculography showed apical and inferior aneurysms of mammillary morphological aspect.

Natural course of subsequent pregnancy after peripartum cardiomyopathy.

OBJECTIVE: To assess the effect of subsequent pregnancy after peripartum cardiomyopathy (PPCM) on maternal and fetal outcome. METHODS: Prospective study of 34 patients with the diagnosis of PPCM (mean age = 26 years). At the time of first diagnosis 5 were in NYHA functional class (FC) II for heart failure, one in FC III and 28 in FC IV. After clinical treatment, patients were advised to avoid new pregnancies and a follow-up was obtained. RESULTS: There were 12 (35.3%) subsequent pregnancies in patients (pt) aged 19 to 44 years (mean 32), divided into two groups: GI: 6 pts who had normalized their heart size and GII: 6 pts with persistent cardiomegaly. GI had initially mild clinical manifestations (3 were in FC II, 1 in FC II and 2 in FC IV) and complete recovery of cardiac function (FC I). A new pregnancy was well-tolerated in 5 (83.3%); 1 pt presented with preeclampsia, and progressed to FC II. Presently, 5 pt are in FC I and 1 in FC II. GII pts had more severe heart failure at the onset of PPCM (1 pt in FC II and 5 in FC IV); during follow-up, 4 pt were in FC I and 2 in FC II. A new pregnancy was well tolerated in all of them, but the eldest, who had had 2 pregnancies and had a progressive worsening of clinical status, dying 8 years after the last pregnancy and 13 years after the diagnosis of PPCM. The remaining 5 pt are still alive, 3 in FC I and 2 in FC II, with worsening of FC in 1. Subsequent pregnancies occurred 3-7 years after clinical treatment of PPCM and no fetal distress was observed. CONCLUSION: Subsequent pregnancies are well-tolerated after PPCM, but not devoid of risk. No fetal distress was observed. A minimum interval of 3 years after the recovery of function seems to be safe for subsequent pregnancies.

[Apical lesion of the left ventricle in clinical evolution of chronic Chagas cardiopathy]. / A lesão apical do ventrículo esquerdo na evolução clínica da cardiopatia chagásica crônica.

PURPOSE: Study of clinical evolutionary aspect in patients with apical lesion of chronic Chagas' heart disease diagnosed by left cineventriculography. PATIENTS AND METHODS: 55 patients, 32 female, aged 22 to 69 years with epidemiologic data and positive serological tests, all presenting cardiovascular symptoms, 20 in cardiac failure (10 with left ventricular failure and 10 in congestive heart failure). Heart size was normal in 35 patients and 20 showed cardiomegaly on chest X-ray examinations (slight in 8, moderate in 6 and marked in 6), EKG showed premature beats in all patients and conduction defects in 38 instances with a predominance of right bundle branch block associated with left anterior divisional block in 19 cases. The following morphological aspects of the apical lesions were observed: mammillary--23 (41.82%); digital--18 (32.73%) and semilunar--14 (25.45%). In 8 cases (14.54%) intraventricular thrombi were detected and in 10 (18.18%) there were associated dyskinetic areas. RESULTS: The clinical course of 36 patients (65%) has been followed in the out patient department for 35 to 192 (97.83) months. Seven patients (12.73%) did not return for consultation after having been studied for 22 to 56 (42.83) months, and 12 (22%) died after a follow-up period of 19 to 176 (68.58) months. Detection of 17 thromboembolic episodes occurred in the 14 (25%) patients, 9 pulmonary encephalic and 1 peripheric, very frequent in patients with cardiac failure (11/14-78%). Cardiac pacemakers were implanted in 18 cases due to complete A-V block in 11, to sinus node dysfunction in 6, and to sinus arrest in 1. Among the survivors 29 (80%) maintained a normal heart size. The most frequent cause of death (12) was heart failure in 8, followed by cerebrovascular attacks in 3 and malignancy in 1. The estimated survival in 192 months was of 75.8%, males (74.5%) and females (76.6%). A presence of heart failure however was a limiting factor, with estimates of 96.8% survival in patients without cardiac decompensation, as compared to 36.5% in cases with heart failure. CONCLUSION: The apical lesion is an additional factor of mortality in Chagas' heart disease after the development of congestive heart failure.

[Apical left ventricular involvement in chronic Chagas' cardiopathy: clinical and ventriculographic aspects]. / Acometimento da ponta do ventrículo esquerdo na cardiopatia chagásica crônica: aspectos clínicos e ventriculográficos.

The present study comprises 62 patients with Chronic Chagas' Heart Disease. In addition to clinical examination, serologic, roentgenologic, hemodynamic, electrocardiographic, left cineventriculographic and cinecoronariographic studies were performed, with subsequent evaluation apical left ventricule. Thirty two patients were women and 30 were men, varying between 21 and 64 years of age, all with positive serological tests, all with cardiovascular symptoms, 26 with myocardial failure (11 with left ventricular failure and 15 with congestive heart failure), heart size was normal on X-ray in 37 patients with cardiomegaly in 25 (slight in 10; moderate in 8 and accentuate in 7). The electrocardiogram revealed in 41 instance of conduction defects. The left ventriculogram showed an apical lesion in 52 patients (83.87%) with: localized hypokicinetic in 4 (6.45%), diffuse hypokicinetic in 6 (9.68%) and, apical lesion in 48 (77.42%). The shaped apical lesion as a nipple in 17 (27.42%), as finger in 17 (27.42%), and half-moon in 14 (22.18%). The apical lesion was observed in 20 of 26 patients with myocardial failure (76.92%). In 9 patients was associated with others aneurysms. In 3 patients apical thrombus was detected.

[Meningococcemia complicated by myocarditis]. / Meningococcemia complicada por miocardite.

We report a case of a 26-year old man with meningococcemia complicated with myocarditis (ventricular dysfunction and myocardial ischemia), that required treatment for heart failure. Regression of myocardial dysfunction was observed six months after the infection.

[Evaluation of a cardiac rehabilitation program. Analysis after ten years of follow-up]. / Avaliação de programa de reabilitação cardíaca. Análise após 10 anos de acompanhamento.

PURPOSE: To study the benefits of the cardiac rehabilitation program (CRP) in patients with coronary artery disease (CAD). METHODS: Between 1986 and 1995 we studied 49 patients with CAD, participants of the CRP, 45 (91.83%) of them men. They were compared with a control group of 37 sedentary patients, 33 (89.18%) men. The main parameters analyzed were the duration of exercise, the maximal oxygen consumption (VO2 max), the metabolic equivalent (MET), the functional aerobic impairment (FAI) and the change in the classification of the cardiorespiratory capacity between two graded exercise tests (GTX). RESULTS: There were improvements in all parameters of the GTX analyzed in the two groups. The patients of the CRP presented a better functional capacity than the sedentary patients and, in relation to the duration of exercise, to the VO2 max and to the MET, the differences in the two groups achieved statistical significance (p < 0.05). We did not observe benefits, in relation to the physical conditioning, with a more prolonged permanence of the patients in the program (more than 24 months). There were no cardiovascular complications with the practice of the exercise in the period analyzed. CONCLUSION: The improvement in the duration of exercise, in the VO2 max and in the MET, the more negative variation in the FAI and the improvement in the classification of the cardiorespiratory capacity between the two GTX of the patients of the CRP demonstrate improvement in functional capacity significantly better than sedentary patients. The CRP analyzed was considered a therapeutic method safe and efficient after a coronary event.

[Silent coronary artery-left ventricular fistula and acute myocardial ischemia]. / Fístula silenciosa das artérias coronárias para o ventrículo esquerdo e isquemia miocárdica aguda.

A 65-year-old woman developed severe coronary insufficiency associated with papillary muscle dysfunction. She was submitted to cineangiocoronarography which ruled out obstructive coronary disease. Coronarography revealed a communication between the coronary arteries and the left ventricle, but a coronary arterial fistula was not seen. The possibility of this uncommon form of coronary drainage to the left ventricle, named silent fistula, being the cause of myocardial ischemia related to the coronary steal phenomenon is discussed.

[Diabetic cardiac dysautonomia. Clinical and pharmacologic evaluation]. / Disautonomia cardíaca diabética. Avaliação clínica e farmacológica.

Thirty-two insulin-dependent (type I) diabetic patients were studied to detect cardiovascular autonomic nervous system involvement. Half percent (16 cases) were men. Their ages ranged from 6 to 64 years (29.03 years). The average time of diagnosed diabetes was 6.5 years. The group was submitted to several clinical (respiratory, arrhythmia, Valsalva, isometric, orthostatic) and pharmacological tests (propranolol and atropine). The physiological responses were measured as heart beat frequency and blood pressure. Results were analyzed by various statistical methods. Evaluation through a diabetic complication scale showed that ten (31.25%) were uncomplicated), 14 (43.75%) at grade 1, four (12.50%) at grade 2, two (6.25%) at grade 3 and two (6.25%) at grade 4. This scale only correlated to the term of diabetes (p less than 0.01). Results from the autonomic test battery indicated that 12 (37.50%) had isolated parasympathetic damage, five (15.62%) sympathetic lesions, and two (6.25%) had mixed type involvement. We observed, as to cardiovascular autonomic involvement, 13 (40.62%) had no involvement and 19 (59.38%) had some degree of damage; in the latter group, 15 (46.78%) had early lesions and four (12.50%) definite.

[Hypocalcemia causing heart failure]. / Hipocalcemia causando insuficiência cardíaca.

A 39-year-old female patient with refractory heart failure has been studied. On February, 1982 she was submitted to right lobar thyroidectomy for remotion of the left thyroid lobe. Following the surgery, she had signs of hypocalcemia and the diagnosis of secondary hypoparathyroidism and heart failure had been made. Seven months after she had acute pulmonary edema, cardiomegaly III (cardiothoracic index = 0.58) with predominant left atrial and left ventricular hypertrophy, which were confirmed by echocardiogram (ECO). The ECO also demonstrated low contractility of the left ventricle. The QT interval was increased on the electrocardiogram (QTc = 0.50 s), the calcium was 5.0 mg/dl with calciuria of 28 mg/day; phosphatemia was 4.8 mg/dl and phosphaturia of 214 mg/day. The level of thyroid hormones (T3 and T4) were in the normal ranges despite the TSH was increased in the beginning of the disease. She was first treated with digitalis, diuretic and vasodilator drugs, thyroid hormone and oral calcium. She had progressive hemodynamic improvement when higher doses of calcium were given with D3 vitamin. The most significant result of this treatment was reduction of the heart size that come back to normal. At the present time patient is treated with thyroid hormone, calcium and D3 vitamin only.

[Acute myocardial infarct in a patient with dextrorotation]. / Infarto agudo do miocárdio em paciente com dextro-rotção.

A 79-year-old woman developed myocardial infarction associated with acute pulmonary edema. The electrocardiogram recorded QRS complex of QS type in V1 with upper ST extending from V3R to V6R. The polarity of the P wave in bipolar leads was positive, so compatible with dextrorotation complicated by myocardial infarction. The dextrorotation was confirmed with chest roentgenogram and echocardiogram.

[Beta-hemolytic streptococcus endocarditis in an adolescent with hypertrophic cardiomyopathy]. / Endocardite por estreptococo beta-hemolítico em adolescente portador de cardiomiopatia hipertrófica.

A 15 year-old male adolescent was hospitalized in a severe septic condition, due to infectious endocarditis which abided for 20 days. The admittance echocardiogram displayed a mitral valve vegetation in conjunction to a hypertrophic cardiomyopathy. In spite of applied antibiotics the patient expired. The authors emphasize the diagnostic difficulties of this compound entity and stress the need of antibiotic prophylaxis for patients who bear a hypertrophic cardiomyopathy, even in those with a non-obstructive disposition.

[Aortic insufficiency due to quadricuspid aortic valve]. / Insuficiência aórtica por valva aórtica quadricúspide.

In a 45 year old patient with clinic diagnosis of aortic regurgitation the two-dimensional echocardiography demonstrated a quadricuspid aortic valve and severe aortic regurgitation by Doppler. The quadricuspid aortic valve is a rare pathology, usually not associated with other cardiovascular pathologies and in which there is evolution with aortic regurgitation due to malposition of the four cusps.

Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

Cardiac tamponade in systemic lupus erythematosus. Report of four cases.

OBJECTIVE: To report and assess the incidence of cardiac tamponade in systemic lupus erythematosus as a cardiac manifestation of the disease. METHODS: We reviewed the medical records of 325 patients diagnosed with systemic lupus erythematosus according to the American Rheumatism Association and their complementary laboratory tests compatible with cardiac tamponade. RESULTS: In the 325 medical records reviewed, we found 108 patients with pericardial effusions corresponding to 33.2% of the total and 54% of the patients studied in the active phase of the disease. Clinical assessment and transthoracic echocardiogram allowed the clinical diagnosis of cardiac tamponade in only 4 (1.23%) patients, 3 of whom were females, white, with ages ranging from 25 to 44 years. The pericardial fluid was hemorrhagic or serosanguineous with high levels of FAN and positivity for LE cells. In the treatment, we successfully used pericardiocentesis associated with high doses of corticosteroids. In clinical and laboratory follow-up performed for a period of 3 years, neither recrudescence of the pericardial effusion nor evolution to constriction occurred. CONCLUSION: Even though rare (1.23%), cardiac tamponade in patients with systemic lupus erythematosus has a benign evolution when properly treated, according to our experience.

[Obstructive ischemic involvement of the anterior descending coronary artery in asymmetrical septal form of hypertrophic cardiomyopathy]. / O acometimento isquêmico obstrutivo na cardiomiopatia hipertrófica do tipo septal assimétrico com envolvimento da artéria descendente anterior.

PURPOSE: The significance of necrosis and fibrosis of the interventricular septum in hypertrophic cardiomyopathy (HCM) is controversial. The purpose of this study was then to evaluate the clinical impact of left anterior descending artery (LAD) disease in HCM. METHODS: Among 158 patients presenting with HCM, 6 (3.79%) had LAD disease. Mean age was 65.16 years (52 to 70), 4 were men and 4 had the obstructive form of HCM. All patients were submitted to complete clinical and laboratory evaluation. Mean time of the diagnosis was 141 months (ranging from 78 to 182) for HCM and 42 months (ranging from one day to 106 months) for LAD disease. RESULTS: Five patients had unstable angina and one had myocardial infarction. LAD disease (60 to 100% coronary narrowing) was present in all patients; one patient had single vessel disease and 5 multivessel disease. During follow-up, 3 patients had coronary artery bypass grafting (CABG), one with associated septal myectomy; one was submitted to coronary angioplasty and 2 were submitted to medical treatment. During a follow-up period ranging from 76 to 124 months after LAD disease diagnosis, one patient died. At the end of the study, a reduction of the thickness of the interventricular septum from 1.53 to 1.40 cm was observed and left ventricular outflow pressure gradient decreased from 56 to 16 mmHg. Left ventricular diastolic diameter increased from 4.55 to 4.85 cm and systolic diameter from 2.83 to 3.13 cm. Left atrium diameter was unchanged. CONCLUSION: LAD disease is well tolerated in the asymmetrical form of HCM and may contribute to septal fibrosis, improving cardiac function. It does not represent an adverse factor in the evolution of HCM.