Comparison of risk of orthostatic hypotension in elderly depressed hypertensive women treated with nortriptyline and thiazides versus elderly depressed normotensive women treated with nortriptyline.

This is a nonblind, case-controlled study comparing the risk of orthostatic hypotension (OH) in 2 groups of elderly depressed women: 22 normotensive and 21 hypertensive patients receiving thiazides. Blood pressure measurements and tilt-table tests produced similar results: increased drop in systolic blood pressure (SBP) after standing (p <0.001), with no significant differences between the groups (p = 0.523). There were no changes on diastolic blood pressure (DBP) after standing, or in SBP or DBP at rest. Dizziness was reported by 23 subjects (53.5%) before treatment, and by 16 subjects (38.1%) at week 8. Complaints of dizziness were not associated with OH (Kappa = 0.07).

Clinical predictors of prognosis in severe aortic stenosis in unoperated patients > or = 75 years of age.

In elderly patients with severe aortic stenosis, clinical evaluation can dictate decision making. Asymptomatic patients in normal sinus rhythm, without left atrial enlargement and without bundle branch block, can be safely followed clinically, regardless of echocardiographic findings.

[Medical treatment of heart failure at a tertiary hospital of São Paulo]. / Tratamento medicamentoso da insuficiência cardíaca em hospital terciário de São Paulo.

PURPOSE: To study how patients with heart failure (HF) are treated in a tertiary hospital in São Paulo. METHODS: One hundred patients with HF during ambulatory care were analyzed. Seventy-six were men, and the average population age was 56.8 years old. All patients were submitted to echocardiogram, which identified ventricular diameters ranging between 48 and 89 mm (average 65.9) and ejection fraction (EF) between 0.22 and 0.59 (average 0.43). The cause of HF was ischemic in 42 cases, dilated cardiomyopathy in 28, valvular heart disease in 12, Chagas' disease in 10 and systemic hypertension in 8 patients. The prescribed treatment was analyzed, with attention to the prescription and dosage of angiotensin converting enzyme (ACE) inhibitors. We also analyzed whether the cause and/or the degree of HF influenced the treatment chosen. RESULTS: Eighty-seven patients received ACE inhibitors, 31 received doses below those recommended in the large trials. Digoxin was prescribed in 69 cases, diuretics in 85, and aspirin in 33. When dividing the patients according to EF, the group with EF below 0.45 was prescribed more often ACE inhibitors (91.5% vs 80.4%) and had more often usage of adequate doses (61% vs 48.7%). CONCLUSION: In this sample the majority of the patients were treated according to modern recommendations and tolerated well ACE inhibitors, however 1/3 did not receive ACE inhibitors in the recommended doses. Treatment based on betablockers or angiotensin II inhibitors were not routinely employed.

[Heart failure at a large tertiary hospital of São Paulo]. / Insuficiência cardíaca em grande hospital terciário de São Paulo.

PURPOSE: To study the incidence, main causes, aggravating factors and secondary diagnoses of heart failure (HF) during 1995 at the Instituto do Coração of São Paulo. METHODS: Data from hospitalized patients according to the PRODESP data base were analyzed. The following data were studied; age, sex, principal and secondary diagnoses, surgical procedures and mortality. To analyze the data, tables according to sex, age and main cause were built. Analysis of variance and t test were employed to verify differences between groups. RESULTS: In 1995, 903 out of 9620 patients were hospitalized due to HF. The majority were male (60.4%) and the patients' age was between two days and 98 years old (mean 52.6). Ischemic (32.6), dilated (25.8%) and valvar heart disease (22%) were the main causes of HF. 32.1% were submitted to correction of the HF main cause, specially those with valvar heart disease (62.3%). There was greater incidence of multiple diagnoses in aged patients. The mortality was greater in patients younger than 20 and in those older than 80 years old. CONCLUSION: The incidence of HF at INCOR during 1995 was 9.38%. Ischemic myocardiopathy was the most frequent HF cause. The mortality was greater among children, probably because of heart disease complexity and, in the above-80 group due to the greater comorbidity.

[Effect of myocardial revascularization on asymptomatic ischemic episodes]. / Efeito da cirurgia de revascularização miocárdica sobre os episódios isquêmicos assintomáticos.

PURPOSE: To evaluate the effect of coronary artery bypass graft surgery (CABG) on ischemic asymptomatic episodes (IAE). METHODS: Twenty eight males (means age 57.3 +/- 9.6 years) with stable angina and no microcirculation abnormalities, who presented with IAE after medication withdrawal, were studied using ambulatory electrocardiography monitoring. Presence of IEA was analyzed before and 4 months after CABG according to its frequency and heart rate (HR) response. CAGB was considered complete in 75% of the cases. RESULTS: The number or IAE was reduced from 162 (9 symptomatic) in the preoperative period to 4 after surgery (p < 0.05). In two patients with IAE in the postoperative period, coronariography confirmed obstruction of aortocoronary grafts. Analysis of HR at the beginning and peak of IAE suggested as mechanisms both reduced blood flow and increased oxygen consumption by the myocardium. CONCLUSION: CABC eliminated IAE regardless of HR. When IAE is present after surgery, graft occlusion should be suspected.

[Effect of beta blockers with intrinsic sympathomimetic activity on blood pressure and blood lipids in patients with essential hypertension]. / Influência de betabloqueadores com atividade simpaticomimética intrínseca sobre pressão arterial e lípides sangüíneos em portadores de hipertensão arterial essencial.

The aim of this study was to compare the effects of a beta-blocker (mepindolol) with intrinsic sympathomimetic activity (ISA) to a beta-blocker (metoprolol duriles) without ISA. Hypertensive patients with more than 50 years of age were selected and randomly allocated to receive either 5 mg/day mepindolol (Group A, 10 patients), or 200 mg/day metoprolol duriles (Group B, 9 patients), or placebo (Group C, 10 patients). They were submitted to clinical exam, stress testing and plasma lipids dosage before and after four weeks of treatment. At rest, there were a significant reduction of systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) in all groups. The mean values for SBP, DBP and HR at rest after treatment were respectively: 154.0, 95.5, 73.7 (Group A); 148.8, 94.4, 70.1 (Group B); 153.0, 96.0, 77.8; (Group C). During stress testing, there were a significant reduction of SBP, HR and double product (DP). The DBP remained unchanged. The mean values for SBP, DBP, HR and DP during stress testing after treatment were respectively; 198.0, 115.5, 124.3, 246.9 (Group A); 198.8, 114.4, 144.6, 283.2 (Group B); 202.2, 119.0, 143.5, 283.4 (Group C). Total cholesterol, HDL-cholesterol, and LDL-cholesterol, have not changed with both beta-blockers. There were a significant increase in plasma triglycerides and VLDL-cholesterol levels after treatment with beta-blockers. In conclusion, both mepindolol and metoprolol were similarly effective in reducing arterial blood pressure of hypertensive patients. There were not significant differences between the beta-blocker with or without ISA in regard to their effects on plasma lipids.

[Cardiac amyloidosis. A disease with many faces and different prognosis]. / Amilóidose cardíaca. Uma doença de muitas faces e diferentes prognósticos.

PURPOSE: To identify the principal forms of cardiac amiloydosis presentation in a terciary hospital. METHODS: Eight cases with cardiac amyloidosis were identified. Five were women, their ages ranged from 23 to 83 years (mean 62). After a medical history and clinical examination the patients were submitted to complementary tests: electrocardiogram (EKG), echocardiogram (ECHO), scintigraphy with technecium pirophosphate and cardiac biopsy these results allowed the identification of their clinical situation. RESULTS: Seven patients referred dyspnea, 6 were in heart failure, 1 patient had syncope. The EKG identified complete atrioventricular (AV) block in 4 patients, and antero septal inactive area in the other 4. The ECHO showed normal cardiac diameter in all (mean left ventricular diastolic diameter of 46.8) and slight reduction of left ventricular ejection fraction; hypertrophy of the left ventricular septal and posterior walls in all cases, in 7 cases there was a hyper refractile granular sparkling ECHO. Two different groups were identified: one with complete AV block and the second with restrictive cardiomyopathy. The prognosis was different in these two groups. Those with complete AV block evolved better after pacemaker implantation and those with restrictive cardiomyopathy had refractory heart failure and 3 of them died. CONCLUSION: The increased free wall and septal thickness, the slight systolic dysfunction and the infiltration aspect at ECHO allow us to identify the great majority of the cases. Those patients with restrictive cardiomyopathy evolve with refractory heart failure and most of them die in a few months.

[Clinical profile of aged patients with severe aortic stenosis]. / Perfíl clínico de idosos portadores de estenose aórtica severa.

PURPOSE: To evaluate clinical symptoms and echocardiographic findings in elderly patients with severe aortic stenosis and possible gender differences. METHODS: We studied 54 patients, 24 (44.5%) males and 30 (55.5%) females aged 80.7 +/- 5.2 years with severe aortic stenosis. The following variables were analyzed: presence of clinical manifestations (dyspnea, angina, and syncope) and echocardiographic indices (left ventricular [LV] dimensions, ejection fraction [EF], and mass index). RESULTS: Dyspnea was the most frequent symptom with overall prevalence of 44%. EF was lower than 50% in only 2 patients. There were no gender differences in the prevalence of any of the clinical manifestations. Male patients had higher LV volumes (p < 0.05) and lower EF (p = 0.03). CONCLUSION: The data showing dyspnea as the most common clinical manifestation; EF > 50%; lower LV volumes and greater EF in female patients suggest that the adaptive mechanisms to this condition may be different between the two sexes.

Effects of chlorthalidone and diltiazem on myocardial ischemia in elderly patients with hypertension and coronary artery disease.

OBJECTIVE: Antihypertensive therapy with thiazides decreases coronary events in elderly patients. However, the influence of diuretics on myocardial ischemia has not been fully investigated. The aim of this study was to compare the effect of chlorthalidone and diltiazem on myocardial ischemia. METHODS: Following a randomized, double-blind, crossover protocol, we studied 15 elderly hypertensive patients aged 73.6+/-4.6 years with myocardial ischemia. All patients had angiographically documented coronary artery disease. We measured patients using 48- hour ambulatory electrocardiogram monitoring and exercise testing. After a 2-week period using placebo, patients received chlorthalidone or diltiazem for 4 weeks. RESULTS: Both treatments lowered systolic and diastolic blood pressures. The number of ischemic episodes on ambulatory electrocardiogram recordings was reduced with the use of chlorthalidone (2.5+/-3.8) and diltiazem (3.2+/-4.2) when compared with placebo (7.9+/-8.8; p<0.05). The total duration of ischemic episodes was reduced in both treatments when compared with placebo (chlorthalidone: 19.2+/-31.9min; diltiazem: 19.3+/-29.6min; placebo: 46.1+/-55.3min; p<0.05). CONCLUSION: In elderly hypertensive patients with coronary artery disease, chlorthalidone reduced myocardial ischemia similarly to diltiazem. This result is consistent with epidemiological studies and suggests that reduction of arterial blood pressure with thiazide therapy plays an important role in decreasing myocardial ischemia.

[Risk factors in elderly patients selected by primary care physicians for hypolipemic treatment]. / Fatores de risco em pacientes idosos selecionados por médicos da comunidade para tratamento hipolipemiante.

PURPOSE: To evaluate the influence of age on response to pravastatin treatment in patients treated by community physicians. METHODS: According to age, 873 patients were divided in three groups: group A with ages ranging from 45 to 59 years (n = 55), group B with ages from 60 to 64 years (n = 182) and group C with ages from 65 to 70 years (n = 143). After four weeks only with diet orientation, patients received 10 mg/day of pravastatin for 12 weeks. RESULTS: There was a greater prevalence of risk factors in elderly patients: hypertension (45.7%, 54.4% and 57.1% in groups A, B and C respectively p = 0.0165), diabetes mellitus (9.3%, 17.6% and 25.8% respectively in groups A, B and C p < 0.0001), and previous heart disease (23.1%, 34.3% and 34.7% in groups A, B and C respectively p < 0.001). During the period of diet orientation there was a similar total cholesterol reduction in the three groups (about 10.5%), the reduction reached 30.0% with the introduction of pravastatin for 12 weeks. Low density cholesterol level decreased during the diet period in the three groups (about 10.5%), pravastatin prescription induced further reduction (about 31.7%). The high density cholesterol level (HDL) increased significantly with pravastatin treatment (12.7%). After pravastatin treatment the increase in HDL levels was more significantly among those patients with initial low levels of HDL (< 35 mg/dL) in the three groups. CONCLUSION: In patients selected by community physicians to receive lipid lowering therapy, increased age was associated with greater prevalence of risk factors and heart disease. Regardless of age, there was a good response to pravastatin treatment, however less than half of patients had received treatment prior to the protocol.

[Prevalence of intraabdominal aneurysm in elderly patients]. / Prevalência de aneurisma intra-abdominal em idosos.

BACKGROUND: A study in old patients on the incidence of aneurysms in abdominal arteries (AAA) and on the maximum diameter of the aorta below the renal arteries in those patients without arterial dilatation. MATERIAL AND METHODS: The study comprised 411 individuals, 218 women and 153 men with an average age of 74.4 years. Physical examination of the abdomen (EF) and abdominal ultrasonography (US) were done, and the latter was considered the "golden standard" of reference. In relation to the aorta, it was considered as an aneurysm the maximum artery diameter larger than 30 mm and for the iliac arteries, the maximum diameter larger than 15 mm. RESULTS: The US showed the presence of aneurysm in the aortic-iliac territory in nine patients, one woman and eight men, corresponding to a prevalence of 2.1%, 4.1% in men and 0.4% in women. Two such aneurysms were in the iliac arteries (one aneurysm in a common iliac artery) and the other seven in the aorta below the renal arteries. The bearers of iliac aneurysm are men. The prevalence of the AAA was of 1.7% (7/411), 3.1% in men and 0.4% in women. The EF showed suspicion of the presence of aneurysm in 3 of these patients. The other 6 patients had no aneurysm. Considering all the aneurysms of the aortic-iliac territory, the EF had a sensitivity of 33.3%, a specificity of 99% and a positive prediction value of 33.3%. Considering only AAA, the sensitivity of the EF was 42.8%, the specificity 98.5%, and the positive prediction value, 33%. In the 402 patients without arterial aneurysm the maximum diameter of the aorta varied from 11 to 29 mm, with an average value of 16-21 mm. CONCLUSIONS: US is a non-invasive diagnostic procedure that should be used for the old age population.

Amilóidose cardíaca. Uma doença de muitas faces e diferentes prognósticos / Cardiac amyloidosis. A disease with many faces and different prognoses

OBJETIVO - Avaliar as formas de apresentaçäo da amilóidose cardíaca em hospital terciário. MÉTODOS - Nos últimos 15 anos, foram identificados 8 pacientes com amilóidose, sendo 5 mulheres, com idades entre 23 e 83 (média 62) anos. Após anamnese e exame físico foram submetidos a eletrocardiograma (ECG), ecocardiograma (ECO), estudo com pirosfofato de tecnécio e biópsia endomiocárdica, cujos resultados permitiram caracterizar suas formas clínicas. RESULTADOS - Sete pacientes apresentavam dispnéia aos esforços, 6 quadro de insuficiência cardíaca congestiva (ICC), 1 síncopes. O ECG identificou bloqueio atrioventricular total (BAVT) em 4 casos e área eletricamente inativa ântero-septal em outros 4. O ECG mostrou diâmetros normais em todos e fraçäo de ejeçÝo discretamente reduzida em 6. Hipertrofia do septo e parede posterior em todos, sendo em 7 com aspecto sugestivo de doença de depósito (aspecto granuloso). Os dados clínicos caracterizam dois grupos. um com BAVT e outro com cardiomiopatia restritiva. A evoluçäo foi difrente com melhora clínica após o implante de marcapasso no primeiro grupo e má evoluçäo no grupo com cardiomiopatia restritiva que evoluiu de maneira refratária, 3 falecendo em menos de 6 meses após diagnóstico. CONCLUSÄO - A presença de aumento da espessura das paredes ao ECO, discreta disfunçäo sistólica e aspecto de doença de depósito identifiram a quase totalidade dos casos. Cardiomiopatia restritiva e distúrbio de conduçÝo foram as formas de apresentaçäo, sendo o prognóstico muito reservado nos pacientes com forma restritiva, evoluindo para ICC refratária

Tratamento medicamentoso da insuficiência cardíaca em hospital terciário de Säo Paulo / Heart failure medical treatment in a tertiary hospital of Säo Paulo

OBJETIVO - Verificar como são tratados pacientes com insuficiência cardíaca (IC) em hospital terciário de Säo Paulo. MÉTODOS - Analisados 100 pacientes com IC, em tratamento ambulatorial, com idade média de 56,8 anos, sendo 76 homens. Todos realizaram estudo ecocardiográfico, que identificou diâmetros ventriculares entre 48 e 89mm (média 65,9) e fraçäo de ejeçäo (FE) entre 0,22 e 0,59 (média 0,43). A etiologia da disfunçäo ventricular (DV) foi isquêmica em 42 casos, cardiomiopatia dilatada em 28, secundária à valvopatia em 12, doença de Chagas em 10 e cardiomiopatia hipertensiva em 8. Analisou-se a terapêutica prescrita, se continha inibidores da enzima conversora de angiotensina (IECA) e qual a sua dosagem. Foi analisado, também, se a etiologia ou o grau de DV tinha influência na prescrita. RESULTADOS - Oitenta e sete pacientes receberam IECA, sendo que em 31 a dose foi inferior à preconizada nos grandes estudos. Digoxina foi prescrita em 69 casos, diuréticos em 85 e ácido acetilsalicílico em 33. Dividindo os pacientes os pacientes em dois grupos, com FE maior e menor que 0,45, observamos que, no último, foi maior a prescrição de IECA (91,5 'por cento' vs 80,4 'por cento') e maior o uso de doses adequadas (61 'por cento' vs 48,7 'por cento'). CONCLUSÄO - A maioria dos pacientes foi tratada conforme recomendaçöes atuais, apresentando boa tolerabilidade para IECA, contudo 1/3 deles não usou IECA em dose considerada adequada. Esquemas terapêuticos com betabloqueadores e inibidores da angiotensina II não fizeram parte da prática clínica rotineira.

Insuficiência cardíaca em grande hospital terciário de São Paulo / Heart failure in a large tertiary hospital of São Paulo

OBJETIVO - Verificar a incidência, principais causas, fatores desencadeantes ou de piora da insuficiência cardíaca (IC) no ano de 1995, no Instituto do Coração de São Paulo. MÉTODOS - Foram analisados os registros referentes a pacientes internados, obtidos do banco de dados da PRODESP. Analisaram-se nos pacientes co IC os dados: idade, sexo, diagnóstico principal e secundários, procedimentos executados e óbitos. Para fim de análise, construiram-se tabelas de distribuição conforme o sexo, idade e diagnóstico principal. Análise de variância e teste do qui-quadrado foram empregados para verificar diferença entre os grupos estudados. RESULTADOS - Dos pacientes internados (903 de 9620) 9,38 'por cento' apresentaram IC. As idades variaram de 2 dias a 98 (média 52,6) anos e a maioria era do sexo masculino (60,4 'por cento'). Miocardiopatia isquêmica (32,6 'por cento'), miocardiopatia dilatada (25,8 'por cento') e valvopatias (22,0 'por cento') foram as principais causas de IC. Foram submetidos à cirurgia, angioplastia, ou implante de marcapasso, 32,1 'por cento' dos pacientes, sendo os valvopatas na maioria submetidos à correção de sua cardiopatia de base (63,3 'por cento'). Houve maior incidência de múltiplos diagnósticos secundários com o aumento da idade. A mortalidade foi maior nos com idade <20 anos e nos >80anos. CONCLUSÄO - A incidência de IC foi de 9,38 'por cento', sendo miocardiopatia isquêmica a causa mais freqüente. Foi possível corrigir a causa da IC em 32,1 'por cento'. A mortalidade foi maior nas crianças provavelmente pela maior complexidade de sua cardiopatia e nos mais idosos devido à maior associação de diagnósticos secundários ou fatores agravantes.

Efeito da cirurgia de revascularizaçäo miocárdica sobre os episódios isquêmicos assintomáticos / Effect of coronary artery bypass graft surgery on ischemic asymptomatic episodes

OBJETIVO - Avaliar o efeito da cirurgia de revascularizaçäo miocárdica (CRM) sobre episódios isquêmicos assintomáticos (EIA). MÉTODOS - Foram estudados 28 homens, com angina estável (idade média 57,3ñ9,6) anos sem condiçöes relacionadas a alteraçöes de microcirculaçäo e que, após retirada da medicaçäo, apresentaram EIA à eletrocardiografia ambulatorial (ECGA). No pré-operatório e 4 meses após a cirurgia foram analisados os comportamentos dos EIA, segundo sua freqüência, e o de suas freqüências cardíacas (FC). A revascularizaçäo miocárdica foi completa em 75 'por cento' dos casos. RESULTADOS - O número dos EIA foi reduzido de 162 (9 sintomáticos) no pré-operatório para, apenas, 4 no pós-operatório (p<0,05). Nos dois pacientes com EIA no operatório, estudo cinecoronariográfico confirmou obstruçäo de enxertos aortocoronários. A análise das FC no início e pico dos EIA sugeriram envolvimento de mecanismo de reduçÝo de oferta e aumento de consumo de oxigênio pelo miocárdio. CONCLUSÄO - A CRM eliminou os episódio isquêmicos relacionados ou näo ao aumento da FC. Quando os EIA encontram-se presentes após CRM, devemos considerar a possibilidade de oclusäo de enxerto.

Arritmias no idoso / Arrhythmias in the elderly

Com o envelhecimento, ocorrem mudanças estruturais nos tecidos do coraçäo, com consequentes alteraçöes eletrofisiológicas que podem gerar vários tipos de arritmias e distúrbios de conduçäo. Muitas vezes torna-se difícil para o clínico decidir até onde säo alteraçöes devidas ao processo normal de envelhecimento e onde se iniciam as alteraçöes patológicas. Neste artigo, säo condensados os conhecimentos atuaia sobre as mudanças fisiológicas encontradas nos coraçöes dos idosos, assim como os processos patológicos que podem causar arritmias nesses pacientes. Foram analisadas as arritmias mais prevalentes na populaçäo idosa, divididas como arritmias supraventriculares, ventriculares e distúrbios de conduçäo. Além disso, foram feitas consideraçöes acerca das principais drogas antiarrítmicas utilizadas neses pacientes, com ênfase nas peculiaridades de seu uso nos idosos. Finalmente, tecemos consideraçöes sobre as técnicas invasivas para tratamento das arritmias nos idosos, que, entre todas, têm apresentado os resultados mais promissores também nessa faixa populacional.