Pode o teste ergoespirométrico de caminhada de seis minutos ser representativo das atividades habituais de pacientes com insuficiência cardíaca? / Can the cardiopulmonary 6-minute walk test reproduce the usual activities of patients with heart failure?

OBJECTIVE: The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS: We studied 12 males, age 45±12 years, ejection fraction 23±7 percent, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS: The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4±1.8, 9.8±1.9 (60±10 percent), and 13.3±2.2 (90±10 percent); heart rate (bpm) 142±12, 110±13 (77±9 percent), and 126±11 (89±7 percent); distance walked (m) 733±147, 332±66, and 470±48; and respiratory exchange ratio (R) 1.13±0.06, 0.9±0.06, and 1.06±0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p<0.05). CONCLUSION: Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients

Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with mitral regurgitation. Initial results

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19 percent to 30 percent (mean: 25.7±3.4 percent), and the postoperative ejection fraction ranged from 21 percent to 40 percent (mean: 31.1± 5.8 percent). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period

Histoplasmose como complicaçäo infecciosa tardia após transplante cardíaco em portador de doença de Chagas / Histoplasmosis as a late infectious complication following heart transplantation in a patient with Chagas' disease

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25 percent of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature

Diagnóstico não-invasivo da doença vascular do enxerto após transplante cardíaco / Noninvasive diagnosis of allograft vascular disease after heart transplantation

OBJECTIVE: To determine the predictive values of noninvasive tests for the detection of allograft vascular disease. METHODS: We studied 39 patients with mean ages of 48Ý13 years and a follow-up period of 86Ý13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or = 50 percent obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results. RESULTS: Allograft vascular disease was found in 15 (38 percent) patients. The Holter test showed 15.4 percent sensitivity, 95.5 percent specificity...

Analise dos fatores de risco da doença vascular do enxerto em pacientes assintomáticos após transplante cardíaco / Analysis of the risk factors for allograft vasculopathy in asymptomatic patients after cardiac transplantation

OBJECTIVE: To study the influence of immune and nonimmune risk factors on the development of allograft vasculopathy after cardiac transplantation. METHODS: We studied 39 patients with a mean age of 46 + or - 12 years. The following variables were analyzed: weight (kg), body mass index (kg/m²), donor's age and sex, rejection episodes in the first and second years after transplantation, systolic and diastolic blood pressures (mmHg), total cholesterol and fractions (mg/dL), triglycerides (mg/dL), diabetes, and cytomegalovirus infection. The presence of allograft vasculopathy was established through coronary angiography. RESULTS: Allograft vasculopathy was observed in 15 (38 percent) patients. No statistically significant difference was observed between the two groups in regard to hypertension, cytomegalovirus infection, diabetes, donor's sex and age, rejection episodes in the first and second years after transplantation, and cholesterol levels. We observed a tendency toward higher levels of triglycerides in the group with disease. Univariate and multivariate analyses showed statistically significant differences between the two groups when we analyzed the body mass index (24.53 + or - 4.3 versus 28.11 + or - 4.6; p=0.019). CONCLUSION: Body mass index was an important marker of allograft vasculopathy in the population studied

Uso de marcapasso provisório e definitivo em pacientes submetidos a transplante cardíaco ortotópico / Permanent and temporary pacemaker implantation after orthotopic heart transplantation

PURPOSE:To determine the indication for and incidence and evolution of temporary and permanent pacemaker implantation in cardiac transplant recipients. METHODS: A retrospective review of 114 patients who underwent orthotopic heart transplantation InCor (Heart Institute USP BR) between March 1985 and May 1993. We studied the incidence of and indication for temporary pacing, the relationship between pacing and rejection, the need for pemanent pacing and the clinical follow-up. RESULTS: Fourteen of 114 (12 per cent) heart transplant recipients required temporary pacing and 4 of 114 (3.5 per cent) patients required permanent pacing. The indication for temporary pacing was sinus node dysfunction in 11 patients (78.5 per cent) and atrioventricular (AV) block in 3 patients (21.4 per cent). The indication for permanent pacemaker implantation was sinus node dysfunction in 3 patients (75 per cent) and atrioventricular (AV) block in 1 patient (25 per cent). We observed rejection in 3 patients (21.4 per cent) who required temporary pacing and in 2 patients (50 per cent) who required permanent pacing. The previous use of amiodarone was observed in 10 patients (71.4 per cent) with temporary pacing. Seven of the 14 patients (50 per cent) died during follow-up. CONCLUSION: Sinus node dysfunction was the principal indication for temporary and permanent pacemaker implantation in cardiac transplant recipients. The need for pacing was related to worse prognosis after cardiac transplantation.

Tratamento ambulatorial de rejeiçäo persistente com methotrexate em pacientes submetidos a transplante cardíaco estáveis clinicamente / Treatment of persistent rejection with methotrexate in stable patients submmitted to heart transplantation

OBJECTIVE:To evaluate the use of methotrexate for the treatment of recurrent rejection in heart transplant recipients. METHODS: We studied 6 patients submitted to heart transplantation that showed rejection grade ü 3A (ISHLT) in two consecutives endomyocardial biopsy specimens. The dose was 11.26ñ3.75mg/week. The evaluated data were: ventricular function, endomyocardial biopsy, white cell count and number of rejection episodes before and after methotrexate administration. RESULTS: There was a reduction in the number of rejection episodes (5.17ñ1.47 before methotrexate; 2.33ñ1.75 after 6 months and 3.17ñ2.99 after 12 months of treatment, p=0.0193). The ventricular function was normal with ejection fraction of 76.5ñ4.80 before and 75.6ñ4.59 after methotrexate (p=0.4859). One patient did not finish the treatment because he showed signs of rejection associated with severe pericardial effusion. Five patients had a reduction in the white cell count (8,108ñ23.72 before and 5650ñ1350 after methotrexate, p=0.0961). One pulmonary infection with complete resolution after antibiotic treatment was observed. CONCLUSION: Methotrexate in low doses is an effective adjunct therapy in the treatment of recurrent rejection after heart transplantation.

Exercício e insuficiência cardíaca. Estudo da relaçäo da gravidade da doença com o limiar anaeróbico e o ponto de compensaçäo respiratório / Exercise and heart failure. Relation of the severity of the disease to the anaerobic threshould and the respiratory compensation point

OBJECTIVE - To identify, the anaerobic threshold and respiratory compensation point in patients with heart failure. METHODS - The study comprised 42 Men,divided according to the functional class (FC) as follows: group I (GI) - 15 patients in FC I; group II (GII) - 15 patients in FC II; and group III (GIII) - 12 patients in FC III. Patients underwent a treadmill cardiopulmonary exercise test, where the expired gases were analyzed. RESULTS - The values for the heart rate (in bpm) at the anaerobic threshold were the following: GI, 122_27; GII, 117_17; GIII, 114_22. At the respiratory compensation point, the heart rates (in bpm) were as follows: GI, 145_33; GII, 133_14; GIII 123_22. The values for the heart rates at the respiratory compensation point in GI and GIII showed statistical difference. The values of oxygen consumption (VO2) at the anaerobic threshold were the following (in ml/kg/min): GI, 13.6_3.25; GII, 10.77_1.89; GIII, 8.7_1.44 and, at the respiratory compensation point, they were as follows: GI, 19.1_2.2; GII, 14.22_2.63; GIII, 10.27_1.85. CONCLUSION - Patients with stable functional class I, II, and III heart failure reached the anaerobic threshold and the respiratory compensation point at different levels of oxygen consumption and heart rate. The role played by these thresholds in physical activity for this group of patients needs to be better clarified

Hormônio do crescimento na otimizaçäo do tratamento da insuficiência cardíaca refratária / Growth hormone for optimization of refractory heart failure treatment

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 mg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 percent to 18 percent and to 28 percent later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2to 13.4 and to 16.2ml/kg/min later). The patient was"de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure

Efeitos do carvedilol (Bloqueador beta 1, Beta 2, alfa), na insuficiência cardíaca refratária / Effects of carvedilol (beta 1, beta 2, alpha 1 bloker) on refractory congestive heart failure

Objetivo - Os efeitos dos Beta-bloqueadores n insuficiência cardiaca (IC) refratária näo tem sido adequadamente estudados. Investigamos os efeitos do caverdilol (Bloqueador Beta1, Beta2, Alfa) nos sintomas e na funçäo ventricular de portadores de IC refratária. Métodos - Foram estudados 21 pacientes, idade média de 56/10 anos, 9 em classe funcional (CF) IV, e 12 em CF III intermitente com IV. A dose inicial de carvedilol foi de 6,25mg e, se tolerada, aumentada progressivamente. A dose média final foi 42/11mg. Os pacientes foram submetidos a avaliaçöes clínicas e eletrocardiográficas seriadas. realizaram-se, antes e com 196/60 dias de evoluçäo, ecocardiograma e ventriculografia radioisotópica. Resultados - O medicamento foi tolerado em (76 por cento ) pacientes. Um paciente está em fase de titulaçäo em CF II. Com 196/60dias de evoluçäo observaram-se 8 pacientes em CF I e 7 em II; reduçäo da frequencia cardiaca de 96/15 para 67/10bpm (p<0,001); reduçäo do diametro diastólicofinal do ventrículo esquerdo (VE) de 73/13 para 66/12mm (ecocardiograma) (p<0,009); e aumento da fraçäo de ejeçäo de VE de 0,21/0,06 para 0,34/0,12 (p<0,003). Conclusäo - O carvedilol aos seus efeitos beneficos na funçäo ventricular ; remodelamento do CF é, se tolerado, uma potencial alternativa terapêutica no tratamento medicamentoso da IC refratária. Entretanto, estudos adicionais säo necessários para definiçäo do efeito a longo prazo neste específico subgrupo de pacientes.

Aspectos radiológicos da endomiocardiofibrose / Radiological findings in endomyocardial fibrosis

PURPOSE: To determine through conventional radiology the type of ventricular involvement in endomyocardial fibrosis (EMF). METHODS: We analyzed 56 cases with EMF confirmed by angiocardiography and 9 by postmortem study, aged between 16 and 56 years (mean 32); there were 42 females. Only one radiologist analyzed X-rays without any knowledge of the cineangiography findings. RESULTS: The right side of the heart was primarily involved in 9 patients and the cardiac silhouette was characteristically globular and had oligemic pulmonary fields (66.66). The cardiothoracic ratio was 0.62 +/- 0.11. Out of 9 patients, 8 were female. The left side of the heart was established as being primarily involved in 11 cases and simulated rheumatic mitral disease. The cardiothoracic ratio was 0.51 +/- 0.09 and there were increased pulmonary fields in 63.6. The biventricular disease occurred in 36 cases. There were radiologic findings of right and left side. The cardiothoracic ratio was 0.63 +/- 0.06 and there was oligemic pulmonary fields in 38.8, increased pulmonary fields in 33.3and was normal in 27.7. There were 4:1 females. CONCLUSION: The radiological study is fundamental in the initial diagnosis of EMF. The type of involvement could be done in 66.07of all cases by chest X-ray.

Bloqueio divisional ântero-medial intermitente em paciente com insuficiência coronária / Intermittent antero-medial divisional block in patients with coronary disease

We report the case of a 69 year-old male who developed congestive heart failure functional class IV (NYHA). The admission electrocardiogram (EKG) revealed sinus rhythm, PR interval of 240 ms, QRS interval of 110 ms, the QRS vector of 0 degree, Q waves from V1 to V6, tall R waves from V1 to V4 that decreased to V5 and V6. The vectocardiogram had anteriorization of the electrical forces of QRS, with vector half area in the horizontal plane at +60 degrees. After two years the patient had a myocardial infarction, the EKG at the admission had the same pattern and after two days developed important changes: enlargement of QRS interval with length of 160 ms, QRS vector of +100 degrees, R waves at D2, D3 e AVF that increase from D2 to D3, QS at D1, AVL, AVR and V1, rS at V2 and V3, R wave is notched and thickened+ at V5 and V6, that return to the initial pattern after one day. The patient progressed to death in the eighth day after infarction. This case reported a intermitent pattern of EKG that is an uncontestable proof to the existence of the left middle fascicular block.

Palpitações persistentes após ablação por cateter com radiofreqüência / Persistence of Palpitations After Successful Radiofrequency Catheter Ablation

PURPOSE: The aim of this study was to determine prevalence and the underlying mechanism of persistent palpitations after successful radiofrequency ablation of reentrant nodal tachycardia and atrioventricular tachycardia. METHODS: One hundred twenty consecutive patients (mean age of 36 +/- 16 years) who underwent radiofrequency catheter ablation of atrioventricular or reentrant nodal tachycardia constituted the analyzed group. Prevalence of palpitations was investigated during out-clinic visits and telephone interviews. Patients complaining of palpitations were divided in 2 groups: 1) those in whom palpitations lasted more than 30 seconds, and 2) those in whom the paroxysms lasted < 30 seconds (group II). All patients underwent clinical evaluation, ECG and Holter monitoring. Transesophageal atrial pacing and electrophysiologic stimulation were carried out when judged necessary. RESULTS: During a follow up period of 9 +/- 4 months, 52 patients complained of palpitations. In 31 group I patients, palpitations were related to ventricular and atrial premature beats as shown during Holter monitoring. In group II patients, eight had recurrence, five presented a new arrhythmia not recognized previously to the ablative procedure and two patients had their symptoms related to arrhythmias recognized before ablation but taken as asymptomatic. The mechanism of palpitations was not identified in six patients. CONCLUSION: Palpitations may persist in 43of patients who undergo radiofrequency ablation to treat reentrant nodal tachycardia and atrioventricular tachycardia. Recurrence and treatment are more likely when palpitations last longer than 30 seconds.

Resultados da cirurgia da estenose aórtica em pacientes com disfunção ventricular grave / Results of Aortic Valve Surgery in Patients with Severe Left Ventricular Dysfunction

PURPOSE: To study the short and long term clinical course of patients with severe aortic stenosis after surgical treatment of the valvular lesion. METHODS: Thirty survivors among 31 consecutive patients with severe left ventricular dysfunction (LVD) due to aortic stenosis (AS) were submitted to clinical and echocardiographic follow-up during a mean of 30 months after surgical treatment of the valvular lesion. Twenty five (83.3) patients were male with a mean age of 50 years (25 to 74). Before operation the following parameters were obtained: diastolic left ventricular diameter (DLVD), shortening fraction (SF), left ventricular ejection fraction (LVEF), aortic valve area (AVA), left ventricular-aortic pressure gradient (PG) and NYHA functional class (FC). During the follow up, after the surgical procedure, FC, DLVD, LVEF and SF could be analysed and compared with previous data. RESULTS: A significant rise in SF (p = 0.001) and LVEF (p = 0.0001), as well as a decrease in DLVD (p = 0.001) were observed in the follow up. Symptoms lessened in severity in the majority of patients. Three of our patients died with progressive LVD and heart failure, after at least 36 months of follow-up. These results indicate that when operation is carried out in patients with AS and left ventricular failure, a significant improvement in left ventricular function and in symptoms takes place. Although the risk of surgical treatment is increased in this group of patients, LVD should not be considered a contraindication to the procedure. CONCLUSION: The left ventricular dysfunction is not a contraindiction for the surgical treatment of the aortic stenosis.

Objetivo - Estudar a evolução imediata e tardia de portadores de estenose aórtica, com disfunção ventricular grave submetidos à cirurgia. Métodos - Estudamos clínica e ecodopplercardio graficamente, por período médio de 30 meses, a evolução pós-operatória de 30 sobreviventes dentre 31 pacientes (mortalidade imediata 3,2%) com estenose aórtica e disfunção grave de ventrículo esquerdo (VE) submetidos consecutivamente à troca valvar aórtica. A idade média foi de 50 (25 a 74) anos, sendo 25 (83,3%) do sexo masculino. A comparação pré e pós-operatória compreendeu fundamentalmente a análise do ∆ D%, diâmetro diastólico do ventrículo esquerdo (DDVE) e classe funcional (CF) de insuficiência cardíaca. No pré-operatório foram analisados também a área valvar aórtica (AVA) e o gradiente de pressão (GP) sistólica entre VE e aorta. Resultados - Houve, no pós-operatório (PO) tardio significativa (p= 0,001) elevação média de ∆ D%, assim como da fração de ejeção do VE (p= 0,0001) e queda da média de DDVE (p= 0,001), bem como regressão para CFI/II em 27 (90%) casos. Ocorreram três (9,6%) óbitos tardios, todos após pelo menos três anos de PO, causados por disfunção ventricular esquerda progressiva. Observamos que nos portadores de estenose aórtica e disfunção ventricular, existe, no PO, melhora significativa das condições clínicas e da função ventricular, o que justifica o tratamento cirúrgico da valva aórtica nestes casos. Conclusão - A disfunção ventricular esquerda não constitui contra-indicação ao tratamento cirúrgico da estenose aórtica.

Efeitos da ventriculectomia parcial nas propriedades mecânicas, forma e geometria do ventrículo esquerdo em portadores de cardiomiopatia dilatada / Effects of Partial Ventriculectomy on Left Ventricular Mechanical Properties, Shape and Geometry in Patients with Dilated Cardiomyopathy

PURPOSE: To investigate the short-term effects of the partial ventriculectomy (resection of lateral wall associated to mitral annuloplasty) on cardiac mechanics, contractility, shape and geometry of the left ventricle (LV). METHODS: Eleven male patients with severe congestive heart failure due to dilated cardiomyopathy were studied. The mean age was 51 +/- 7 years and the functional class was III (five patients) or IV (six patients) before the surgery. Patients were evaluated before and at 17 +/- 4 days after the surgery by simultaneous LV pressure and echocardiographic data. End-diastolic pressure (EDP-mmHg), wall stress (EDS-g/cm2) and diameter (EDD-cm); endsystolic wall stress (ESS) and diameter (ESD), fractional shortening (FS-) and maximal elastance (Emax-mmHg/ cm/s); the diastolic slope of the pressure-diameter (Kp-mmHg/cm) and stress-strain (Km-g/cm2) loops; shape (L/ EDD, adimensional, where L is the LV long axis) and geometry (Th/EDD, adimensional, where TH is the LV diastolic thickness) were obtained. RESULTS: 1) The ressected muscle fragments (diamond shape) were 10.8 +/- 1.3 cm in length and 5 +/- 0.6 cm in width; 2) all patients were discharged from hospital (15-29 days) in class I (eight cases), II (two), and III (one); 3) it was observed a decrease in EDP (24.3 +/- 7.7 x 17.5 +/- 3.2, p = 0.016); in EDD (8.0 +/- 0.7 x 7.2 +/- 0.8, p = 0.002); in EDS (57.9 +/- 26.8 x 37.4 +/- 19.2, p = 0.005); in ESS (199 +/- 46.9 x 102.8 +/- 33.1, p = 0.004); in ESD (7.1 +/- 0.7 x 5.7 +/- 0.8, p < 0.001); in Kp (22.3 +/- 15.9 x 11.5 +/- 6.9, p = 0.014); and in K(m) (467.4 +/- 212 x 214.6 +/- 87.4, p = 0.01); and, 4) it was noted an increase in FS (11.5 +/- 1.8 x 19.8 +/- 3.9, p < 0.001); in Emax (13.8 +/- 2.2 x 18.6 +/- 3.2, p < 0.001); and in L/EDD (1.32 +/- 0.1 x 1.47 +/- 0.13, p < 0.007) and Th/Dd (0.11 +/- 0.04 x 0.17 +/- 0.08, p < 0.038). CONCLUSION: The partial ventriculectomy showed multiple significant beneficial effects in these dilated myopathic hearts.

Quando interromper, na sala de emergência, as manobras de ressuscitação cardiopulmonar na parada cardiorrespiratória sem atendimento pré-hospitalar? / When Should we Stop Cardiopulmonary Resuscitation in Patients Brought to the Emergency Room in Cardiac Arrest with no Out-ofHospital Care

PURPOSE: The decision of stopping cardiopulmonary resuscitation (CPR) in patients brought to emergency room in arrest remains a challenge. Such decision is even more difficult when someone is brought by bystanders, after an acute loss of consciousness without any out-of-hospital care. To evaluate the probability of survival of these patients we reviewed retrospectively charts in our institution, during a period of five years. METHODS: One hundred and one patients that fulfilled these characteristics came to our emergency in arrest. The time to arrival since symptoms started, cardiac rhythm at first electrocardiogram (EKG), age, gender, initial CPR success, late outcomes and previous diseases were obtained. Patients were divided in two groups regarding which cardiac rhythms they had at first EKG: A-patients arriving in asystole; and VF-patients arriving in ventricular fibrillation. To evaluate time to arrival, we arbitrarily choose 15 min as a reference point. RESULTS: In these 101 subjects the mean age was 62 +/- 13.7 years and 63 (62.3) were men. Previous heart disease was documented in 74 [dilated cardiomyopathy in 22 (21.7), coronary heart disease in 41 (40.6), arterial hypertension in 25 (24.7) and others in 6 (5.6)]. In 66 episodes we were sure of the time patients spent before arrival (mean 2.5 +/- 11 min). Only in 63 subjects we had no doubts about the rhythm at entrance: VF in 37 (58.7), A in 22 (34.9) and an accelerated idioventricular rhythm (AIR) in four (6.3). Time to arrival was 18.6 +/- 10.6 in VF vs 32.5 +/- 11.7 min in A (p = 0.012). Fourteen (13.8) subjects resumed a supraventricular rhythm with systolic pressure > or = 90 mmHg after CPR and all of them were in VF (13) or AIR (one). Nine patients (8.9) evolved in coma. Only five (4.9) were discharged from the hospital without any neurological disturbance and their time to arrival ranged from one to 15 (9 +/- 5.8) min. CONCLUSION: Delayed arrival to the emergency room (> 15 min) associated with asystole were predictors of unsuccessful CPR, and both data are helpful in deciding when to stop CPR in subjects arriving at the emergency department with no out-of-hospital care.

Objetivo - Avaliar a chance de sobrevivência dos pacientes trazidos à emergência em parada cardiorrespiratória, sem atendimento pré-hospitalar, situação de difícil decisão quanto a se interromper as manobras de ressuscitação cardiopulmonar (RCP). Métodos - Retrospectivamente, analisamos os prontuários de 101 indivíduos trazidos à emergência em parada cardiorrespiratória (PCR) de janeiro/89 a dezembro/93. Avaliamos o tempo em minutos do início do sintomas até a chegada, o ritmo cardíaco ao eletrocardiograma (ECG), idade, sexo, taxa de sucesso inicial da RCP, evolução tardia e doenças pregressas. Dividimos os pacientes em 2 grupos, de acordo com o ritmo inicial: A - assistolia e FV -fibrilação ventricular. Na avaliação do tempo de chegada, consideramos arbitrariamente 15min como referência.Para avaliar diferenças entre os grupos realizamos os testes de Student e do X2 Resultados - A idade média foi de 62±13,7 anos e 63 (62,3%) eram homens. Pôde-se confirmar a existência de doença prévia em 74 casos [cardiomiopatia dilatada em 22 (21,7%), doença coronária em 41 (40,6%), hipertensão arterial em 25 (24,7%) e outras em seis (5,6%)]. Em 66 episódios tivemos certeza do tempo decorrido até a chegada à emergência (média de 22,5± 11 min.). Em 63 casos tivemos certeza do ritmo de chegada: FV em 37 (58,7%), A em 22 (34,9%) e ritmo idioventricular acelerado em quatro (6,3%). O tempo para a chegada foi de 18,6±10,6 no grupo FV vs 32,5±11,7min. no grupo A (p= 0,012). Quatorze (13,8%) indivíduos, nenhum do grupo A, reassumiram ritmo supraventricular com pressão arterial sistólica>90mmHg após a RCP. Desses, nove (8,9%) evoluíram em coma e somente cinco (4,9%) tiveram alta hospitalar, todos sem distúrbios neurológicos e do grupo FV. O tempo de chegada nesses cinco sobreviventes variou de 1 a 15 (9±5,8)min.Conclusão - Um tempo de chegada >15min associado a assistolia pode ajudar na decisão de se terminar os esforços de RCP em indivíduos que chegam à emergência sem atendimento pré-hospitalar

Persistencia de palpitaciones luego de ablaciones con éxito de taquicardia supraventricular / Persistence of palpitations following succesful ablations of supraventricular tachycardia

Objetivos: determinar la incidencia, caracterizar y establecer los mecanismos de las palpitaciones (P) que persisten luego de ablaciones exitosas, utilizando energía de radiofrecuencia (RF) en pacientes portadores de taquicardias supraventriculares. Métodos: en el período de octubre de 1992 hasta marzo de 1994, 120 pacientes, 64 mujeres, con edad media de 36+- 16,4 años (6 a 84) se realizó con éxito ablación con RF de vía accesoria (85 pacientes) y de la vía lenta nodal (35 pacientes). En éstos, la incidencia de P fue investigada inicialmente a través de consultas en la historias clínicas y por contactos telefónicos. Posteriormente se realizó examen clínico, ECG de 12 derivaciones, Holter de 24 horas, y si era necesario estudio electrofisiológico. Resultados: luego de un seguimiento de 3 a l9 meses (media 9,3+- 4,2) 52 pacientes presentaron P después de la ablación. En 16 (30,7 por ciento) las P fueron clasificadas como "amenaza" de inicio de taquicardia (grupo,1), en 15 pacientes (28,8 por ciento) como extrasístoles II (grupo II) y en 21 pacientes (40,3 por ciento) como "taquicardia" (grupo III). Dentro de este grupo los mecanismos de la arritmia fueron clasificados en 4 subgrupos: a. recurrencia en 8 pacientes (44,4 por ciento); b. arritmia asociada diagnosticada antes en 2 pacientes (11,1 por ciento); c. arritmia nueva diagnosticada después de la ablación en 5 pacientes (27,7 por ciento) y d. el mecanismo no pudo ser aclarado en 4 pacientes (22,2 por ciento). Conclusiones: la presencia de palpitaciones luego de ablaciones consideradas exitosas puede ser importante. La evaluación no invasiva es decisiva en la mayoría de los casos. Diversos mecanismos pueden explicar las palpitaciones, aunque en algunos casos no pueden ser aclaradas

Compliance with pharmacological treatment in outpatients from a Brazilian cardiology referral center

To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.

Cardiomiopatias näo-inflamatórias / Non-inflammatory cardiomyopathies

Cardiomiopatias, conforme definiçäo de 1995, säo doenças do miocárdio associadas à disfunçäo cardíaca. Neste artigo discutiremos as cardiomiopatias primárias, hoje simplesmente denominadas cardiomiopatias. Säo quatro as formas de apresentaçäo das cardiomiopatias: jipertrófica, dilatada, restritiva e displasia arritmogênica do ventrículo direito. Cada uma apresenta suas próprias peculiaridades, com diferentes manifestaçöes clínicas e conduta diversa. A cardiomiopatia dilatada é a mais frequente delas, e seus portadopres evoluem com insuficiência cardíaca congestiva. No artigo destacamos a importância do diagnóstico precoce e do emprego de doses corretas dos inibidores da enzima conversora. A cardiomipatia hipertrófica é doença geneticamente transmitida, com peculiaridades diferentes conforme a mutaçäo que a provocou. A terapêutica é diferente, conforme a forma de manifestaçäo. Betabloqueadores ou bloqueadores de canais de cálcio säo empregados quando predominam as manifestaçöes da disfunçäo diastólica. Amiodarona é a droga mais utilzada para controlar a frequente arritmia observada nos portadores da doença. marcapasso bicameral ou cirurgia säo indicados nos pacientes em que os sintomas näo säo controlados com a terapêutica clínica. A cardiomiopatia restritiva é a forma mais rara. Endomiocardiofibrose, amiloidose e cardiomiopatia restritiva idiopática säo três formas de apresentaçäo da doença, com condutas e prognóstico diversos. Aspectos dessas formas de apresentaçäo säo discutidos no artigo. Displasia arrtimogênica do ventrículo direito é a mais recente cardiomiopatia descrita. Atinge jovens e é controlada com betabloqueadores, na maioria dos casos em sua forma inicial.

Fatores de risco em pacientes idosos selecionados por médicos da comunidade para tratamento hipolipemiante / Risk Factors in Elderly Patients Selected by Primary Care Physicians for a Hypolipemic Treatment Protocol

OBJETIVO- avaliar a influência da idade sobre a conduta e a resposta para terapêutica com pravastina, em pacientes seguidos por médicos da comunidade.MÉTODOS- Conforme a faixa etária, 873 pacientes foram divididos em três grupos:grupo A com idades entre 45e 59 anos(n=544), grupo B com idades entre 60 e 64 anos (n=182) e grupo C com idades entre 65 e 70 anos (n=147).Após quatro semanas recebendo apenas orientaçäo dietética, os pacientes receberam 10mg/dia de pravastatina por período de 12 semanas.RESULTADOS- Observou-se prevalência maio em faixas etárias mais idosas de fatores de risco, como hipertensäo arterial (45,7 por cento, 54,1 por cento nos grupos A, B e C, respctivamente, p=0,0165), diabetes mellitus (9,3 por cento, 17,6 por cento e 25,8 por cento grupos A,B,C, respectivamente, p<0,0001), e doenças cardíacas prévia (23,1 por cento, 34,3 por cento e 34,7,Grupos A,B e C, respectivamente, p<0,001).Durante o período de orientaçäo dietética houve reduçäo nos níveis de colesterol total em cerca de 10 por cento e de LDL colesterol de 10,5 por cento, resposta semelhante nos três grupos.Com a administraçäo de pravastina, a reduçäo foi mais importante, atingindo percentual médio de 30,0 por cento, o mesmo sendo obeservado com o LDL colesterol com níveis de 31,7 por cento, sem diferenças entre os grupos.Os níveis de colesterol de alta densidade (HDL) aumentaram, significativamente, com a introduçäo da pravastatina (12,7 por cento).Com a introduçäo da terapêutica, o aumento percentural nos níveis de HDL colesterol foi maior nos pacientes com HDL prévio baixo (_<35mg/dL) nos três grupos.A intervençäo terapêutica foi bem tolerada nos três grupos.CONCLUSAO- Em Pacientes selecionados por médicos da comunidade para terapêutica hipolipemiante, o aumento da idade relacionou-se com frequência a fatores de risco e cardiopatia.Independentemente da idade, houve boa resposta à terapêutica com pravastatina

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 10mg/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 respectivelly p=0.0165), diabetes mellitus (9.3%, 17.6% and 25.8% respectivelly 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 respectivelly 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 (<35mg/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