The relationship between mitral annular calcification, metabolic syndrome and thromboembolic risk

Abstract Introduction: Metabolic syndrome (MetS) is defined as an association between diabetes, hypertension, obesity and dyslipidemia and an increased risk of cardiovascular disease. Mitral annular calcification (MAC) is associated with several cardiovascular disorders, including coronary artery disease, atrial fibrillation (AF), heart failure, ischemic stroke and increased mortality. The CHA2DS2-VASc score is used to estimate thromboembolic risk in AF. However, the association among MAC, MetS and thromboembolic risk is unknown and was evaluated in the current study. Methods: The study group consisted of 94 patients with MAC and 86 patients with MetS. Patients were divided into two groups: those with and those without MAC. Results: Patients with MAC had a higher MetS rate (P<0.001). In patients with MAC, the CHA2DS2-VASc scores and the rate of cerebrovascular accident and AF were significantly higher compared to those without MAC (P<0.001, for both parameters). The results of the multivariate regression analysis showed that history of smoking, presence of MetS and high CHA2DS2-VASc scores were associated with the development of MAC. ROC curve analyses showed that CHA2DS2-VASc scores were significant predictors for MAC (C-statistic: 0.78; 95% CI: 0.706-0.855, P<0.001). Correlation analysis indicated that MAC was positively correlated with the presence of MetS and CHA2DS2-VASc score (P=0.001, r=0.264; P<0.001, r=0.490). Conclusion: We have shown that CHA2DS2-VASc score and presence of MetS rates were significantly higher in patients with MAC compared without MAC. Presence of MAC was correlated with CHA2DS2-VASc score, presence of MetS, AF and left atrial diameter and negatively correlated with left ventricular ejection fraction.

Hipertension pulmonar tromboembolica cronica con y sin sindrome antifosfolipido / Chronic thromboembolic pulmonary hypertension with and without antiphospholipid syndrome

La hipertensión pulmonar tromboembólica crónica (HPTC) está dada por la obstrucción de arterias pulmonares y sus ramas por trombos organizados. El objetivo fue evaluar las características y evolución de la HPTC en pacientes con y sin síndrome antifosfolípido (SAF). Se analizaron retrospectivamente todos los pacientes con HPTC en nuestra institución entre junio de 1993 y junio del 2005. De los 38 pacientes evaluados, 16 tenían SAF (grupo A) y 22 pacientes (grupo B) presentaban estudio de trombofilia normal (n = 10) u otras anormalidades trombofílicas (n = 12). Ambos grupos fueron similares en cuanto a la media de edad (41 vs. 50 años), la clase funcional que presentaban al diagnóstico (81 vs. 100% en clase III-IV), y la presencia de trombosis en otros territorios (31 vs. 27%). El 62.5% de pacientes del grupo A y el 54.5% del grupo B fueron sometidos a tromboendarterectomía pulmonar. La media de seguimiento fue de 45 meses (rango de 0.5 a 144). Al final del mismo todos los pacientes con SAF y todos los pacientes operados estaban en clase funcional I-II. La mediana de sobrevida desde el momento del diagnóstico alcanzó los 59 meses para el grupo A vs. 27 meses en el grupo B (p = 0.199). La media de sobrevida del total de los pacientes operados fue de 56 meses para el grupo A vs. 33 meses para el grupo B (p = 0.08). En conclusión: Los pacientes con HPTC y SAF tendieron a lograr una mejor sobrevida que los pacientes con HPTC sin SAF. Aquellos con HPTC y SAF que fueron operados lograron mejoría de su clase funcional y tendieron a una mayor sobrevida respecto de los no operados.

Chronic thromboembolic pulmonary hypertension (CTE-PH) is defined as the chronic obstruction by organized thrombi in pulmonary artery and their branches causing pulmonary hypertension. The objective is to evaluate features and outcome of CTE-PH in patients with and without coexisting antiphospholipid syndrome (APS). All patients studied at our Institution with CTE-PH between June 1993 and June 2005 were analyzed retrospectively. Sixteen out of 38 patients were APS positive (group A), and 22/38 patients (group B) disclosed normal results (n = 10) or other thrombophilic abnormalities (n =12). Results: both groups were similar in age (mean 41 vs. 50 years), NYHA class at diagnosis (81 vs. 100% in III-IV) and the presence of previous or coexistent thrombosis in other territories (31 vs. 27%). Sixty three percent of patients in group A and 55% of patients in group B underwent thromboendarterectomy. The patients were followed during an average of 45 months (0.5- 144). At the end of follow up all the APS patients and all the chirurgical patients were in I-II functional class (p=0.053). The median survival from diagnosis was 59 months for group A and 27 months for group B (p=0.199). The mean survival of patients who underwent thromboendarterectomy was 56 months for group A vs. 33 months for group B (p=0.08). We conclude that patients with CTE-PH and APS disclosed a trend to a better survival than patients with CTE-PH without APS. Those patients with CTE-PH and APS who underwent thromboendarterectomy tended to achieve a better functional class and survival than those who received medical treatment.

Embolia pulmonar no paciente idoso internado / Pulmonary embolism in ederly patients admited into a hospital

Introdução: A prevalência da embolia pulmonar(EP)aumenta com a idade, porém pouco se conhece a respeito dos fatores associados ao óbito no idoso.Objetivo: Identificar as características clínicas e os fatores que se associam com a mortalidade por EP confirmada, internados, entre Março de 2000 a Maio de 2004. A associação com a mortalidade foi analisada pelo teste exato de Fisher e pelo teste t, considerando-se 5 por cento como nível de significância estatística.Resultados: A média de idade foi de 80 anos(máximo 98 anos, mínimo 65 anos) e do Escore APACHE 13, seno 72 por cento do sexo feminino. O seguimento foi de 6 meses. A mortalidade diretamente relacionada à EP foi de 21 por cento. Os demais óbitos foram por choque séptico ou diátese hemorrágica. Houve associação significtiva com mortalidade por EP com: neoplasia (p igual 0,024), acidente vascular encefálico(p igual 0,024), pressão sistólica inferior a 100mmhg(p igual 0,005), e com o intervalo entre o início dos sintomas e a internação(p igual 0,0001).Conclusão: Conclui-se que na EP, fatores associados como a neoplasia, acidente vascular encefálico, hipotensão e intervalo entre o início dos sintomas e a internação correlacionaram-se com a mortalidade

Complicações tromboembolíticas da leucemia linfoblástica aguda em crianças e adolescentes: efeitos da doença e do tratamento sobre o sistema hemostático / Thromboembolic complications of acute lymphoblastic leukemia in children and adolescents: effects of the disease and the therapy on the hemostatic system

O recente aumento na incidência dos eventos tromboembólicos e a necessidade de seu tratamento em crianças e adolescentes têm justificado o desenvolvimento de estudos e programas específicos. As tromboses são causas importantes de morbidade e mortalidade em pacientes com câncer. Em especial, na leucemia linfoblástica aguda (LLA) da infância, o tromboembolismo é uma complicação grave que ocorre em conseqüência da interação entre a doença, o hospedeiro e o tratamento. Este estudo teve por objetivos avaliar prospectivamente o comportamento dos marcadores de ativação da coagulação e das proteínas anticoagulantes naturais em pacientes com LLA no momento do diagnóstico e durante o tratamento de indução de remissão. Correlacionar os resultados da avaliação da hemostasia com a ocorrência de eventos tromboembólicos e com a presença da mutação G1691A do fator V e do polimorfismo G20210A do gene da protrombina. No período de fevereiro a novembro de 2003 foram avaliados 16 crianças e adolescentes com diagnóstico de LLA admitidos na Unidade de Oncologia do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. As avaliações clínicas e laboratoriais foram realizadas no momento do diagnóstico, durante e ao final do tratamento de indução de remissão (Protocolo GBTLI LLA-99) / The recent increase in the incidence of thromboembolic events and the need of treatment in children and adolescents justify the development of specialized programs to provide optimal management. Thromboembolic disease is a major cause of morbidity and mortality in cancer patients. Especially in acute lymphoblastic leukemia (ALL) of infancy, thromboembolic events are severe complications that occur as a result of the interaction of the disease, the host and the treatment. The main purpose of this study was to evaluate thrombin generation and thrombin inhibitors in patients with ALL at presentation and during the induction therapy...

Trombofilia, tromboembolia y el uso de las heparinas no fraccionadas y de bajo peso molecular / Thrombophilia, thromboembolism and the user of the unfractionated and low-molecular-weight hepatins

Se hace una revisión sobre los puntos sobresalientes en relación con la detección de los estados trombofílicos, el establecimiento de factores de riesgo para el desarrollo de trombosis, el diagnóstico de los estados tromboembólicos y un análisis sobre la experiencia en el uso de heparina no fraccionada y heparinas de bajo peso molecular. La enfermedad vasooclusiva es multifactorial y su manejo debe ser inter y multidisciplinario, para realizar un diagnóstico oportuno e instalar la profilaxis o el tratamiento antitrombótico adecuado. Aún cuando, utilizando heparinas de bajo peso molecular se observan ventajas importantes en cuanto a la respuesta terapéutica, la heparina no fraccionada mantiene sus indicaciones específicas y en muchas ocasiones, ambas heparinas son complementarias para un mejor tratamiento de la tromboembolia. Consideramos que cada unidad médica debe establecer sus propios criterios y algoritmos diagnósticos y terapéuticos que permitan detectar, diagnosticar y tratar la trombosis en forma oportuna y disminuir la morbimortalidad por esta causa.

natural anticoagulants

The incidence of inherited thrombotic diseases have generally been overlooked, however, data has shown that their incidence is three times more common than the more dramatically presenting inherited bleeding disorders. This article deals specifically with the inbuilt anticoagulant systems within the body; a defect or deficiency in this system would lead to a hypercoagulable state. Catastrophic situations like myocardial infarction in conventional risk free young individuals, strokes, peripheral embolic phenomena and placental infarctions are some of the resultant clinical settings of a hypercoagulable state. In this paper, an attempt has been made to describe the different mechanisms of action, clinical implications and laboratory methodologies available for the diagnosis of these conditions, as well as available therapeutic remedies

Natural History of chronic Chagas' heart disease: prognosis factors

Chronic Chagas' disease shows several progression modes. Usually, the different clinical syndromes manifest themselves together, however, isolated forms can occur. Cardiac arrhythmias, which are very frequent, are present in about 50 percent of patients. The cardiac damage manifests itself later, with the emergence of heart failure. Thromboembolism can occur in both pulmonary and systemic circulation. Pulmonary embolism is the most frequent, appearing in more advanced phases of heart disease. Sudden death is the fatal outcome of these patients. It predominates in males and it generally occurs in a disease stage when patients have their highest productivity. The presence of serious ventricular arrhythmias, conduction disturbances in the electrocardiogram, and heart failure, provide an unfavorable prognosis.

Hemodilución: fundamentos y aplicaciones en cirugía / Hemodilution: basis and applications in surgery

La hemodilución normovolémica ha sido utilizada en la cirugía cardiaca por más de tres décadas. A pesar de sus beneficios tanto en ahorro de sangre como en disminución de la incidencia de tromboembolismo (mejoría del aspecto hemodinámico), su aplicación aún no se extiende a todas las ramas de la cirugía en este país, aunque ya su uso se ha difundido en diversos procedimientos quirúrgicos no cardiaco. Se hace una revisión del aspecto fisiológico, el incremento en el gasto cardiaco, la mejoría del flujo capilar y la asuencia de lesiones a sistemas vitales como el neurológico, así como la experiencia clínica de otros países en cirugía reconstructiva, urología, ginecología, etc., concluyendo que los beneficios de la hemodilución deben ser aprovechados por el resto de las especialidades quirúrgicas