[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.

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.

[Cardiopulmonary exercise test in the evaluation of healthy elderly men]. / Avaliação cardiorrespiratória ao exercício no idoso sadio.

PURPOSE: To study methodological aspects and results of cardiopulmonary exercise tests in elderly. METHODS: Twenty-five men (mean age 65 +/- 5 years) performed a cardiopulmonary exercise test using a bicycle ergometer and a progressive continuous work load increase protocol was employed. A computadorized system (2001 CAD/Net System-MGC), which includes a gas analyser and a pneumotacograph, was used for on line monitoring of oxygen and carbon dioxide expired fraction and also of pulmonary flow. RESULTS: We observed the following values of oxygen uptake, pulmonary ventilation and respiratory gas exchange: rest=4 +/- 1 ml/kg-1/min-1, 11 +/- 2 l/min-1 and 0.80 +/- 0,1, respectively: anaerobic threshold=12 +/- 3 ml/kg-1/min-1, 29 +/- 6 l/min-1 and 0.90 +/- 0.1, respectively: respiratory compensation point=18 +/- 4ml/kg-1/min-1, 47 +/- 1 l/min-1 and 1.07 +/- 0.1, respectively, and peak of exercise = 13 +/- 5 ml/kg-1/min-1, 76 +/- 18 l/min-1 and 1.21 +/- 0.2, respectively. The anaerobic threshold and the respiratory compensation point were achieved at 53 +/- 11 and 77 +/- 9% of peak oxygen uptake respectively. The elderly shown slightly increased values of the relation volume dead/tidal volume at rest with a slightly smaller decrease of its values during exercise in comparison to data obtained from young healthy untrained subjects. The heart rate prescription for exercise based on the heart rate reserve was higher than that based on the cardiorespiratory and metabolic responses (113-126bpm vs 96-114bpm). CONCLUSION: The cardiorespiratory and metabolic responses pattern in the elderly is quite heterogeneous. The heart rate prescription for exercise based on conventional stress tests seems to overestimate cardiorespiratory and metabolic capacity in healthy elderly men. The determination of anaerobic threshold and respiratory compensation point from cardiopulmonary exercise test data optimize exercise prescription for healthy elderly men.

[Chronotropic and pressoric response in myocardiopathy in patients with heart failure during ergometric test. Correlation of spirometry variables with effort]. / Resposta cronotrópica e pressórica nas miocardiopatias em portadores de insuficiência cardíaca durante prova ergométrica. Correlação das variáveis espirométricas ao esforço.

PURPOSE: To correlate the variables heart rate (HR), blood pressure (BP) and double product (DP) during the ergometric test with the variables oxygen consumption (VO2) and pulmonary ventilation (VE) of spiroergometry. METHODS: A study was carried out with 40 male patients suffering from cardiomyopathy with heart failure (functional class II-IV of NYHA)-of ischemic (IS), Chagas' disease (CH) and idiopathic (ID) etiology. These three groups were compared to a group of 10 normal individuals (N). The 4 groups were evaluated under 4 different conditions: rest (RES), anaerobic threshold (LA), power peak of exercise (P) and in the fourth minute recovery (REC). The investigation was carried out with the data obtained through spiroergometry (using a treadmill and spiroergometric equipment specific for the effort), as well as data related to HR, BP, DP, VO2 and VE. RESULTS: There were significant differences observed in the ergometric evaluate of the HR, BP and DP responses in the IS, CH and ID groups as compared with the N group. There were significant difference observed in the spirometric evaluation to the VO2 and VE efforts in the IS, CH and ID groups as compared with the N group. CONCLUSION: The HR, BP and DP variables studies, obtained by means of classic ergometry, unaided by direct methodology (spiroergometry) enabled them to infer valuable data for the control and evaluation of cardiomyopathies with IC, taking into consideration the low chronotropic and pressoric responses in the various phases of evaluation during this study, corresponding to the concomitant low performance of O2 consumption and pulmonary ventilation.

[Prevalence of primary dyslipidemia in subjects with and without family history of coronary disease, based on the reference values of the "National Cholesterol Education Program" (NCEP)]. / Prevalência de dislipidemias primárias em indivíduos com e sem história familiar de coronariopatia, tendo como referência os valores do "National Cholesterol Education Program" (NCEP).

PURPOSE--To compare the prevalence of primary dyslipidemia in 2 groups, based on NCEP guidelines: a) first degree relatives of revascularized patients and b) hospital employees without family history of coronary heart disease (CHD). METHODS--1162 subjects aged over 20 years, were divided in two groups: G Fam consisted of 312 women and 221 men, mean age 30.8 years, siblings, brothers or sisters of revascularized patients (under 55 years old); G Serv consisted of 425 women and 204 men, mean age 30.7 years, all of them being healthy employees of Hospital das Clínicas (Clinics Hospital) with no family history of CHD. There were performed clinical, electrocardiographic and laboratory tests (total blood cholesterol--CT, triglycerides--TG and HDL cholesterol--HDL-C): and VLDL-C and LDL-C values were calculated according to Friedwald, besides CT/HDL-C and LDL-C/HDL-C ratios. Based on NCEP guidelines, the frequencies on values ranges for each parameter were determined. RESULTS--G Fam group showed a higher incidence of women and men with CT and LDL-C levels above 240 mg/dl and 160 mg/dl, respectively; CT/HDL-C and LDL-C/HDL-C values over 5.0 and 3.5, respectively, were seen more often in G Fam group. There were no significant differences on HDL-C and TG. About 35% of men and women in G Serv group showed CT levels higher than 200 mg/dl. CONCLUSION--First-degree relatives, aged over 20 years, from revascularized patients under 55 years old, showed more often lipid levels above those established by NCEP. In accordance to them, 62% of men and 28% of women of this group should undergo to LDL-C analysis, as well as 35% of men and 28% of women in teh G Serv group. It is called the attention for the importance of cholesterolemia evaluation in high risk groups for CHD.

[Ergospirometry as a method for predicting the clinical course of ischemic, Chagas and idiopathic myocardiopathy]. / Ergoespirometria como método de predição do comportamento evolutivo da miocardiopatia isquêmica, chagásica e idiopática.

PURPOSE: To compare and evaluate the modifications variables obtained through spyroergometry in groups of patients with ischemic cardiomyopathy (IS), Chagas' disease (CH), and idiopathic cardiomyopathy (ID). To study tolerance to anaerobic conditions of patients from the above groups who died. METHODS: A study was carried with 50 male patients, 10 of which were found in normal conditions whereas 40 presented cardiomyopathy with compensated heart failure. We observed that from the 40 patients from the cardiomyopathy groups, nine died, subgroups OB--during the study period of 1.005 days. These were compared to subgroups NOB--the remaining 31 patients. These patients were evaluated under 4 conditions--Rest (Rep), anaerobic threshold (LA), power peak of the exercise (P) and in the fourth minute recovery (REC). The investigation was based on data collected by means of spyroergometry: oxygen consumption (MET), production of CO2-(VCO2), respiratory equivalent of oxygen (VE/VO2), oxygen pulse (VO2/FC) and the time elapsed between LA and P. RESULTS: There were significant differences when the three pathological groups (IS, CH, ID) were compared with the control groups (N). There were no significant differences when the three pathological groups compared among themselves. In relation to tolerance to anaerobic conditions significant differences were found among the patients of subgroup OB--1.33 min--who died when compared to subgroup NOB--3.26 min (time elapsed between LA and P). CONCLUSION: The authors conclude that the variables studied, obtained through spyroergometry may indicate important data towards the prognosis with heart failure.

[Indeterminate form of Chagas' disease. A polymorphic disease]. / Forma indeterminada da doença de Chagas. Uma doença polimórfica.

PURPOSE: To evaluate the association between the indeterminate form of Chagas' disease and abnormalities in non-invasive cardiovascular propedeutics. PATIENTS AND METHODS: Twenty-two patients in the indeterminate form of Chagas' disease, 17 female, with ages between 25 and 50 years were submitted to studies of: vectorcardiography, echocardiography, stress test, dynamic electrocardiography and scintigraphic studies (scintigraphic ventriculography and cardiac mapping with pyrophosphate of technetium), in a period of two months after first consultation. RESULTS: The analysis shows the percentual of altered exams: vectorcardiogram--68.2% (conduction disturbance--22.7%); echocardiogram--15.8% (apical hypokinesia); cardiac mapping 61.8%; scintigraphic ventriculography--68.2%; stress test--72.2% (reduced delta PS--50%, ventricular arrhythmia--50%); and dynamic electrocardiographic--50% (ventricular arrhythmias). We could observe also that the great majority of the patients has more than three exams altered (63.6%). The study of relation between methods, shows only association between reduced delta PS and ventricular arrhythmia, with concordant results in 72.7%. CONCLUSION: Indeterminate form of Chagas' disease appears to be a really chronic form, may be of attenuate aggressive potential, with indeterminate evolution and with polymorphic clinical exteriorization seeing only through invasive and non invasive propedeutic techniques.

Frequency and significance of cardiac rhythm disturbances in healthy elderly individuals.

The authors examined the prevalence and significance of cardiac rhythm disturbances in healthy elderly individuals. They selected 26 men with active lifestyles, aged 70-81 years, after clinical, routine blood tests, chest radiographs, echocardiography, resting and exercise electrocardiography, and Gated cardiac blood imaging evaluations. The men were submitted to continuous electrocardiographic monitoring during their daily routine. The recording time ranged from 838 to 1,432 min (average = 1,307 +/- 153 min). Clinical follow-up was done every six months. Sinus rhythm predominated in all subjects. The maximal, minimal, and average heart rate ranges (beats/min) were, respectively: during sleeping periods, 60-115 (85.8 +/- 13.2), 42-80 (56.6 +/- 8.7), 51-85 (64.0 +/- 8.8); and during awake periods, 85-150 (118.4 +/- 16.4), 50-85 (64.1 +/- 9.1), 61-90 (75.3 +/- 8.3). The longest sinus pauses were observed during sleep and ranged from 0.8 to 2.5 sec (1.25 +/- 0.34 sec). Atrial ectopic beats were observed in 20 individuals (76.9%). They were frequent in four (15.4%) and repetitive in nine (34.6%) of them. Short-lasting episodes of paroxysmal atrial tachycardia and paroxysmal atrial flutter were observed in one case each. Ventricular ectopic beats were recorded in 20 individuals (76.9%). They were frequent in 6 (23%) and multiform in 13 (50%) of them. Couplets were observed in 5 cases (19.2%) and episodes of nonsustained ventricular tachycardia were present in 3 individuals (11.5%). No symptoms were referred by any individual during recording. No clinical signs of heart disease or symptoms were noticed during the average 40 +/- 7.2 months of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

[Hemodynamic study at the bedside of patients with acute myocardial infarction over 60 years of age]. / Estudo hemodinâmico à beira do leito em portadores de infarto agudo do miocárdio com mais de 60 anos de idade.

Aiming to study the hemodynamic behavior of the aged during the first 36 hours after acute myocardial infarction (AMI), 41 patients of at least 60 years at age (63.3 +/- 3) were submitted to a bedside hemodynamic study, through a Swan-Ganz catheter. The results obtained for the different variables (right atrial pressure, right ventricular pressure, pulmonary-arterial pressure, pulmonary-capillary, cardiac index, systolic index, left and right ventricular performance, and systemic pulmonary-arterial resistance) were compared to those of 39 individuals with age less than 60 years (49.6 +/- 1.5). It was also considered the electrocardiographic localization of the infarcted area. Eventual differences in the distribution of frequency of the individuals were also investigated, considering the four clinical-hemodynamic groups proposed by Forrester. Upon separate analysis of the hemodynamic variables, the results did not reveal significant differences between the younger and the older. However, by Forrester's classification, it was observed a significantly higher number of aged patients in group III (hypovolemic). Therefore, there was a tendency in the aged to present hypovolemia during the first 36 hours after myocardial infarction. The difficulties to recognize this status clinically and its prognostic importance justify the performance of hemodynamic bedside study in elderly with acute myocardial infarction with hemodynamic instability.

[Myocardial revascularization surgery in an 87-year-old patient. A case report]. / Cirurgia de revascularização miocárdica em pacientes de 87 anos de idade. Relato de caso.

A 87 years old patient, with independent life style, presented unstable angina in spite of medication. Cineangiocoronariography demonstrated severe triarterial lesions, with good distal segments and preserved left ventricular contractility. Three saphenous vein grafts were performed. Some clinical measures were employed: a) manitol, furosemide and Ringer solution were infused two hours before and during surgery; the infusion was maintaned during the two postoperative days; b) limited use of nephrotoxic agents; c) adequate doses of medication; d) red cells infusion in spite of higher hematocrit levels than those present in younger patients; e) early start of respiratory physiotherapy and deambulation. Mean arterial pressure was maintained over 80 mm/Hg during surgery. During the period of extracorporeal circulation a hollow capillary membrane oxygenador was employed. Immediate postoperative course, up till six months, was free of coronary insufficiency symptoms. This case demonstrates the benefits of myocardial revascularization in elderly patients, respecting some peculiarities of the geriatric therapeutics.