Influenza vaccination in older adults and patients with chronic disorders: A position paper from the Portuguese Society of Pulmonology, the Portuguese Society of Diabetology, the Portuguese Society of Cardiology, the Portuguese Society of Geriatrics and Gerontology, the Study Group of Geriatrics of the Portuguese Society of Internal Medicine, and the Portuguese Society of Infectious Diseases and Clinical Microbiology.

Influenza affects millions of people worldwide each year and can lead to severe complications, hospitalizations, and even death, especially among vulnerable populations such as older adults and those with chronic medical conditions. Annual vaccination is considered the most effective measure for preventing influenza and its complications. Despite the widespread availability of influenza vaccines, however, vaccination coverage rates remain suboptimal in several countries. Based on the latest scientific evidence and expert opinions on influenza vaccination in older people and patients with chronic disease, the Portuguese Society of Pulmonology (SPP), the Portuguese Society of Diabetology (SPD), the Portuguese Society of Cardiology (SPC), the Portuguese Society of Geriatrics and Gerontology (SPGG), the Study Group of Geriatrics of the Portuguese Society of Internal Medicine (NEGERMI-SPMI), and the Portuguese Society of Infectious Diseases and Clinical Microbiology (SPDIMC) discussed best practices for promoting vaccination uptake and coverage and drew up several recommendations to mitigate the impact of influenza. These recommendations focus on the efficacy and safety of available vaccines; the impact of influenza vaccination on older adults; patients with chronic medical conditions, namely cardiac and respiratory conditions, diabetes, and immunosuppressive diseases; and health care professionals, optimal vaccination timing, and strategies to increase vaccination uptake and coverage. The resulting position paper highlights the critical role that vaccinations play in promoting public health, raising awareness, and encouraging more people to get vaccinated.

Atropine in exercise stress echocardiography? Case report.

Stress echocardiography is widely used in the investigation of coronary heart disease. Exercise stress echocardiography offers the advantage of visualizing myocardial motion abnormalities during physiological stress testing. The authors report the use of atropine, as an adjunct to exercise echocardiography, in risk stratification after myocardial infarction.

[Assessment of aortic atherosclerosis with transesophageal echocardiography]. / Avaliação da aterosclerose aórtica por ecocardiografia transesofágica.

OBJECTIVE: To image the thoracic aorta by transesophageal echocardiography (TEE) and study atherosis (morphology and extent of atheroma plaques) and sclerosis (stiffness) and secondarily correlate them with serum lipid levels (cholesterol, HDL, LDL and triglycerides). METHODS: We studied 29 patients (pts) who underwent TEE electively (male 18 pts, age 57.8 +/- 14.6 years). The parameters evaluated were: the stiffness coefficient = ln (PAsist/PAdiast)/(Dsyst/Dmin), and the morphology, location and extent of atheroma plaques. The systolic distension (Dsyst) was the difference between the maximal and the minimal dimensions (Dmin) of the aortic diameter measured by M mode. The lesions were classified in 4 degrees (0-3): 0--normal intima, 1--intimal thickening, 2--atheroma, 3--complicated lesion. Five aortic segments were studied: arch, D1-D4 (descending aorta at 5 cm intervals from the first 25 cm distal of the incisors line). We calculated the individual score = 1 x theta 1/180 + 2 x theta 2/180 + 3 x theta 3/180, theta n represents the angles occupied by the lesions and n (1-3) the severity of atherosis of each lesion. The total atherosis index (TAI) was sigma scores/(n. degree of visualized segments). RESULTS: The arch was not visualized in 3 pts, and the segment D4 was only visualized in 3 pts. TAI mean = 0.82 +/- 0.74, stiffness coefficient mean (SC) = 9.56 +/- 15.072. There were no significant correlations between the lipid levels and the TAI or SC. The only significant positive correlations were: TAI vs age (r = 0.62, p < 0.001) and SC and diastolic blood pressure (BP) (r = 0.42, p < 0.05). CONCLUSIONS: The best visualized segments belong to the descending aorta (25 to 40 cm from the incisors). In this group of patients the lipid levels did not seem to be a preponderant factor in aortic atherosclerosis. The most important factors were age for atherosis and BP for sclerosis.

Acute type A aortic dissection involving the left main coronary artery and the aortic valve--a case report.

The authors report a case study of a 60 year-old-male admitted to the Coronary Care Unit with severe chest pain, hypertension and ST depression on the anterior and lateral leads of the electrocardiogram. A diastolic murmur was heard in the aortic area. The chest X-ray showed an enlarged superior mediastinum. The transthoracic echocardiogram revealed an image that indicated an intimal flap above the aortic plane with severe aortic regurgitation. An aortography was performed and confirmed the diagnosis of acute type A aortic dissection with partial obstruction of the left main coronary artery, probably due to compression by the hematoma. The patient underwent emergency surgical repair with replacement of the aortic valve and ascending aorta. The patient survived without complications post surgery and was discharged ten days after onset of symptoms. Twenty months later, the patient was asymptomatic and the transesophageal echocardiogram showed a dissection of the descending thoracic aorta, mild aortic regurgitation and good left ventricular systolic function.

[Changes in regional wall contractility induced by effort in women with normal coronary angiography --report of a clinical case]. / Alterações da contractilidade segmentar induzidas pelo esforço em mulheres com coronárias angiograficamente normais--caso clínico.

The diagnosis of coronary artery disease in women has been thought to be more difficult than in men, owing to the lower overall prevalence of disease in women, as well as more subtle clinical presentations and unspecific changes in ST segment. The authors report a clinical case of a 61-year old woman, with low cardiovascular risk and history of atypical chest pain and a positive treadmill exercise test on the inferior leads. She did an exercise echocardiogram that revealed severe hypokinesis on the anterior wall and septum with late normalization. The patient was submitted to a coronary angiography that revealed normal arteries. An echocardiogram with hyperventilation was later performed and showed the same ischemic changes as exercise did, on the inferior leads but no regional wall motions abnormalities occurred. The patient is currently asymptomatic under calcium antagonist treatment.

Acute type A aortic dissection involving the left main coronary artery and the aortic valve--a case report.

The authors report a case study of a 60 year-old-male admitted to the Coronary Care Unit with severe chest pain, hypertension and ST depression on the anterior and lateral leads of the electrocardiogram. A diastolic murmur was heard in the aortic area. The chest X-ray showed an enlarged superior mediastinum. The transthoracic echocardiogram revealed an image that indicated an intimal flap above the aortic plane with severe aortic regurgitation. An aortography was performed and confirmed the diagnosis of acute type A aortic dissection with partial obstruction of the left main coronary artery, probably due to compression by the haematoma. The patient underwent emergency surgical repair with replacement of the aortic valve and ascending aorta. The patient survived without complications post surgery and was discharged ten days after onset of symptoms. Twenty months later, the patient was asymptomatic and the transesophageal echocardiogram showed a dissection of the descending thoracic aorta, mild aortic regurgitation and good left ventricular systolic function.

Neisseria meningitidis native valve endocarditis. A case report.

The so-called nonpathogenic neisseriae are common inhabitants of the upper respiratory tract in humans and are not usually regarded as pathogens. Neisseria meningitidis on the contrary may cause severe disease. These organisms are an uncommon cause of infective endocarditis. The authors report a case of a 64 year-old male, type II diabetic, previously asymptomatic, admitted to hospital because of fever, aphasia and right hemi-paresis. A systolic murmur was heard at the cardiac apex, and three blood cultures were positive for Neisseria meningitidis. The echocardiogram showed a vegetation on the posterior leaflet of the mitral valve, allowing the diagnosis of meningococcal endocarditis. The patient's clinical condition improved on intravenous penicillin therapy, and regression of fever, disappearance of the neurological signs and of the mitral valve vegetation were observed.

Cardiac rupture during exercise stress echocardiography: a case report.

Stress echocardiography is widely used in the evaluation of coronary artery disease. Dobutamine stress echocardiography has been the preferred method, but many centers have adopted exercise stress echocardiography, which can visualize myocardial motion during physiologic stress testing. The complications of this method in the post-myocardial infarction period are the same as those identified in conventional exercise testing. We report a case of myocardial rupture in the postinfarction period during exercise stress echocardiography.

[Plasma total anti-oxidant status in young survivors of myocardial infarction]. / Estado anti-oxidante total do plasma em doentes jovens com enfarte do miocárdio.

UNLABELLED: Free oxygen radicals are involved in the endothelial lesion process which leads to the formation of the atheroma plaque and thrombosis. There is some evidence that antioxidant therapy may be beneficial in coronary heart disease prevention. Our objective was to study the plasma total anti-oxidant status in young survivors of acute myocardial infarction. POPULATION: 23 patients, mean age 35.2 years (22-40) admitted for acute myocardial infarction from January 1995 to June 1998 (20 males). RISK FACTORS: Tobacco smoking 22/23, systemic arterial hypertension 4/23, hypercholesterolemia 17/23, positive family history for coronary heart disease 5 patients, previous history of angina 4 patients, none of these patients had diabetes mellitus. The location of the infarct was anterior in 12 patients, inferior in 10 patients and non-Q wave in one patient. Blood samples were drawn after overnight fasting and the plasma total antioxidant status (TAS) was determined by a colorymethric method (Trolox equivalent). The mean time elapsed since the acute myocardial infarction until sample collection was 16.5 +/- 10.7 months. RESULTS: 18 patients had low TAS values, mean 1.23 +/- 0.11 mmol/L (below the reference values: 1.3-1.77 mmol/L). CONCLUSIONS: In this group of patients, the plasma total antioxidant capacity was globally decreased, which may constitute a risk factor for coronary heart disease.

[Non-infectious thrombotic endocarditis: a case report]. / Endocardite trombótica não infecciosa: a propósito de um caso clínico.

A 48 year-old female patient, admitted with an ischemic stroke, had a transesophageal echocardiogram (TEE) that revealed a dense vegetation in the noncoronary aortic cusp, which was considered the probable source of embolism. The clinical investigation did not identify any other disease or infectious process. However the lack of histologic proof, the absence of fever, the fact that the blood cultures were persistently negative, the patient recovery with no need of antibiotics, and the results of the TEE, are highly suggestive of the presence of a non infectious thrombotic endocarditis. After 18 months of anti-platelet treatment, the patient showed no new embolic episodes and TEE demonstrated the resolution of the vegetation.

[Stress-exercise echocardiography]. / Ecocardiografia de sobrecarga-esforço.

The authors review the methodology and clinical applications of exercise echocardiography. This is a method that can be done in most of the patients with indication to the treadmill exercise test. There is an excellent relationship between costs and benefits associated to high sensitivities and specificities in the diagnosis of ischemia. This can lead to the preferential use of this technique, in the opinion of the authors, when it is indicated and in all patients that can do exercise.

[The new indications for permanent cardiac pacing]. / Novas indicações para pacing cardíaco permanente.

In spite of conflicting data from several studies, pacing is being used in several indications beyond the classic ones, namely to treat patients with hypertrophic cardiomyopathy, severe heart failure and to prevent atrial fibrillation. In this article the authors briefly review the new indications for this therapeutic intervention and discuss the utilization criteria, the technical details and the results of trials with dual-chamber pacing in patients with hypertrophic cardiomyopathy and severe heart failure. In obstructive hypertrophic cardiomyopathy, dual-chamber pacing significantly reduces the gradient and improves symptoms. Criteria suggested for the application of pacemaker therapy are: 1) persistent symptoms in spite of an adequate medical therapy trial (i.e., B-blockers, calcium antagonists, disopyramide): 2) left ventricular tract gradients of > 30 mmHg at rest or > 50 mmHg with provocation. In heart failure (NYHA class III ou IV with ejection fraction < 35) only a small percentage seems to benefit from this new therapeutic approach. They are those with a long PR interval on the surface electrocardiogram, with presystolic mitral regurgitation and with abbreviated diastolic filling period on the mitral inflow velocity on Doppler echocardiography. On the basis of some preliminary results, it appears that pacing may decrease the frequency of paroxysms of atrial fibrillation in some patients with vagal mediated fibrillation, chronotropic incompetence and those with long interatrial conduction times. Noninvasive detection of acute cardiac allograft rejection in heart transplant recipients by the analysis of some pacing parameters with telemetry is, at present, in an experimental stage.

[The therapeutic approach in refractory supraventricular tachycardias]. / Abordagem terapêutica nas taquicardias supraventriculares refractárias.

In recent years, considerable progress has been achieved on the understanding of the mechanisms of the different supraventricular tachyarrhythmias. These advances have led to the development of rational procedures that can effectively cure most of the patients. Radiofrequency catheter ablation is highly effective in supraventricular tachycardia, with favorable cost-benefit analysis compared to lifelong antiarrhythmic drug therapy and should be considered as an initial option. In atrial fibrillation, only few patients are currently considered for non-pharmacologic therapeutic modalities, but this number should grow as this is the area of most promising research and the one expected to make more progress in the years to come.

[Direct coronary angioplasty versus thrombolysis in the acute phase of myocardial infarction--inpatient outcome]. / Angioplastia coronária directa versus trombólise na fase aguda do enfarte do miocárdio--evolução intra-hospitalar.

Both thrombolysis and percutaneous transluminal coronary angioplasty (PTCA) are effective methods for the treatment of acute myocardial infarction (AMI). In our centre we perform primary PTCA during the available schedule of the hemodynamics laboratory. In this article we compare the predischarge evolution of patients submitted to each therapeutic procedure. From January 1996 to June 1997, 298 patients were admitted with the diagnosis of AMI. Eighty-four patients (28%) were thrombolysed (TB group) and 30 patients (10%) underwent primary PTCA (PTCA group). There were no significant differences among the two groups concerning demographic characteristics: age (61 +/- 13--TB and 59 +/- 12 years--PTCA); sex (male 81%--TB; 83%--PTCA), risk factors and previous cardiac history. The mean time since the onset of symptoms until arrival at the hospital was 156 +/- 156 minutes for TB and 202 +/- 210 minutes for PTCA (p < 0.02). The delay since admission until the beginning of treatment was 100 +/- 88 minutes for TB and 119 +/- 142 minutes for PTCA. The primary success rate of PTCA was 94% and there were no complications during the procedure. During the hospital stay, 12 patients developed post-infarction angina in the TB group and two patients in the PTCA group; in 15 patients of the TB group a revascularization procedure was performed (surgery in 5 and PTCA in 10 patients); one patient suffered reinfarction in the TB group. Two patients of the TB group (2.4%) had intracranial hemorrhage; the in-hospital mortality was 9.5% in the TB group and 3.3% in the PTCA (p < 0.001). The mean in-hospital stay was 11 +/- 5.6 in the TB group and 7.8 +/- 2.5 days in the PTCA group (p = 0.055). In our experience, primary PTCA in AMI appeared to be a safe procedure with lower occurrence of coronary events and hemorrhagic complication, with an earlier hospital discharge when compared to thrombolysis.

[Is the stress test useful in the detection of post-angioplasty restenosis?]. / Será a prova de esforço útil na detecção de reestenose pós-angioplastia?

Restetenosis is still the greatest limitation of coronary angioplasty (PTCA). The systematic use of ergometry (PE) with the objective of identifying restenosis is controversial and, namely, the ACC/AHA does not recommend its routine use. Our objective was to conduct a retrospective study of the use of PE when performed late (3 to 6 months) for the detection of restenosis. As a protocol, our group performed "late" PE on all the patients without contraindications, the patients with positive ergometry or CCS class II-IV angor submitted to angiographic control. Between January 1996 and July 1997, 121 patients (pts) were submitted to PTCA. Our study population was composed of patients submitted to complete revascularisation with follow-up in our centre: 59 pts (49%) with an average age of 58 +/- 12 years, 82% male. Eighty-three percent of the pts had revascularisation in a context of unstable angina, 10% in the acute phase of myocardial infarction and 7% due to chronic angina. Stents were implanted in 42% of the pts. In the follow-up after six months, 7 pts complained of CCS class II or III angor. The ergometry showed positive electrocardiographic criteria in 11 pts (18.6%). All pts with angor had positive PE. All these pts were submitted to angiographic control; restenosis (residual stenosis equal to or above 50%) was observed in all the patients who complained of angor (100% positive predictive value); restenosis occurred in 9 pts with positive ergometry (82% positive predictive value). In asymptomatic pts, PE indicated 2 pts with restenosis (2/59-3.4%) and two false positive (2/11-18%). At six months, PE detected 22% of the pts with restenosis. In conclusion, complete post-revascularisation angor due to coronary angioplasty has a higher positive predictive value than ergometry. However, the stress test, performed systematically, can identify an additional percentage of pts with restenosis with an acceptable percentage of false positives.

[Abciximab (ReoPro) in primary angioplasty]. / Uso de abciximab (ReoPro) na angioplastia primária.

UNLABELLED: The aim of the study was to evaluate the efficacy and safety of abciximab (ReoPro) in primary percutaneous transluminal coronary angioplasty (P.T.C.A.) in patients with myocardial infarction (M.I.). From June 96 to October 97, 16 patients with a mean age of 58 +/- 12 years, 86% males, with myocardial infarction (less than 12 hours of pain) were treated with ReoPro during P.T.C.A. The infarction was anterior in seven patients (44%), inferior in eight patients (50%) and non-Q wave in one patient (6%). Nine patients (47%) had a previous history of angina or myocardial infarction. The mean time from onset of symptoms to hospital arrival was 306 +/- 370 min and the mean time between hospital admission and the beginning of the procedure was 79 +/- 86 min. P.T.C.A. was performed on the anterior descending artery and right coronary in 44% and 56%, respectively. The success rate was 94%. Stents were used in 31%. In patients with angiographic success, we obtained TIMI III flow in 14 patients and TIMI II in one patient. No complications arose during P.C.T.A; no significant changes in platelets or hemoglobin were observed after the procedure. In this group of patients, one case of hematoma was found at the site of puncture with no need for transfusion. During hospitalization, no major coronary events were found. During the follow-up of 10.5 +/- 4.9 months, one patient died after non cardiac surgery and one patient was submitted to coronary artery bypass graft; there was no reinfarction nor new P.T.C.A. CONCLUSIONS: In our experience with ReoPro during direct angioplasty, we obtained good immediate and long term results, with no significant bleeding complications.

[Antihypertensive effect of fosinopril in mild hypertension]. / Efeito anti-hipertenso do fosinopril na hipertensão ligeira.

The aim of this double-blind randomized placebo-controlled study was to evaluate the antihypertensive and safety of fosinopril in mild essential hypertension. After a 2-week placebo period, patients received either placebo or fosinopril 20 mg, once daily. Thirty-four patients finished the study (18 patients in the placebo group and 16 patients in the fosinopril group). Systolic blood pressure decreased from 160.1 +/- 22.1 mmHg to 156.0 +/- 24.2 in the placebo group (NS) and from 151.8 +/- 14.0 mmHg to 141.5 +/- 14.5 in the fosinopril group (p < 0.005); diastolic blood pressure decreased from 100.1 +/- 2.4 mmHg to 94.3 +/- 7.4 mmHg in the placebo group (p < 0.005) and from 100.8 +/- 4.8 mmHg to 88.1 +/- 9.0 mmHg in the fosinopril group (p < 0.001). Mean decrease in diastolic blood pressure was 5.7 mmHg in the placebo group and 12.6 mmHg in the fosinopril group (p < 0.05). A statistically significant difference was seen between the percentage of controlled patients in the two groups: 16.6% in the placebo group vs 56.2% in the fosinopril group (p < 0.05). No statistically significant difference in biochemical parameters was seen between the two groups. Tolerance was good and no patients were withdrawn from the study for adverse events.