[Thrombolytic therapy in acute myocardial infarct--is it being used to the fullest?]. / Terapêutica trombolítica no enfarte agudo do miocárdio--estará a ser utilizada em pleno?

OBJECTIVE: To evaluate the experience with thrombolytic therapy (TT) in the treatment of patients with the discharge diagnosis of acute myocardial infarction (AMI). DESIGN: Retrospective analysis of the clinical records of patients with the discharge diagnosis of AMI, between May 1988 and December 1995. SETTING: Intensive Cardiac Care Unit (UCIM-Medicina IV) of Santa Maria University Hospital, Lisbon, Portugal. PATIENTS: 1319 patients, 958 men (73%) and 361 women, mean age 64 +/- 12 years. MAIN RESULTS: Thrombolytic therapy was administered in 391 patients (30%). Female patients received less thrombolytic therapy compared with male (17% vs. 34%; p < 0.001). Anterior wall infarction was more frequent (38%). Patients in Killip class I-II (77%) received more thrombolytic therapy than class III-IV (33% vs. 17%). The utilization rate of thrombolytic therapy increased from 25% in 1988 to 34% in 1995. Two major categories of patients were not treated with thrombolysis: 1) patients presented more than 12 hours after pain onset (38%); 2) patients without ST segment elevation or LBBB on the ECG presented (37%). Overall hospital mortality was 15.6%. The mortality in patients receiving thrombolytic therapy was significantly lower than in those excluded (9.4% vs. 18.2%; p < 0.001). CONCLUSION: Only 30% of patients with AMI receive TT. Of those excluded from this important therapeutic intervention, 75% had no ECG criteria or were outside the standard therapeutic "window". This significant group of patients need new diagnostic and intervention strategies.

[Dobutamine stress echocardiography in patients after an acute myocardial infarct: what is the significance of arterial patency related to the infarct?]. / Ecocardiografia de sobrecarga com dobutamina nos doentes pós-enfarte agudo do miocárdio: qual a importância da permeabilidade da artéria relacionada com o enfarte?

BACKGROUND: Dobutamine stress echocardiography is a very promising technique for assessing myocardial viability, ischemia and prognosis in patients with a recent acute myocardial infarction. Recent studies have shown that the type of perfusion in the infarct-related artery also plays a role in the prognosis of these patients. PURPOSE: To evaluated in patients with non complicated infarction the ability of low-dose and high-dose dobutamine stress echocardiography to assess the presence of both viability and inducible ischemia and correlate the results with the patency of the infarct related artery and the accuracy to predict cardiac events during one year follow-up. PATIENTS AND METHODS: Fifty one consecutive in-hospital patients (47 male and four female, mean age 52 +/- 11 years, range 31-75 years) with acute myocardial infarction were evaluated both by dobutamine stress echocardiography and by coronary angiography and followed-up for a mean of 12 +/- 8 months. RESULTS: With low-doses of dobutamine, the incidence of myocardial viability was 33% and with high-doses, the incidence of residual inducible ischemia was 41%. The patency of infarct-related artery showed significant correlation with score wall motion index for viability and for myocardial ischemia. Twenty four (47%) patients suffered cardiac events. Dobutamine stress echocardiography showed a positive predictive value of 67% and a negative of 70% and identified high and low risk patients. CONCLUSIONS: Dobutamine stress echocardiography in patients with acute myocardial infarction is a safe and well tolerated test, and provides in a single test useful information regarding viability, ischemia and prognosis.

[Whipple's disease]. / Doença de Whipple.

The authors describe a case of Whipple's disease, characterized by arthralgias, chronic diarrhea and weight loss. The diagnosis was established on clinical, laboratorial and radiological grounds and confirmed histologically, through a duodenal biopsy. Rapid improvement occurred, soon after the beginning of antibiotic therapy.