[Pulmonary thromboembolism -- current concepts]. / Tromboembolismo pulmonar--conceitos actuais.

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography are promising. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractionated heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused on epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.

[Hypothyroid coma and thyrotoxic crisis]. / Coma hipotiroideu e crise tireotóxica.

Two clinical cases of endocrinologic emergency are presented: myxedema coma and thyrotoxic crisis. These are very severe situations with a high mortality rate. In myxedema coma it reaches 50% and in thyrotoxic crisis the range is between 25 and 30%. These entities are not the always present in mind because of their rarity. Consequently, they may well be undiagnosed. In our cases, the myxedema coma was initially diagnosed as brainstem stroke, and the hyperthyroidism was taken for concealed malignant tumor. The management of both situations is briefly commented.

[A false incisional hernia during coumarin anticoagulation]. / Falsa hérnia incisional no decurso de anticoagulação cumarínica.

This short clinical report presents a case of giant pelvic hematoma with infiltration of the abdominal wall, initially misdiagnosed as incisional hernia by means of the old McBurney laparotomy. The patient, a 56-year-old female, was under chronic coumarin anticoagulation to prevent systemic embolism recurrence (rheumatic polyvalvular disease, atrial fibrillation, and previous brain embolism). On admission, the I.N.R. was 6.6. The risks versus benefits dilemma of chronic oral anticoagulation is briefly commented.

[The ventricular dysrhythmia profile in patients with mitral valve pathology]. / Perfil disrítmico ventricular em doentes com patologia valvular mitral.

OBJECTIVE: To study the relation between ventricular arrhythmias and echocardiographic left ventricular data, in patients with mitral valve pathology. DESIGN: Retrospective study, based on Holter department data on ventricular arrhythmias. POPULATION: We studied 128 patients: 36 were male, 92 were female. Their mean age was 52 +/- 11 years. Three groups were outlined: 54 patients had mitral stenosis (ME), 15 patients had mitral disease (MD) and 59 had associated aortic pathology (MA). METHODS: Patients clinical records were reviewed according to an evaluating protocol. In each Holter recorded the number of premature ventricular contractions per hour (PVC/h), as well as the existence of complex ectopic forms (CF) was considered. Echocardiographic left ventricular data used was: diastolic diameter (DD), systolic diameter (DS) and shortening fraction (SF). Treatment was not significantly different between the three groups, when 24 hour monitoring was performed. RESULTS: We found the average number of PVC/h to be 14 +/- 45 in the ME group, 58 +/- 85 in the MD group and 52 +/- 11 in the MA group. There is significant difference between ME and either DM, or MA. In patients with ME significant relations were found between the occurrence of CF a greater DS (p < 0.01) and a lesser SF (p = 0.02). No significance was found for the occurrence of PVC. In patients diagnosed as DM, the occurrence of PVC/h (> or = 10) was related with greater DD (p = 0.01) or DS (p = 0.04), but there was no relation to SF. Finally in the MA group PVC occurrence was strongly related (p < 0.01) with all the echocardiographic values and thinner relations were found towards SF (p = 0.02 for DD, p = 0.03 for DS and p = 0.05 for SF). CONCLUSIONS: Ventricular arrhythmic occurrence is less frequent in ME. However, in the three groups, there is worsening left ventricular arrhythmic frequency in direct relation to greater ventricular dimensions, or compromised systolic function.

[Arterial hypertension in the elderly and renal function]. / Hipertensão arterial no idoso e função renal.

STUDY OBJECTIVE: to evaluate the effects of antihypertensive treatment on renal function, in an elderly population of 29 patients with arterial hypertension. DESIGN: retrospective study of the first six months follow-up. SETTING: outpatients clinic of arterial hypertension in the elderly at a central hospital. PATIENTS AND METHODS: twenty nine elderly (> or = 65 years old) patients with a mean age of 71.8 +/- 5.6 years, with arterial hypertension (> or = 160/95 mmHg) submitted to antihypertensive treatment. Fourteen males and fifteen females. The systolic, diastolic and mean blood pressure was determined with a DINAMAP 1846, previously and at the first, third and sixth month of antihypertensive treatment (diuretic, calcium antagonists and angiotensin converting enzyme inhibitors). The serum creatinine was evaluated in the beginning of treatment and six months later. Means (+/- standard deviation) were compared with Student's t-test (statistically significant findings < 0.05). MEASUREMENTS AND RESULTS: the initial mean arterial pressure was 127.0 +/- 17 mmHg; with the antihypertensive treatment, was 119.1 +/- 16 mmHg in the first month, 114.4 +/- 12 mmHg in the third and 117.6 +/- 12 mmHg in the sixth month. The serum creatinine was 1.26 +/- 0.75 mg/dl in the beginning of the study and the final result was 1.30 +/- 0.74 mg/dl (p-NS). CONCLUSIONS: the antihypertensive treatment was effective in reducing the blood pressure, without a significant increase in serum creatinine.

[Arterial hypertension and ischemic cardiopathy]. / Hipertensão arterial e cardiopatia isquémica.

Up update of the literature related with the relationship between arterial hypertension and ischemic heart disease is done. The epidermiological aspects, J-curve phenomenon, relationship between arterial hypertension and acute myocardial infarction and the consequences of left ventricular hypertrophy are analysed.

[Non-invasive evaluation of a population with WPW syndrome]. / Avaliação não invasiva de uma população com o síndroma de WPW.

OBJECTIVE: Evaluation of a WPW Syndrome population by non invasive methods; identification of the sudden death risk; results of treatment and patient selection for Electrophysiologic Studies (EPS). DESIGN: Retrospective study. SETTING: Arrhythmology Outpatients Clinic from a Cardiac Department. PATIENTS: Successive patients older than 12 years with a WPW pattern on the ECG and history of paroxysmal tachycardia followed-up for a period of 46 +/- 29 months. MATERIAL AND METHODS: The clinical, ECG, Holter, stress test and echocardiographic data from 32 patients, were analysed. A study evaluating clinical follow up and the results of treatment was done. RESULTS: The group of patients was very symptomatic. The main complaint was a feeling of tachycardia (84.4%). Orthodromic tachycardia was documented in 7 cases and atrial fibrillation with rapid ventricular rate in five. Intermittent delta wave pattern was found in 21 patients, with 11 cases identified by Holter and 4 by stress test. A predominant left accessory pathway was found (47%), but the anteroseptal location was frequent too (25%). The echocardiogram was not useful in any case. Eighty per cent of the patients became asymptomatic with medical treatment. Beta blockers and amiodarone (the last chance) were the most useful drugs. No mortality was found in the study group. EPS was considered for the 5 patients with paroxysmal atrial fibrillation and the 7 cases resistant to medical treatment. CONCLUSIONS: The difficulty to define the risk of a population with WPW Syndrome by non invasive methods was demonstrated. Eighteen one cases were included in a low risk group, due to the intermittent WPW pattern in the ECG. A high risk group was considered for the 5 patients with atrial fibrillation with fast ventricular rate. The risk was not established in 9 cases. Most of the patients became asymptomatic by medical treatment.