[High risk percutaneous transluminal coronary angioplasty after mechanical recanalization of the unprotected left main stem coronary artery and during myocardial infarction]. / Angioplastica coronariana transluminal percutânea de alto risco após recanalização mecânica do tronco de artéria coronária esquerda não protegido e infarto agudo do miocárdio.

A 70 years-old man, with acute myocardial infarction, was submitted to successfull percutaneous transluminal coronary angioplasty of the left main stem coronary artery, following recanalization of that artery.

Angioplastia coronariana transluminal percutânea de alto risco após recanalizaçäo mecânica do tronco de artéria coronária esquerda näo protegido e infarto agudo do miocárdio / High risk percutaneous transluminal coronary angioplasty after mechanical recanalization of the unprotected left main stem coronary artery and during myocardial infarction

Homem de 70 anos, portador de infarto agudo do miocário, foi submetido, com sucesso, à angioplastia percutânea do tronco de artéria coronária esquerda.

A 70 years-old man, with acute myocadial infarction, was submitted to successfull percutaneous transluminal coronary angioplasty of the left main stem coronary artery, follow in a recanalization of that artery

Valor do precondicionamento isquêmico na circulaçäo colateral, funçäo ventrícular e evoluçäo clínica no infarto agudo do miocárdio / The effecft of ischemic preconditioning on collateral circulation, ventricular function and clinical outcomes after acute

Objetivo - Avaliar a influência do precondicionamento isquêmico no fenômeno do desenvolvimento de circulaçäo colateral (CC), na funçäo ventrícular precoce e na evoluçäo hospitalar de pacientes com infarto agudo do miocárdio (IAM). Métodos - Foram estudados 97 pacientes com IAM anterior nas primeiras 6h, com oclusäo proximal da artéria coronária descendente anterior e divididos em 2 grupos na dependência da presença (GA) ou ausência (GB) de angina precedendo o IAM. Coronariografia e ventriculografiaoram realizadas nas primeiras 6h , antes de qualquer tentativa de reperfusäo. A fraçäo de ejeçäo global do ventrículo esquerdo (FEVE), foi obtida através do método de áreas e a funçäo regional da parede anterior anterior através da linha do centro. Resultados - Os grupos foram superponíveis em relaçäo ao sexo, idade, pico de CKMB, tratamento instituído (perfusäo química ou mecânica) e sucesso na reperfusäo. A média da FEVE e a mobilidade da parede anterior foram similares nos 2 gupos, respectivamente, 3+_9 por cento e -2,55+/_1,17 dp/corda no GA e 37 por cento+/_8 por cento e -2,75+/_0,79 dp/corda no GB (p=ns). A CC esteve presente em 6 pacientes do GA e em 8 do GB (p=ns). A evoluçäo clínica foi melhor no GA (todos Killip classe 1) em comparçäo ao GB (8 pacientes Killip > ou igual a 2) p=0,007. Conclusäo - Embora näo exista diferença entre os grupos em relaçäo a presença de CC, funçäo ventricular e regional do ventrículo esquerdo, a presença de angina precedendo o infarto associado à melhor evoluçäo hsptalar, a qual poderia em parte ser explicada pelo fenômeno denominado precondicionamento esquêmico.

[Role of circumflex coronary artery involvement in non-Q wave myocardial infarction]. / Papel do acometimento da artéria coronária circunflexa no infarto do miocárdio sem onda Q.

PURPOSE: To determine the patency and incidence rates of left circumflex coronary artery (LCX) as the infarct related artery (IRA) in Q-wave and non-Q wave acute myocardial infarction (AMI). METHODS: Two-hundreds and twenty one patients (172 men) with AMI were stratified in Q and non-Q waves groups. All patients were submitted to cinecoronary angiography 72 hours after the beginning of symptoms and the IRA and its patency were evaluated. RESULTS: In non-Q wave AMI, the LCX was considered to be the IRA in 35% of the patients. In Q wave AMI, this incidence was 8% (p < 0.001). Occlusion of LCX was seen in all non-Q wave AMI patients when it was the IRA. CONCLUSION: The incidence of LCX as IRA was significantly higher in non-Q wave AMI patients. This group did not have the previously expected greater patency rates, what could result in different clinical and evolutive characteristics.

[Hospital outcome of patients with right ventricular infarction and the importance of right coronary artery patency]. / Evolução hospitalar de pacientes com infarto de ventrículo direito e a importância da perviabilidade da artéria coronária direita.

PURPOSE: To evaluate the importance of the right coronary artery (RCA) patency in patients with right ventricular infarction. METHODS: Fifty-two patients with inferior wall myocardial infarction and right ventricular involvement were studied and divided in two groups: group A (GA) included 35 patients in whom the RCA was patent at coronary angiography, and group B (GB), 17 who had an occluded RCA. They were prospectively evaluated for electrical and hemodynamic complications, as well as in-hospital mortality. RESULTS: The mortality in GA was 11% and 29% in GB, p = 0.13; electrical complications were 11% in GA and 35% in GB, p = 0.06; hemodynamic complications were 8% in GA and 41% in GB, p = 0.009. CONCLUSION: These findings suggest a trend towards reduction in mortality and electrical complications, and significant reduction of hemodynamic complications in patients with inferior wall myocardial infarction with involvement of the right ventricle who have the RCA patent. Thus, RCA patency appears to be important in determining in-hospital outcomes of these patients.

[Significance of the nuclear magnetic resonance in the detection of coronary artery patency after thrombolysis]. / Valor da ressonância nuclear magnética na detecção da perviabilidade da artéria coronária após trombólise.

PURPOSE: To determine the value of magnetic resonance imaging (MRI) in the noninvasive detection of infarct related coronary artery patency after thrombolysis. METHODS: We studied 26 patients with acute myocardial infarction submitted to thrombolysis underwent MRI studies before and after 0.1mmol/kg gadolinium-DTPA injection within the first 48 h of MI. Signal intensity was assessed by circumferential profile analysis techniques. RESULTS: The average ratio of signal intensity of infarcted tissue over normal myocardium (I/N) was significantly higher in patients with patent arteries (1.3 +/- 0.13 vs 1.12 +/- 0.07, p < 0.02). Compared to coronariography MRI, sensitivity of 81% and specificity of 100% for the diagnosis of coronary patency. CONCLUSION: Gadolinium infusion increased infarcted and normal myocardium differentiation. The study of gadolinium kinetics at MRI is a promising technique for noninvasive diagnosis of coronary patency.

Ressuscitaçäo cardiopulmonar / Cardiopulmonary ressuscitation

A parada cardiorrespiratória (PCR) é definida como interrupçäo abrupta da ventilaçäo e da perfusäo sistêmica espontânea e efetiva. Há muitos anos se estuda as suas causa e mecanismos, bem como seu manuseio, visando uma ressuscitaçäo com melhores resultados. Na evoluçäo das técnicas de PCR, fatos importantes foram a descriçäo da compressäo torácica externa, fieta em 1960 por Kauwenhoven e Jude, no Johns Honkins Hospital, cujo uso hoje é inquestionável, assim como a cardioversäo elétrica da fibrilaçäo ventricular, com eletrodos aplicados externamente que foi descrita em 1956. Ainda hoje existem pontos que permanecem obscuros e estudos nessa área continuam sendo feitos visando esclarecê-los. Várias conferências foram realizadas, näo apenas para esclarecer alguns pontos, como também para padronizar condutas frente a uma vítima de PCR, para qu se otimize o tratamento, melhorando os índices de sucesso. A conferência da American Heart Association, realizada em 1986, e mais recentemente em 1992, a Conferência nacional de Ressuscitaçäo Cardiopulmonar, representam uma revisäo das recomendaçöes definidas anteriormente. Aqui discutiremos o diagnóstico e o manuseio das vítimas adultas de PCR, procurando dar um enfoque prático e noçòes da fisiopatologia dos eventos relacionados.

[Early revascularization of the arteries not related to infarction improves regional and global function of the left ventricle after acute myocardial infarction]. / A revascularização precoce das artérias não relacionadas ao infarto melhora a função regional e global do ventrículo esquerdo após o infarto agudo do miocárdio.

PURPOSE: To evaluate if early interventions which increase flow in the non-infarct related arteries (NRA) could improve long-term ventricular function in the non-infarct (NI) area after an acute myocardial infarction (MI). METHODS: We studied regional wall motion analyzed by the center-line method in two groups of patients with significant stenoses (> or = 70%) in the NRA after successful coronary reperfusion (chemical or mechanical thrombolysis). Group I (GI) consisted of 21 patients that were submitted to early (mean 14 days) complete surgical revascularization of both NRA and infarct related artery (IRA); the 12 group II (GII) patients underwent successful revascularization of the IRA only, with percutaneous transluminal coronary angioplasty (mean 6 days). Paired ventriculograms were obtained within 48 hours of the infarction and a mean of 17 months later. RESULTS: NI area contractility in GI patients improved from -0.35 +/- 2.16 to +0.62 +/- 1.6sd/chord (p < 0.05), whereas in GII decreased from +0.54 +/- 1.78 to -0.66 +/- 1.72 sd/chord (p < 0.05), p < 0.05 between the groups at follow-up. Mean infarct area wall motion did not differ between the two groups: from -3.04 +/- 2.43 to 2.61 +/- 2.49 sd/chord in GI (p = NS), and from -2.68 +/- 2.54 to -2.93 +/- 2.35 sd/chord in GII (p = NS). Mean global left ventricular (LV) ejection fraction did not change in GII patients (0.72 +/- 0.09 and 0.67 +/- 0.12, p = NS), but significantly increased from 0.63 +/- 0.12 to 0.72 +/- 0.11 in GI patients (p < 0.01). CONCLUSION: These data suggest that early revascularization of NRA with significant stenoses can improve not only the NI area regional contractility, but also the global LV function in the long-term follow-up of post MI patients treated with thrombolytic therapy.

[Thrombolytic treatment in pulmonary thromboembolism in the postoperative period following heart surgery complicated by ischemic cerebrovascular attack]. / Tratamento trombolítico no tromboembolismo pulmonar em pós-operatório de cirurgia cardíaca complicado por acidente vascular cerebral isquêmico.

A 69 years old man with pulmonary embolism early after coronary bypass surgery complicated by ischemic stroke received thrombolytic therapy. Reperfusion of the pulmonary artery was achieved. Conversion of the ischemic stroke to hemorrhagic infarction was observed at the CT-Scan without neurological impairment.

[Salvage coronary angioplasty in a young patient with Takayasu arteritis and myocardial infarction]. / Angioplastia coronária de salvamento em jovem com arterite de Takayasu e infarto do miocárdio.

A 16 year old boy with Takayasu's disease was admitted with myocardial infarction. Thrombolytic therapy with intravenous streptokinase showed no signs of reperfusion. Rescue angioplasty of the left descending coronary artery was performed with success.

Early administration of captopril and nitroglycerin in combination after acute myocardial infarction: an invasive haemodynamic study.

The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) could lead to a dangerous decrease in blood pressure coronary perfusion. To evaluate the safety aspects and haemodynamic effects of this combination, we studied 36 first 'Q wave' thrombolysed anterior wall AMI patients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusion of nitroglycerin and were submitted to pulmonary artery catheterization. Those patients with mean arterial pressure (MAP) > or = 70 mmHg, cardiac index > or = 2.2 l.min-1.m-2, and wedge pressure > or = 10 mmHg were included and randomized to receive 6.25 mg of captopril every 6 h on the first day and 12.5 mg qid on the second if MAP > or = 70 mmHg (group 1). A second group (group 2) received a placebo. Haemodynamic parameters were determined after 1, 6 and then every 6 h up to 48 h after basal measurements. Significant differences were observed only for the MAP and the rate-pressure product (reduction in group 1 values, P < 0.05). However, MAP was maintained within acceptable limits. Our data support the fact that the combination of captopril and nitroglycerin in the early hours of a non-complicated anterior wall AMI is safe, and could guarantee its use in large clinical trials to determine the effects on left ventricle remodelling and survival after AMI.

Diagonal earlobe crease as a marker of the presence and extent of coronary atherosclerosis.

This study evaluates the association between the presence of diagonal earlobe creases (ELC) and coronary artery disease (CAD). One thousand four hundred twenty-four patients (760 men and 664 women, aged 30 to 80 years) were examined for the presence of ELC and classified into 2 groups: group I control--1,086 consecutive patients who denied symptoms of myocardial ischemia and were admitted to a general hospital for other reasons; group II CAD--338 patients with documented CAD (presence of > or = 70% coronary diameter stenosis at angiography). ELC was present in 304 patients (28%) in group I and 220 (65%) in group II (p < 0.0001). The patients were stratified in age groups to isolate the influence of age because the prevalence of ELC and CAD increased with advancing age (p < 0.0001 for both). This association remained statistically significant in all decades, except for patients aged > 70 years. To further remove the confounding effect of different age and sex distributions between the groups, a direct adjustment of the ELC prevalence was performed. When adjusted for age and sex, the prevalence of creases was still 58% higher in patients with CAD than in control subjects (p < 0.001). The presence of ELC was also related to the extent of CAD as measured by the number of major arteries narrowed (p = 0.015). The observed sensitivity of the sign for the diagnosis of CAD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%.

[Mapping with Technetium-99 methoxy-isobutyl isonitrile at the bedside after coronary thrombolysis]. / Mapeamento com metoxi-isobutil-isonitrila marcada com tecnécio99 à beira do leito após trombólise coronária.

PURPOSE: To evaluate the feasibility of bedside Technetium99-methoxy-isobutyl-isonitrile (99mTc-MIBI) cardiac imaging to assess perfusion after thrombolytic therapy (TT) for myocardial infarction (MI). METHODS: We studied 9 patients (mean age 59 +/- 9 years) submitted to TT with 100 mg of rt-PA in 90 minutes within the 6 hours of the onset of MI with subsequent angiography. 99mTc-MIBI was injected intravenously in a doses of 740 MBq immediately before TT start. Imaging was performed in three moments: study 1--as soon as the TT finished, study 2--3-18 hours after TT; study 3--7-10 days after TT. A perfusion score was established in each study and then compared to determine the perfusion patterns after TT. We compared through linear regression, the perfusion score with left ventricle ejection fraction, and with CKMB enzymatic peak. RESULTS: All patients had a patent infarct related artery. The perfusion score of study 1 varied from 12 to 22, mean 15.8 +/- 3.7, and correlated with ejection fraction (r = 0.9, p < 0.01) and peak CKMB (r = 0.78, p = 0.03). Four (44%) patients presented perfusion score improvement in study 2 (varied from 12 to 23, mean 16.8 +/- 4.3) and 8 (88%) in study 3 (varied from 12 to 28, mean 19.0 +/- 4.3). CONCLUSION: Bedside 99mTc-MIBI cardiac imaging is useful to quantify myocardial area under risk before TT, and to identify the late (7 to 10 days) benefit of TT.

[The influence of lipoprotein (a) in thrombolysis with r-TPA for myocardial infarction]. / Influência da lipoproteína (a) na trombólise com rt-PA no infarto do miocárdio.

PURPOSE: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA for myocardial infarction (MI). METHODS: Thirty-eight MI patients, 28 male, mean age 51 +/- 9 years, submitted to thrombolysis with rt-PA, divided in two groups according the result of the thrombolysis: A) Successful, B) Failure. Serum fibrinogen (SF) was assessed before and 90 minutes after treatment. Lp (a) levels were determined six months later. These parameters were analyzed in both groups. RESULTS: Lp (a) levels were similar in groups A and B (p = 0.45). The SF levels were not different in the groups. CONCLUSION: Lp (a) seems to have no influence in thrombolysis with rt-PA for MI.

[Systemic lytic state as marker of therapeutic success after rt-PA in bolus in myocardial infarction]. / Estado lítico sistêmico como marcador do sucesso terapêutico após rt-PA em bolo no infarto do miocárdio.

PURPOSE: Evaluate the lytic state (LS) expressed by the level of plasmatic fibrinogen (PF) after rt-PA "in bolus" infusion for acute myocardial infarction (MI) and its relation to coronary reperfusion. PATIENTS AND METHODS: Fifty-one patients (38 men, mean age of 53.0 +/- 9.8 years) with demonstrated occlusion of the infarct related artery (IRA) received an intravenous bolus infusion of 70 mg of rt-PA, PF was assessed before and 90 minutes after the treatment and the levels were compared in patients with (group 1) and without (group 2) reperfusion of the IRA. RESULTS: Basal levels of PF were within the normal range in all patients. There was a decrement of 35.1% in the PF dosed at 90 minutes, from 276.8 +/- 55.5 mg/dl to 168.0 +/- 68.2 mg/dl. Both groups were similar in the levels of PF 90 after treatment (145.1 +/- 95.7 mg/dl in group 1 versus 187.0 +/- 53.7 mg/dl in group 2). CONCLUSION: "In bolus" rt-PA treatment for MI significantly reduces the PF, but the LS obtained was similar in patients with or without reperfusion of the IRA.

[ST segment as an arterial recanalization indicator after thrombolytic therapy in myocardial infarction]. / Segmento ST como indicador de recanalização arterial após terapêutica trombolítica no infarto do miocárdio.

PURPOSE: To evaluate the importance of the segment ST in the identification of coronary recanalization in patients submitted to intravenous thrombolysis during acute myocardial infarction (MI). PATIENTS AND METHODS: Seventy four patients with MI, 62 male with mean age of 52.6 +/- 10 years. All patients had angiographically demonstrated occlusion of the infarct-related artery (IRA) before the thrombolytic treatment with intravenous "in bolus" infusion of 50 mg, 60 mg and 70 mg of rt-PA. The recanalization of the IRA was assessed 90 minutes later. The real status of the IRA in the angiograms was compared with the ST segment changes between the ECGs obtained before and after the thrombolytic therapy. RESULTS: Fifty six (75.6%) patients presented a significant reduction in the ST segment elevation (groups I and II). Of these, 47 possessed an opened IRA. From the 18 patients who did not show ST segment decrement (group III), 13 had an occluded IRA, and 5 an opened one. The method presented sensitivity of 90.3% and a specificity of 59.1%, positive predictive value of 83.9% and negative predictive value of 72.2%. CONCLUSIONS: The ST segment is an important marker of coronary recanalization or not following intravenous thrombolytic therapy.

[Doppler echocardiographic diagnosis of atherosclerotic aneurysm of the coronary artery]. / Diagnóstico ecodopplercardiográfico de aneurisma aterosclerótico de artéria coronária.

A 74 year-old man with acute myocardial infarction submitted to thrombolytic therapy had the diagnosis of atherosclerotic aneurysm of the coronary artery attained with Doppler echocardiography. Subsequently diagnosis was confirmed by angiography and the atherosclerotic etiology identified in pathology.

[Percutaneous transluminal angioplasty of the left main coronary artery in acute myocardial infarction]. / Angioplastia de tronco de coronária esquerda no infarto agudo do miocárdio.

Percutaneous transluminal coronary angioplasty is unusual in acute myocardial infarction after left main coronary artery occlusion. We applied this therapy in two cases. The first, a 54-year-old man, submitted to mechanical reperfusion and left main coronary artery angioplasty 145 minutes after the beginning of the symptoms and coronary artery surgery 12 hours later; the second, a 77-year-old woman, submitted to both procedures but not to surgery. In the first case there was a satisfactory follow-up but in the second, the patient died twelve hours later.