The impact of preinfarct angina on the incidence of acute kidney injury in patients with myocardial infarction: interaction with pre-existent chronic kidney disease.

AIM: Remote ischemic conditioning may reduce acute kidney injury (AKI) in patients undergoing a coronary intervention. As preinfarct angina (PIA) might act as a preconditioning stimulus in patients with ST-elevation myocardial infarction (STEMI), we aimed to study whether PIA reduces AKI in accordance to pre-existing chronic kidney disease. PATIENTS AND METHODS: We conducted a retrospective study including 891 consecutive STEMI patients who underwent primary coronary intervention from January 2008 to March 2016. AKI was determined on the basis of KDIGO criteria. The impact of PIA was evaluated in three groups according to the baseline glomerular filtration rate: less than 45 ml/min/1.73 m (group 1, n = 89), 45-59 ml/min/1.73 m (group 2, n = 117), and greater than or equal to 60 ml/min/1.73 m (group 3, n = 642). Univariate and multivariate predictors for AKI were determined. RESULTS: AKI developed in 13.8% of patients (n = 117) and was more prevalent in patients with worse baseline renal function (35% in group 1; 22% in group 2; and 9% in group 3, P < 0.01). The prevalence of PIA was similar across groups (28-34%, P = 0.2). Only in group 1 did patients with PIA have a significantly lower rate of AKI than patients without PIA (19 vs. 42%, P = 0.033). In multivariate analysis, the absence of PIA in group 1 patients conferred an almost three-fold risk of developing AKI (odds ratio = 2.92, P = 0.009), whereas no differences were found for the other groups. Age, total ischemic time, and intra-aortic balloon pump utilization were also related independently to AKI. CONCLUSION: In our series, STEMI patients with at least stage 3B chronic kidney disease had a three-fold risk of developing AKI in the absence of PIA. These findings suggest that patients with worse renal function may be more susceptible to the renoprotective effect of myocardial ischemic preconditioning.

Developments in pre-hospital patient transport in ST-elevation myocardial infarction. / Evolução e impacto do transporte pré­hospitalar em doentes com enfarte agudo do miocárdio com elevação do segmento ST.

INTRODUCTION: ST-elevation myocardial infarction (STEMI) is a medical emergency that benefits from rapid access to specialized care. The objective of this study was to describe developments in patient transport via the pre-hospital emergency medical system (EMS) and its impact on clinical outcomes. METHODS: We retrospectively studied STEMI patients who underwent primary percutaneous coronary intervention between January 2008 and July 2015. Patients were divided according to type of admission. Total ischemic time (TIT), door-to-balloon time (DBT) and in-hospital and one-year clinical outcomes were assessed for each group. RESULTS: A total of 764 patients were included, of whom 33.5% were transported by the EMS and 45.8% by their own means, 13.7% were transferred from another institution and 6.9% were transported by non-EMS ambulance. There was a trend for more frequent recourse to the EMS over the eight-year period. There was a higher percentage of patients with prior myocardial infarction and Killip class III/IV in the EMS group compared to the non-EMS group. Significant differences were seen between groups in reperfusion times, EMS patients having the shortest TIT and DBT (195 vs. 286 min, p<0.001 and 61 vs. 90 min, p<0.001, respectively), but no significant difference in event rates was observed. Patients presenting to the hospital early had higher rates of effective reperfusion and lower in-hospital mortality (6.9% vs. 33.9%, p<0.001). CONCLUSIONS: Recourse to the EMS significantly reduced ischemic times. Although this improvement was not directly associated with significant differences in event rates, it was associated with higher rates of effective reperfusion that were reflected in lower in-hospital mortality.

Effects of a Phase IV Home-Based Cardiac Rehabilitation Program on Cardiorespiratory Fitness and Physical Activity.

BACKGROUND: Cardiovascular diseases are the leading cause of death globally and sedentary lifestyle is one of the main risk factors. Home-based cardiac rehabilitation (CR) programs appear to be effective to improve exercise tolerance. The aim of the study, therefore, was to evaluate the effects of a phase IV (maintenance) home-based CR program on cardiorespiratory fitness and daily physical activity of patients recovering from an acute myocardial infarction. METHODS: This pilot study, with a sub-group randomised controlled trial, included 32 individuals recovering from a myocardial infarction, randomly divided into the experimental group (EG, n=16) and the control group (CG, n=16). The EG performed an exercise program, three times per week, at home during eight weeks. The two groups received health education sessions. Baseline and final assessments included cardiorespiratory fitness, resting and peak heart rate, blood pressure and rate pressure, heart rate recovery and daily physical activity. (ClinicalTrials.gov: NCT01887080). RESULTS: At baseline no significant differences were observed between groups. After eight weeks of exercise, the EG significantly increased peak oxygen uptake (p=0.02), test duration (p=0.019), peak rate pressure (p=0.003), peak heart rate (p=0.003) and heart rate recovery (0.025) when compared to the CG. No changes were observed on daily physical activity in both groups. CONCLUSION: This specific phase IV home-based exercise program seems to improve cardiorespiratory fitness, haemodynamics at peak exercise and heart rate recovery, an indicator of cardiac autonomic function.

A rare cause of hoarseness in a young patient.

Syphilis is nowadays a rare cause of aortic aneurysms in developed countries. Commonly saccular, syphilitic aneurysms are frequently single, involving the ascending aorta and arch and are frequently asymptomatic unless large enough to cause symptoms due to compression of surrounding structures or death from rupture. In this paper, the authors present the case of a 32-years old patient presenting with progressive weakness, anorexia, weight loss and hoarseness, who was diagnosed with a multiple saccular aortic aneurysms, which were syphilitic in nature. The patient underwent surgery for a hemiarch replacement after receiving a cycle of antibiotics and had an uneventful recovery. This case illustrates that, although rare, syphilis must be recognized as a potential source of aneurismal disease as it warrants antibiotic therapy and screening of involvement of other organs.

A sífilis é atualmente uma causa rara de aneurisma da aorta em países desenvolvidos. Normalmente saculares, os aneurismas sifilíticos são frequentemente simples, envolvendo a aorta ascendente e arco. São frequentemente assintomáticos a menos que grandes o suficiente para causar sintomas devido à compressão das estruturas vizinhas, ou morte por ruptura. Neste artigo, os autores apresentam o caso de um paciente de 32 anos de idade com queixas de fraqueza progressiva, anorexia, perda de peso e rouquidão, a quem lhe foi diagnosticado múltiplos aneurismas saculares da aorta, de natureza sifilítica. O paciente foi submetido a uma cirurgia de substituição do hemiarco aórtico depois de receber um ciclo de antibióticos e teve uma recuperação sem intercorrências. Este caso ilustra que, embora rara, a sífilis deve ser reconhecida como uma fonte potencial de doença aneurismática, tanto aórtica como também de outros órgãos.

A 75-year-old woman with chest pain and transient severe left ventricular systolic dysfunction.

INTRODUCTION: Coronary spasm can cause myocardial ischemia and angina in both patients with and without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine (ACh) have been rarely performed in the Western world. CASE REPORT: We report a case of a 75-year-old woman with a history of hypertension and a mechanical aortic prosthesis who presented in the emergency room with acute-onset chest pain, widespread ST-segment depression and severe left ventricular systolic dysfunction, with no signs of prosthesis dysfunction. Emergent coronary angiography excluded obstructive coronary artery disease. Pain relief and normalization of ST segment and systolic function occurred within six hours. The patient was treated for a possible thromboembolic myocardial infarction and was discharged home asymptomatic. Two weeks later, cardiac magnetic resonance was performed showing inferoseptal transmural infarct scar, inferior and inferolateral subendocardial infarct and mid-basal ischemia in the anterior and anterolateral walls. She was readmitted with recurrence of chest pain and it was decided to perform a provocation test with ACh. After injection of ACh into the left anterior descending artery, chest pain, ST-segment depression, blood flow impairment (TIMI 1) and transient grade 3 atrioventricular (AV) block occurred. Intracoronary administration of nitrates reversed the coronary spasm and AV conduction disturbances. Twenty minutes later, chest pain and ischemic ST changes recurred; there was no response to vasodilators and the patient developed cardiac arrest with pulseless electrical activity. Advanced life support was maintained for 32 minutes without return of spontaneous circulation. CONCLUSIONS: Provocation tests have a high sensitivity and specificity for the diagnosis of vasospastic angina. Although it is rare, these tests have the potential risk of irreversible spasm leading to arrhythmia and death.

Effects of the Mediterranean diet and exercise in subjects with coronary artery disease.

INTRODUCTION: The association of the Mediterranean diet and exercise appears to have a protective role, reducing cardiovascular risk. This study investigated the effects of education sessions on the Mediterranean diet and an exercise program in modifying eating behaviors, body composition and abdominal fat. METHODS: An experimental study was performed on 20 subjects with known coronary heart disease randomly assigned to experimental (n=10) and control (n=10) groups. Both groups received education sessions on the Mediterranean diet, but the experimental group also followed an eight-week program of specific exercises. A semiquantitative food frequency questionnaire was administered to analyze food intake, bioimpedance was used to measure weight, fat mass and lean mass, and waist circumference was measured to calculate waist-to-height ratio. RESULTS: After eight weeks, protein (p<0.05) and cholesterol (p<0.05) intake in the experimental group had decreased significantly compared with the control group. Between the beginning and end of the study, there were significant decreases in the control group in carbohydrate (p<0.05) and saturated fat intake (p<0.05). In both groups the percentage of total fat (p<0.05) and fat mass (p<0.05) was significantly decreased. In the experimental group the waist-to-height ratio was significantly reduced (p<0.05). CONCLUSION: The Mediterranean diet reduced carbohydrate and saturated fat intake, reflected in reduced fat mass. The association of the exercise program showed additional benefits in reduction of protein and cholesterol intake and abdominal fat.

Acute hepatitis after amiodarone infusion.

Acute hepatitis is a very rare, but potentially fatal, adverse effect of intravenous amiodarone. We present a case of an 88-year-old man with history of ischemic dilated cardiomyopathy and severely depressed left ventricular function that was admitted to our coronary care unit with diagnosis of decompensated heart failure and non-sustained ventricular tachycardia. A few hours after the beginning of intravenous amiodarone he developed an acute hepatitis. There was a completely recovery within the next days after amiodarone withdrawn and other causes of acute hepatitis have been ruled out. This case highlights the need for close monitoring of hepatic function during amiodarone infusion in order to identify any potential hepatotoxicity and prevent a fatal outcome. Oral amiodarone is, apparently, a safe option in these patients.

Extracorporeal membrane oxygenation as bridge-to-decision in acute heart failure due to systemic light-chain amyloidosis.

PATIENT: Female, 58. FINAL DIAGNOSIS: Acute hear failure. SYMPTOMS: Dispnoea • edema • fatigue. MEDICATION: ­ CLINICAL PROCEDURE: Bone marrow biopsy • endomyocardial biopsy • abdominal subcutaneous fat biopsy under ECMO support. SPECIALTY: Cardiology. OBJECTIVE: Rare disease. BACKGROUND: Cardiac amyloidosis results from the amyloid deposition in heart tissue, either in the context of a systemic disease or as a localized form. Several pro-amyloid proteins can produce amyloid deposits in the heart. Each of these amyloidoses has characteristic clinical (cardiac and extracardiac) features, and a specific diagnosis and treatment. CASE REPORT: A 58-year-old woman who presented with acute heart failure and echocardiographic findings strongly suggestive of infiltrative cardiomyopathy needed percutaneous veno-arterial extracorporeal membrane oxygenation (ECMO) as bridge-to-decision. Amyloid deposition was found on endomyocardial and bone marrow biopsies. Bone marrow plasma cell infiltrate with acute renal lesion and hypercalcemia confirmed the diagnosis of multiple myeloma-associated systemic light-chain amyloidosis (AL). Refractory shock with multi-organic failure syndrome persisted and no improvements in left ventricular function and structure were seen. After extensive discussion by a multidisciplinary team, and with the patients' family, she was not considered eligible for high-dose chemotherapy and/or autologous stem cell transplantation, heart transplantation, or sequential heart with autologous stem cell transplantation. The patient died a few hours after ECMO withdrawal. During the 14 days of ECMO support no major bleeding or thrombotic complications occurred. CONCLUSIONS: The clinician must consider a diagnosis of cardiac amyloidosis in patients with heart failure, a restrictive type of cardiomyopathy with ventricular hypertrophy in the absence of valve abnormalities, or uncontrolled arterial hypertension. Although developments in chemotherapy have greatly improved the outcomes in AL amyloidosis, the prognosis of patients with severe cardiac involvement remains very poor. ECMO is potentially a reliable bridge-to-diagnosis and bridge-to-decision in these patients. An experienced ECMO team, careful patient selection, and rigorous management protocols with objective criteria to wean or stop ECMO are needed.

Aortic intramural hematoma: an unpredictable evolution.

Aortic intramural hematoma (IMH) is an acute aortic syndrome characterized by bleeding into the media of the aortic wall without intimal disruption or the classic flap formation. Its natural history is variable and still poorly understood, so strategies for therapeutic management are not fully established. In some cases there is partial or complete regression of the hematoma under medical treatment, but most progress to dissection, aneurysmal dilatation or aortic rupture. The authors present the case of a 44-year-old hypertensive male patient admitted with a diagnosis of IMH of the descending aorta. Despite initial symptom resolution and optimal medical therapy, the IMH evolved to a pseudoaneurysm, which was successfully treated by an endovascular approach.

Anatomical versus functional assessment of coronary artery disease: direct comparison of computed tomography coronary angiography and magnetic resonance myocardial perfusion imaging in patients with intermediate pre-test probability.

Computed tomography coronary angiography (CTA) and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) are state-of-the-art tools for noninvasive assessment of coronary artery disease (CAD). We aimed to compare the diagnostic accuracy of CTA and CMR-MPI for the detection of functionally relevant CAD, using invasive coronary angiography (XA) with fractional flow reserve (FFR) as a reference standard, and to evaluate the best protocol integrating these techniques for assessment of patients with suspected CAD. 95 patients (68 % men; 62 ± 8.1 years) with intermediate pre-test probability (PTP) of CAD underwent a sequential protocol of CTA, CMR-MPI and XA. Significant CAD was defined as >90 % coronary stenosis, 40-90 % stenosis with FFR ≤ 0.80 or left main stenosis ≥50 %. Prevalence of significant CAD was 43 %. CTA was more sensitive (100 %) but less specific (59 %) than CMR-MPI (88 and 89 %, respectively) for detection of significant CAD, with a strong trend for higher global diagnostic accuracy of CMR-MPI (88 vs. 77 %, p = 0.05). An integrated approach based on an initial CTA and subsequent referral to CMR-MPI of positive/inconclusive results had the best diagnostic performance (AUC 0.91). The direct referral to XA of patients with positive/inconclusive CTA performed worse than a selective approach based on CMR-MPI results (AUC 0.80 vs. 0.91, p = 0.005). In this intermediate PTP population, CMR-MPI showed a strong trend toward better performance compared to CTA for the assessment of functionally significant CAD. A combined protocol integrating coronary anatomy and function seems to be a very effective approach in the accurate diagnosis of CAD.

[Isolated left ventricular non-compaction: a single-center experience]. / Não compactação isolada do ventrículo esquerdo: experiência de um centro.

Isolated left ventricular noncompaction (LVNC) is a rare cardiomyopathy characterized by excessive and prominent trabeculations associated with deep recesses that communicate with the ventricular cavity. Determining the natural history of this condition has been hampered by differences in clinical features and prognosis in published series, which are partly the result of differing diagnostic criteria and the lack of management guidelines. This work aims to contribute to the characterization of isolated LVNC by analyzing an affected population in terms of clinical presentation, diagnosis, risk stratification, treatment and follow-up. We also discuss the most relevant data from the literature concerning this cardiomyopathy.

Omeprazole, but not pantoprazole, reduces the antiplatelet effect of clopidogrel: a randomized clinical crossover trial in patients after myocardial infarction evaluating the clopidogrel-PPIs drug interaction.

BACKGROUND: Proton pump inhibitors (PPIs) are usually prescribed to patients undergoing dual antiplatelet therapy to decrease the risk of gastrointestinal bleeding. Recent studies have raised concerns that PPIs could reduce clopidogrel's efficacy by competitive inhibition of cytochrome P450 2C19 isoenzyme. All PPIs are metabolized by cytochrome P450 2C19, although to varying degrees, and according to in-vitro studies, pantoprazole is the weakest inhibitor of this isoenzyme. We hypothesized that this drug interaction might not be a class effect. METHODS: One month after an acute myocardial infarction 34 consecutive patients undergoing dual antiplatelet therapy were prospectively analyzed. Platelet function was measured (VerifyNow system), in each patient, in three consecutive clinical scenarios: (i) first, after a 1-month washout period, without any PPI, (ii) after a 4-week period taking omeprazole 40 mg, and (iii) after another 1-month washout period, followed by 4-weeks taking pantoprazole 40 mg. In this crossover trial, patients were first randomized to receive either omeprazole or pantoprazole. RESULTS: We observed a significant reduction in clopidogrel's effect when patients were initiated with omeprazole; the mean P2Y12 reaction units (PRU) increased from 202±52 to 235±58 with omeprazole (P<0.001). With pantoprazole, clopidogrel efficacy was preserved (PRU 215±54, P=0.16). Without any PPI, 26% of patients were 'nonresponders' to clopidogrel (PRU >240) but when patients started omeprazole, this proportion increased to 45 versus 23% with pantoprazole. CONCLUSION: In this randomized crossover study analyzing patients after acute myocardial infarction, omeprazole coadministration showed a significant pharmacodynamic interaction with clopidogrel, whereas pantoprazole did not. These data suggest that the clopidogrel-PPIs drug interaction may not be a class effect.

[Percutaneous intervention in left main coronary disease: medium and long term clinical outcomes in a high risk population]. / Angioplastia do tronco comum: resultados clínicos a médio e longo prazo de uma população de doentes de alto risco.

PURPOSE: Coronary artery bypass graft (CABG) remains the standard therapy for left main coronary artery (LMCA) disease.However, in recent years, percutaneous coronary intervention (PCI) has shown good results and is being used in an increasing number of patients. We aimed to assess mid and long term clinical outcomes of patients undergoing LMCA PCI in a hospital with cardiac surgery. METHODS: Retrospective analysis of consecutive patients undergoing LMCA PCI between January 2005 and June 2011.F our groups (G) of indications for PCI were defined: G1 - patients refused for surgery (29.2%), G2 - emergent PCI (14.6%),G3 - PCI of protected LMCA (37.5%) and G4 - LMCA PCI as preferred revascularization strategy due to favorable coronary anatomy (18.8%). RESULTS: Ninety-six patients were treated, mostly male (69.8%), mean age of 69.4±10.5 years. Most patients (69%) had acute coronary syndrome and 14% were in cardiogenic shock. Critical stenosis of distal LMCA was seen in 58% and drug-eluting stents were used in 60%. Mean logistic EuroScore was 13.9±11.9%. Patients from groups 1, 2 and 3 had more multivessel disease (96, 79 and 89%, respectively) than those from G4 (isolated LMCA disease in 58%). Follow-up was performed in 100% of patients (median of 21 months; IQR 10.0 - 43.5), with a total mortality rate of 28.1% (14.6% of cardiovascular (CV) causes). Seven patients (7.3%) had in-hospital death. MACCE rate (CV death, nonfatal myocardial infarction, stroke and LMCA reintervention) was 26% and one-year mortality was 15.4%. Five patients (5.6%) required percutaneous reintervention; CABG was performed only in 1 patient.In subgroup analysis it was found that total mortality in G1 and G2 (46.4% and 64.3%) was significantly higher than that of G3 and G4 (11.1% and 5.6% respectively), p <0.001. The same trend was observed for CV mortality: G1 (25.0%) and G2 (35.7%) vs G3 (5.6%) and G4 (0%), p = 0.005. CONCLUSION: LMCA PCI proved to be a safe technique with low mortality in patients with protected LMCA and those with favorable coronary anatomy for percutaneous revascularization. Patients undergoing emergent PCI or refused for surgery had a large number of events, according to their very high baseline risk profile.

Incidence and predictors of permanent pacemaker requirement after transcatheter aortic valve implantation with a self-expanding bioprosthesis.

BACKGROUND: Previous reports have suggested the occurrence of cardiac conduction disorders and permanent pacemaker (PPM) requirement after transcatheter aortic valve implantation (TAVI). Based on a single-center experience, we aim to assess the incidence of postprocedural conduction disorders, need for PPM, and its determinants after TAVI with a self-expanding bioprosthesis. METHODS: From August 2007 to October 2009, 32 consecutive patients underwent TAVI with the Medtronic CoreValve (MCV) System (Medtronic Inc., Minneapolis, MN, USA). Three patients paced at baseline and two cases of procedure-related mortality were excluded. We analyzed the 12-lead electrocardiogram at baseline, immediately after procedure and at discharge. Requirements for PPM were documented and potential clinical, electrophysiological, echocardiographic, and procedural predictors of PPM requirement were studied. RESULTS: After TAVI, eight patients (29.6%) required PPM implantation due to high-grade atrioventricular (AV) block. The prevalence of left bundle branch block increased from 13.8% to 57.7% directly after implantation (P = 0.001). Need for PPM was correlated to the depth of prosthesis implantation (r = 0.590; P = 0.001). At a cutoff point of 10.1 mm, the likelihood of pacemaker could be predicted with 87.5% sensitivity and 74% specificity and a receiver operator characteristic curve area of 0.86 ± 0.07 (P = 0.003). Of the seven patients with preexisting right bundle branch block (RBBB), four (57.1%) required PPM implantation after TAVI. CONCLUSIONS: High-grade AV block requiring PPM implantation is a common complication following TAVI and could be predicted by a deeper implantation of the prosthesis. Patients with preexisting RBBB also seem to be at risk for the development of high-grade AV block and subsequent pacemaker implantation.

[Clopidogrel--proton pump inhibitors drug interaction: implications to clinical practice]. / Interacção clopidogrel--inibidores da bomba de protões: implicações para a prática clínica.

Recent studies have raised the concern that proton pump inhibitors (PPIs) could potentially interfere with clopidogrel antiplatelet effect. This association is frequent in clinical practice and is recommended by recent consensus guidelines in patients taking dual antiplatelet therapy to prevent gastrointestinal (GI) bleeding. Clopidogrel is a pro-drug which needs to be metabolized into its active metabolite, by cytochrome P450, especially by CYP2C19 isoenzyme. Various PPIs can inhibit CYP2C19, which could possibly decrease clopidogrel bioactivation process and, therefore, its antiplatelet effect. Various platelet function studies have shown that omeprazol can significantly decrease clopidogrel inhibitory effect on platelet P2Y12 receptor, leading to an increase in the number of patients who are "nonresponders" to clopidogrel. These pharmacokinetic studies also shown that this is not probably a class effect of PPIs, because they are metabolized to varying degrees by CYP2C19. The clinical impact of these observations remains uncertain, because various observational studies have shown conflicting results, and remains to demonstrate if PPIs can really increase the risk of cardiovascular events in patients taking clopidogrel. In this review we will discuss the pharmacokinetic basis underlying this drug interaction, the effect of different PPIs on platelet function tests and we will analyze in detail the potential clinical implications of using this association, both on cardiovascular and gastrointestinal events. Until further data is available, some clinical strategies can be recommended: (1) individual gastrointestinal risk assessment, with PPIs administration only to patients on dual anti-platelet therapy with additional GI risk factors; (2) preferential use of PPIs that have shown less interference with clopidogrel efficacy; (3) wide separation of PPI and clopidogrel dosing to minimize the risk of interaction (PPI may be given before breakfast and clopidogrel at bedtime); (4) or alternative use of histamine-2-receptor antagonist therapy, in patients at low GI risk.

Percutaneous aortic valve implantation.

INTRODUCTION: Percutaneous aortic valve implantation is an emerging procedure for the treatment of patients with severe aortic stenosis. METHODS: The procedure was performed in patients with severe symptomatic aortic stenosis, who had been refused for aortic valve replacement surgery. A self-expanding bioprosthesis within a nitinol frame delivered by an 18F catheter was used. Most of the procedures were performed through a femoral artery approach and under local anesthesia and sedation. RESULTS: Thirty-two patients were treated, mean age 80 years, with various comorbidities and mean logistic EuroSCORE of 22%. The procedure was successful in all patients, with a significant improvement in transvalvular gradients. Two patients died due to procedure-related complications. The most common complications were vascular access related and high-degree atrioventricular block requiring permanent pacemaker. No events were reported after one month follow-up, with most patients showing improvement in functional capacity. After 23 months of follow-up (mean 13 months) five additional deaths had occurred. No prosthesis-related events were observed. CONCLUSIONS: Percutaneous aortic valve implantation is safe and improves quality of life in patients with severe symptomatic aortic stenosis. It may be an alternative therapeutic option for patients with high risk features for aortic replacement surgery.

[Primary myxoma of the pulmonary artery. Clinical report]. / Mixoma do tronco daartéria pulmonar. Caso clínico.

The cardiac myxoma is a benign clinical entity, characterised by the growth of a gelatinous mass composed by primary connective tissue and stroma, representing the most common cardiac tumour. Usually found within one of the cardiac chambers, it affects the left atrium in 75% of the cases. Rare cases in literature describe extra-cardiac locations of myxomas. In this paper, the authors report the clinical case of a patient with a primary myxoma of the pulmonary artery.

Myocardial bridging: retrospective analysis and scintigraphic testing of patients with no angiographically significant atherosclerotic coronary disease.

INTRODUCTION AND OBJECTIVE: The clinical relevance of myocardial bridging (MB) is a matter of debate. The objective of this work was to examine its prevalence, clinical presentation, prognosis, and functional features on scintigraphy in a group of patients with no significant atherosclerotic coronary disease. METHODS: We retrospectively examined 7039 consecutive cardiac angiograms performed between January 1994 and December 2004, selecting cases in which MB was not accompanied by significant coronary disease (defined as luminal stenosis > 50%), valvular heart disease or cardiomyopathy. Patient characteristics such as age, gender, vascular risk factors and clinical presentation were recorded. We then contacted these patients by telephone to determine cardiovascular events since diagnosis (hospitalization, infarction, death) or symptoms of angina, and to invite them for myocardial perfusion scintigraphy (MPS) with stress testing. RESULTS: The prevalence of MB was 0.97% (68 patients). The study population without significant coronary disease, valvular heart disease or cardiomyopathy was composed of 31 subjects, mean age 51.45 +/- 13.77 years, 94% (29 patients) male. Clinical presentations were: non-ST elevation acute coronary syndromes with or without biomarkers of necrosis 34% (14 patients), stable angina 23% (7 patients), atypical chest pain 16% (5 patients), ST-elevation myocardial infarction 13% (4 patients), other 3% (1 patient). Left ventricular function was normal in all patients, and angiography showed MB of the left anterior descending artery, 63% (19 patients) in the mid portion, and 33% (12 patients) in the distal portion. All subjects were treated medically. We were able to contact 24 (77%) of the 31 patients, all of whom underwent MPS; mean time since angiography was 61.25 months, with no cardiovascular events (hospitalization, infarction, death) or symptomatic angina. MPS only identified three patients with findings consistent with anterior wall ischemia. CONCLUSIONS: In this series, 58% of the patients with MB and no significant atherosclerotic coronary disease presented with acute coronary syndromes. In all the subjects contacted, the prognosis had been good during the time since diagnosis. In the majority of them, no signs of ischemia were detected on MPS.

Pesquisa bioestatística e nutricional na cidade de Salgueiro, 1983 / Biostatistical and nutritional research in the city of Salgueiro, 1983

Apresentam-se informaçöes oriundas de uma pesquisa simples, pouco onerosa e de caráter experimental, mas que conduz a ilaçöes variadas e valiosas, levando em consideraçäo a persistente deficiência da coleta rotineira de alguns dados estatísticos, principalmente os que se referem a fatos vitais e a outras condiçöes de saúde, com reflexos os mais significativos nos atuais programas prioritários. Foram objeto do estudo realizado os indicadores de natalidade e mortalidade, a situaçäo ponderal dos recém-nascidos e o aleitamento materno. Verificou-se a boa qualidade da coleta de nascimentos efetuada pelo serviço de visitaçäo domiciliar da Unidade Sanitária da Fundaçäo SESP e, por outro lado, a reconhecida evasäo de dados do registro civil, reduzindo artificialmente os coeficientes de mortalidades geral e infantil. Quanto ao peso das crianças ao nascer, 63% apresentavam 3.500g e mais (média de 3.600g para todos os recém-natos), provável influência do bom estado nutritivo das mäes. Contribuiçäo ponderável para a baixa mortalidade infantil (75 por mil) deve ter oferecido o aleitamento materno, como se deduz do seu tempo médio de duraçäo de 5,2 meses entre as mäes pesquisadas