[National registry of non-invasive electrocardiology in 1999]. / Registo Nacional dos recursos em electrocardiologia não-invasiva em 1999.

The Portuguese Association of Arrhythmology. Pacing and Electrophysiology undertook a national registry on resources available in noninvasive laboratories in 1999. Forty-eight hospital centres answered the inquiry. Holter monitoring is an established technique, owned by all cardiology departments in the main hospitals and in 86% of district hospitals. The 40 centres with the technique have a total of 50 analysers and 166 recorders. The number of examinations performed was 14,046 in 1998 and 14,516 in 1999, which shows a remarkable stability. Ninety-three percent of equipments allow ST segment, 38% QT interval and 33% heart rate variability analysis. It is worth nothing the high activity of cardiopneumology technicians in the reading of the exams (94%). Late potential study is less spread. It is only possible in 38% of centers and between 1998 and 1999 the number of exams declined from 592 to 357. Only 12 centers have event recorders, nevertheless the number performed increased from 251 in 1998 to 283 in 1999. Finally, eight centres have tilt test facilities, but we do not have numbers of the examinations that were performed.

[Nitrates in the treatment of congestive heart failure]. / Os nitratos no tratamento da insuficiência cardíaca congestiva.

In this revision article, after referring the mechanisms of action of nitrates in the relief of heart failure symptoms, the author presents the results of the controlled studies which show the beneficial effect of the nitrates on heart failure symptoms and mortality. The results of the therapy with nitrates are compared to other heart failure therapies, such as the administration of the angiotensin conversion enzyme (ACE) inhibitors. In spite of the highly favourable results regarding mortality shown by the latest studies with ACE inhibitors, the nitrates still occupy an essential place in the therapy of patients with heart failure, since they have the advantage of a much faster onset of action and are more effective in relieving symptoms than ACE inhibitors. Ancient problems of controversial clinical significance are focused such as resistance and tolerance to nitrates, its clinical implications, and possible methods for prevention of nitrate tolerance and resistance are reviewed. Finally, the author suggests some dosage and administration routes of the nitrates in heart failure, giving attention to particular clinical groups, namely the elderly and other special cases, and their adverse events.

[The use of nitrates in the treatment of heart failure]. / O uso dos nitratos na terapêutica da insuficiência cardíaca.

In this revision article, after referring the mechanisms of action of nitrates in the relief of heart failure symptoms, the author presents the results of the controlled studies which show the beneficial effect of the nitrates on heart failure symptoms and mortality. The results of the therapy with nitrates are compared to other heart failure therapies, such as the administration of the angiotensin conversion enzyme (ACE) inhibitors. In spite of the highly favourable results regarding mortality shown by the latest studies with ACE inhibitors, the nitrates still occupy an essential place in the therapy of patients with heart failure, since they have the advantage of a much faster onset of action and are more effective in relieving symptoms than ACE inhibitors. Finally, the author suggests some dosage and administration routes of the nitrates in heart failure.

[The clinical significance of mitral insufficiency detected by Doppler echocardiography in acute myocardial infarct]. / Significado clínico da insuficiência mitral detectada por ecocardiografia-Doppler no enfarte agudo do miocárdio.

OBJECTIVE: To assess the clinical significance of mitral regurgitation (MR) diagnosed by pulsed Echo-Doppler in patients with acute myocardial infarction (AMI). SETTING: Admission in a coronary care unit and a mean follow-up of 12 months. PATIENTS: Seventy nine patients admitted in a coronary care unit, and 66 patients were followed-up for 12 months (mean). METHODS: Pulsed Echo-Doppler were performed within three days after admission and the presence of MR was analyzed by apical four and two chamber views. RESULTS: There were 62 males and 17 females (mean age: 61.4 +/- 10.8 (31-84) years). The location of AMI was: anterior--40, inferior--30, non-Q wave--6, indeterminate--2 and combined--1. Killip classes were: class I--50, class II--20, class III--7 and class IV--2. 17 patients had a previous AMI. The in-hospital mortality was 9 patients (12%) and the post-hospital mortality was 3 patients (4.5%). MR was detected in 24 patients (30%) in whom 14 (58%) had no murmur of MR previously auscultated. MR was considered moderate in 10 patients and mild in the others 14 patients. There were no significant statistical differences in the frequency of MR in relation to AMI location: anterior 57%, inferior 40% (chi 2 = 0.71, NS); to the presence of a previous AMI: 47% vs 26% (chi 2 = 1.93, NS); to age (61 vs 62 years). The patients with MR suffered a more serious degree of heart failure (class III + class IV): 29% vs 4% (chi 2 = 8.41, p < 0.005); higher hospital mortality: 29% vs 4% (chi 2 = 8.41, p < 0.005); and higher one year mortality: 37.5% vs 5.5% (chi 2 = 10.9, p < 0.001). CONCLUSION: The presence of MR had no relationship with AMI location, the presence of a previous AMI or patients age. The patients with MR had a more serious degree of heart failure, higher hospital and one year mortality. The presence of MR detected by pulsed Echo-Doppler is a sign of bad prognosis although being auscultatory silent in a half of patients.

[A case of incessant junctional tachycardia in a female patient with aneurysm of the interauricular septum]. / Um caso de taquicardia juncional incessante numa doente com aneurisma do septo interauricular.

A permanent supraventricular tachycardia (SVT) was diagnosed in a 54-year-old hypertensive but cardiologically asymptomatic female patient, admitted to a surgery department for biliary lithiasis and hepatic echinococcosis. Heart rate was about 130 bpm and ECGs showed negative P waves in leads I, II, III, aVF, and precordial leads V2 to V6, being the RP' interval longer than P'R interval. Pharmacological intervention during Holter monitoring (20 hours) was instituted: following i.v. propranolol (4 mg), heart rate progressively decreased (to 112 bpm), mainly due to an increase in SVT RP' interval, and brief, spontaneous SVT interruptions occurred, preceded by P'R interval prolongation; SVT stopped after P' recording, and resumed after 2 sinus beats, (showing enlarged P waves and slightly prolonged PR interval), induced by cycle length shortening; later on, under i.v. amiodarone infusion (100 mg/hour) and coincident with the sleeping period, SVT cycle length progressively increased (to 600 msec), due to equivalent increases in P'R and R'P intervals. Two premature ventricular contractions (PVC) occurred during Holter monitoring at a coupling interval of 80-85% of SVT cycle length (480 msec): one PVC apparently originated in left ventricle lateral wall, captured the atria, which were activated 75 msec earlier than expected; the other PVC, apparently originated in left ventricle septoapical region, did not interfere with SVT cycle length. Before these data, a diagnosis of circus movement tachycardia, incorporating a concealed accessory pathway with slow retrograde conduction and ventricular insertion in the postoroseptal or left posterior paraseptal region, and showing minor impairment of antegrade AV nodal conduction, was made. Invasive electrophysiological study was then discarded. With combined oral antiarrhythmic therapy (amiodarone, 600 mg/d), plus propafenone, 450 mg/d), sinus rhythm was permanently restored, with evidence of intraatrial block, slightly prolonged PR interval and no preexcitation. Transesophageal echocardiography revealed a small atrial septal aneurysm associated with a small atrial septal defect; echocardiographic features were consistent with the hypothesis of incomplete regression of the atrial septal aneurysm after partial closure of the atrial septal defect. Abdominal surgery (cholecystectomy plus partial hepatic pericystectomy) was performed without any complications or SVT recurrences. During a 6-month follow-up period, maintaining amiodarone (200 mg/d) and propafenone (450 mg/d), the patient remained SVT-free, and Holter monitoring performed at 3 and 5 months showed permanent sinus rhythm and 1:1 AV conduction with slightly prolonged PR interval (less than 0.29 sec and shortening at faster heart rates). This case documents Holter monitoring capability for the evaluation of tachycardia mechanisms in patients with permanent SVT.

[Rhythmic profiles of the late phase of acute myocardial infarction as a function of age]. / Perfis rítmicos da fase tardia do enfarte agudo do miocárdio em função da idade.

OBJECTIVES: To evaluate the incidence of ventricular arrhythmias in the late phase of acute myocardial infarction (AMI) and to compare it with the following clinical parameters: age, sex, AMI localization, ventricular function (Killip classes), maximal creatinokinase (CK max) and the presence of sinus tachycardia. DESIGN: Prospective study, during a period of 31 months, of a non-selected group of patients with AMI. SETTING: Coronary Care Unit (UTIC-Arsénio Cordiero). PATIENTS: Non-selected group of 153 patients with acute myocardial infarction who survived the second week of disease. MATERIAL AND METHODS: 24-hour Holter ECG performed between the 4th and the 25th day of AMI. The patients were divided into two groups according to the hourly frequency of premature ventricular beats (PVB): less than 3 per hour (PVB less than 3/h) and 3 or more per hour (PVB greater than or equal to 3/h). RESULTS: PVB greater than or equal to 3/h occurred in 36 patients (24%). There was no differences in the occurrence of ventricular arrhythmias between sex, AMI localization, AMI size evaluated by CK max, and the presence of sinus tachycardia. Patients in Killip class III had more ventricular arrhythmias (67%) than patients in Killip class I (23%) (p less than 0.005), in Killip class II (18%) (p = 0.007), and in Killip IV (0%) (p = 0.017). In patients with serious left ventricular failure (classes III + IV) the ventricular arrhythmias were not significantly higher (40%) than in patients without serious left ventricular failure (classes I + II) (22%) (chi 2 = 2.5; p less than 0.25 NS). Patients with less than 41 years old had less PVB greater than or equal to 3/h (4%) than patients between ages 41-69 (24%) (p less than 0.05), and than patients over 70 years old (47%) (p = 0.00075). CONCLUSIONS: The majority of patients (76%) showed a low risk rithmic profile (PVB less than 3/h) in the late phase of AMI. Among all parameters the age of the patients was the one best related to the occurrence of ventricular arrhythmias. Sex, AMI localization, AMI size, and the presence of sinus tachycardia were not related to the presence of PVB. A slight tendency was found in patients with heart failure to have more PVB. On the other hand the elder group carried a statistically significant risk factor for a higher occurrence of ventricular premature beats.

[Surgical treatment of variant angina. Apropos of a clinical case]. / Terapêutica cirúrgica na angina variante. A propósito de um caso clínico.

A case of a male 66 years-old patient who presented with a clinical picture of Prinzmetal's variant angina early in the evolution of an acute myocardial infarction is reported. Transient elevation of ST-segment was documented on Holter monitoring in association with angina at rest as well as asymptomatic episodes of ST-segment changes. Significant two-vessels obstructive lesions (left anterior descending and circumflex arteries) was present. As variant angina had several recurrences in spite of medical therapy with nitrates and calcium antagonists, the patient was submitted to coronary by-pass surgery associated to plexectomy. A Thallium myocardial scintigraphy suggests that a peroperative infarction had occurred. The patient was asymptomatic at six months follow-up.

[Valve insufficiency. Evaluation using color Doppler]. / Insuficiências valvulares. Valorização pela técnica Doppler a cores.

Color Doppler is undoubtedly in the last years main breakthrough in the non invasive definition of regurgitant flows. The detection and quantification of the regurgitant streams, the study of their spatial distribution, the appraisal of their relationships, to anatomical structures, meant a new sight of the physiopathology of valvular insufficiencies. Although this method has an immediate quantitative and qualitative clinical diagnostic interest, its limitations and pitfalls need further investigation. This improvement of technical quality of the equipment and the lowering of its price will surely extend its application beyond its actual limits making color Doppler a routine diagnostic tool in the evaluation of the cardiac patient.