Análise comparativa do risco cardiovascular com características clínicas não inclusas no escore de Framingham / Comparative analysis of cardiovascular risk with clinical features not included in the Framingham risk score

OBJETIVO: Avaliar o risco de doença cardiovascular em 10 anos, por meio do escore de Framingham, em pacientes internados nas enfermarias de clínica médica de um hospital geral, e a prevalência de variáveis clínicas não contempladas por este escore nessa mesma população, além de correlacionar a prevalência dessas variáveis com o risco cardiovascular calculado. MÉTODOS: De dezembro de 2014 a maio de 2015, foram examinados os pacientes sem história ou evidência de doença cardiovascular. Foram coletados os dados para cálculo do risco. Foram ainda avaliadas as seguintes variáveis não inclusas no escore de Framingham: histórico familiar de doença cardiovascular, sedentarismo, circunferência abdominal, etnia e pressão arterial diastólica. Dividimos os pacientes em dois grupos: um com risco cardiovascular elevado e outro com risco não elevado. RESULTADOS: O risco cardiovascular em 10 anos na casuística (n=100) foi de 17,89%. A prevalência das variáveis não inclusas no escore foram antecedente familiar (48%); sedentarismo (81%); obesidade central (70%); brancos vs. não brancos (56% vs. 44%); pressão arterial diastólica média (79,53mmHg). O único dado não incluso no escore que apresentou associação estatisticamente significativa com o risco cardiovascular elevado foi a pressão arterial diastólica (χ²=5,8275; p=0,0158). CONCLUSÃO: O achado da pressão arterial diastólica sugere valor preditivo cardiovascular para este fator. As demais variáveis ausentes no escore não se associaram com o risco cardiovascular elevado.

OBJECTIVES: To assess the risk of cardiovascular disease in tem years, through Framingham score, in patients admitted to the medical wards of a general hospital, and the prevalence of clinical variables not contemplated by this score in that population, in addition to correlate the prevalence of these variables with calculated cardiovascular risk. METHODS: From December 2014 to May 2015, patients with no history or evidence of cardiovascular disease were examined. Data for risk calculation were collected. In addition, the following variables that were not included in Framingham risk score were evaluated: family history of cardiovascular disease, physical inactivity, abdominal circumference, ethnicity and diastolic blood pressure. Patients were divided into two groups: one with high cardiovascular risk, and another with low risk. RESULTS: Cardiovascular risk in ten years in the series (n=100) was 17.89%. The prevalence of the variables not included in the score were: family history, 48%; sedentary lifestyle, 81%; central obesity, 70%; white vs. non-white, 56% vs 44%; mean diastolic blood pressure, 79.53mmHg. The only data showing statistically significant association with increased cardiovascular risk that were not included in the score was diastolic blood pressure (χ²=5.8275; p=0.0158). CONCLUSION: The finding of diastolic blood pressure suggests cardiovascular predictive value for this factor. The other variables that were not present in the score were not associated with increased cardiovascular risk.

Viabilidade miocárdica na lesão uniarterial: papel da ecocardiografia de estresse com dobutamina / Myocardial viability in a single-vessel disease: the role of a dobutamine stress echocardiography

OBJETIVO: Estudar um grupo de pacientes com lesão significativa em apenas uma artéria coronária e demonstrar se a ecocardiografia de estresse com dobutamina (EED) tem boa sensibilidade e especificidade na avaliação de viabilidade miocárdica nesse grupo de pacientes. MÉTODOS: Foram estudados 20 pacientes submetidos a angioplastia coronariana transluminal percutânea (ATC). Esse grupo foi avaliado 2 a 7 (3,65 ± 1,69) dias antes do procedimento, e 2 a 5 (4 ± 0,80) dias depois, realizando-se EED. Para a determinação de viabilidade miocárdica foi utilizado ecocardiograma bidimensional três meses após o procedimento. Doze pacientes foram submetidos a ATC de artéria descendente anterior (DA), 7 de artéria coronária direita (CD) e 1 de circunflexa (CX). Apenas um procedimento (CD) não obteve pleno êxito. RESULTADOS: Dos 340 segmentos estudados, 99 (29,18 por cento) demonstraram alterações contráteis, sendo 63 hipocinéticos (63,4 por cento), 28 acinéticos (28,28 por cento) e 8 discinéticos (8,08 por cento). Quanto aos segmentos envolvidos, obtivemos sensibilidade de 92,59 por cento, especificidade de 84,45 por cento, acurácia de 88,88 por cento para o exame EED. O único caso de ATC de CX demonstrou sensibilidade de 100 por cento; para DA, sensibilidade de 88,58 por cento, especificidade de 95 por cento e acurácia de 90,91 por cento. Para segmentos da CD, sensibilidade de 91,30 por cento, especificidade de 83,33 por cento e acurácia de 88,71 por cento. Todos os segmentos discinéticos eram inviáveis. Dos 63 hipocinéticos, a EED previu recuperação em 91,48 por cento. CONCLUSÃO: A EED é útil na avaliação de viabilidade miocárdica em pacientes com lesão significativa de apenas uma artéria.

[Myocardial viability in a single-vessel disease: the role of a dobutamine stress echocardiography]. / Viabilidade miocárdica na lesão uniarterial: papel da ecocardiografia de estresse com dobutamina.

OBJECTIVE: To investigate a group of patients that have a significant lesion in a single-vessel and to demonstrate whether or not the sensitivity and specificity of a dobutamine stress echocardiography (DSE) was valuable in the evaluation of myocardial viability for these patients. METHODS: Twenty patients who had undergone percutaneous transluminal coronary angioplasty (PTCA) were studied. This group was evaluated 2 to 7 days (3.65 +/- 1.69) before the procedure and 2 to 5 days (4 +/- 0.80) after the procedure with a DSE. Myocardial viability was assessed three months after the procedure using a two dimensional echocardiogram. Twelve patients underwent PTCA on the left anterior descending artery (LAD), 7 on the right coronary artery (RC) and 1 on the circumflex artery (CX). Only one right coronary artery procedure was not 100% successful. RESULTS: From the 340 segments that were studied, 99 (29.18%) demonstrated contractile alterations of which 63 were hypokinetic (63.4%), 28 akinetic (28.28%) and 8 dyskinetic (8.08%). In reference to the segments involved, we obtained a sensitivity of 92.59%, specificity of 84.45%, and accuracy of 88.88% for the DSE. The solitary case of PTCA for the circumflex artery demonstrated 100% sensitivity. The LAD demonstrated a sensitivity of 88.58%, specificity of 95% and accuracy of 90.91%. For the RC segments, sensitivity was 91.30%, specificity 83.33% and accuracy 88.71%. All dyskinetic segments were unviable. The DSE predicted a 91.48% recovery rate for the 63 hypokinetic segments. CONCLUSION: The DSE is an effective test for evaluating myocardial viability in patients with a significant single-vessel disease.

Myocardial contrast echocardiography in patients with suspected or known coronary artery disease: comparison with myocardial nuclear scintigraphy.

OBJECTIVE: To compare myocardial contrast echocardiography (MCE) using PESDA and adenosine in bolus (ADN) with myocardial nuclear scintigraphy (NS) in patients (pts) undergoing routine investigation with a high probability of having coronary artery disease. METHODS: This study comprised 125 pts (85 men) with 58.4 +/- 10.6 years, who underwent MCE and NS within 4 weeks. MCE was performed with PESDA in a continuous infusion at rest and after administration of an adenosine bolus. The LV walls was divided into 3 territories related to the coronary arteries, in a total of 375 territories. MCE was normal when an increase in contrast intensity occurred after ADN. The reduction in contrast intensity at rest or after ADN was defined as an abnormal MCE result. NS was performed according to classical protocols. When compared per patient, both examinations were considered concordant when they were normal or abnormal, independent of its location. The comparison by territory was considered concordant when perfusion defects existed or not in the same territory. The chi-square test was used to determine the significance of concordance. RESULTS: In 106/125 pts, MCE and NS were concordant (84.8% - P < 0.001). Concordance occurred in 342/375 territories (91.2% - P < 0.001). For the LAD territory, concordance was 87.2%; for the RCA, 93.6%; and for the CX, 92.8% (P < 0.001). CONCLUSION: An excellent concordance exists between MCE and NS in assessing pts for coronary artery disease; therefore, MCE may represent a good alternative for assessing myocardial perfusion.

Ecocardiografia de contraste miocárdico em pacientes com doença arterial coronariana suspeita ou conhecida: comparação com a cintilografia miocárdica com radioisótopos / Myocardial contrast echocardiography in patients with suspected or known coronary artery disease: comparison with myocardial nuclear scintigraphy

OBJETIVO: Comparar a ecocardiografia de contraste miocárdico (ECM) usando PESDA e adenosina em bolus (ADN) com a cintilografia miocárdica com radioisótopos (CM) em pacientes (pts) submetidos a investigação e alta probabilidade de doença arterial coronariana. MÉTODOS: Foram estudados 125 pts, 58,4 ± 10,6 anos, 85 homens, com ECM e CM, realizados com intervalo máximo de 4 semanas. ECM foi realizada com PESDA em infusão contínua em repouso e após ADN. As paredes do VE foram divididas em 3 territórios relacionados às artérias coronarianas, totalizando 375 territórios. ECM foi normal quando houve aumento da intensidade do contraste após ADN. Diminuição da intensidade do contraste em repouso ou após ADN foi definida como ECM anormal. CM foi realizada usando protocolos clássicos. Comparados por pacientes, foram considerados concordantes quando ambos exames eram normais ou anormais independente de localização. A comparação por território foi considerada concordante quando havia ou não déficit perfusional num mesmo território. A significância da concordância foi feita pelo teste do qui-quadrado. RESULTADOS: Em 106/125 pts ECM e CM foram concordantes (84,8 por cento - p<0,001). Houve concordância em 342/375 territórios (91,2 por cento - p<0,001). Para o território de DA a concordância foi de 87,2 por cento, para CD 93,6 por cento e para CX 92,8 por cento (p<0,001). CONCLUSAO: Existe uma ótima concordância entre ECM e CM nos pts em investigação para doença arterial coronariana, podendo a ECM representar uma alternativa à avaliação da perfusão miocárdica.

Study of coronary flow reserve with intravenous use of microbubbles (contrast echocardiography) and adenosine: protocol for clinical application in patients suspected of having coronary heart disease.

OBJECTIVE: To test the feasibility, safety and accuracy of the adenosine protocol in the study of myocardial perfusion with microbubbles contrast echocardiography. METHODS: 81 pts (64 male, 60+11 years) were submitted to contrast echocardiography with PESDA (sonicated solution of albumin 20%-1ml, dextrose 5%-12ml and deca-fluorobutane gas-8ml) to study the myocardial perfusion at rest and after bolus injection of adenosine (6 to 18mg) and to coronary angiography within 1 month each other. For each patient 3 left ventricle perfusion beds were considered (total of 243 territories). 208 territories were analyzed and 35 territories were excluded. PESDA was continuously infused (1-2ml/min), titrated for best myocardial contrast. Triggered (1:1) second harmonic imaging was used. RESULTS: Coronary angiography showed 70 flow limiting (> 75%) lesions and 138 no flow limiting lesions. At rest an obvious myocardium contrast enhancement was seen in at least 1 segment of a territory in all patients. After adenosine injection an unquestionable further increase in myocardial contrast was observed in 136 territories (99%) related to no flow limiting lesions, lasting < 10 s, and a myocardial perfusion defect was detected in 68 territories (97%) related to flow limiting lesions. It was observed only 4 false results. There were no serious complications. CONCLUSION: Myocardial perfusion study with PESDA and adenosine protocol is a practical, safe and accurate method to analyze the coronary flow reserve.

Study of coronary flow reserve with intravenous use of microbubbles (contrast echocardiography) and adenosine: protocol for clinical application in patients suspected of having coronary heart disease / Estudo da reserva de fluxo coronariano com uso endovenoso de microbolhas (ecocardiografia com contraste) e adenosina. Apresentação de protocolo para aplicação clínica em pacientes com suspeita de doença arterial coronariana

OBJECTIVE: To test the feasibility, safety and accuracy of the adenosine protocol in the study of myocardial perfusion with microbubbles contrast echocardiography. METHODS: 81 pts (64 male, 60+11 years) were submitted to contrast echocardiography with PESDA (sonicated solution of albumin 20 percent-1ml, dextrose 5 percent-12ml and deca-fluorobutane gas-8ml) to study the myocardial perfusion at rest and after bolus injection of adenosine (6 to 18mg) and to coronary angiography within 1 month each other. For each patient 3 left ventricle perfusion beds were considered (total of 243 territories). 208 territories were analyzed and 35 territories were excluded. PESDA was continuously infused (1-2ml/min), titrated for best myocardial contrast. Triggered (1:1) second harmonic imaging was used. RESULTS: Coronary angiography showed 70 flow limiting (> 75 percent) lesions and 138 no flow limiting lesions. At rest an obvious myocardium contrast enhancement was seen in at least 1 segment of a territory in all patients. After adenosine injection an unquestionable further increase in myocardial contrast was observed in 136 territories (99 percent) related to no flow limiting lesions, lasting < 10 s, and a myocardial perfusion defect was detected in 68 territories (97 percent) related to flow limiting lesions. It was observed only 4 false results. There were no serious complications. CONCLUSION: Myocardial perfusion study with PESDA and adenosine protocol is a practical, safe and accurate method to analyze the coronary flow reserve

Correlação clinicopatológica de 50 casos de síndrome de imunodeficiência adquirida: estudo retrospectivo / Clinicopathologic Correlation in 50 Cases of Acquired Immunodeficiency Syndrome. Retrospective Study

PURPOSE--To analyze myocardial abnormalities in patients of acquired immunodeficiency syndrome with clinical and pathological correlation. METHODS--We selected 50 cases, retrospectively, age ranged from 3 months to 40 years, all of them had myocardial changes and the data of clinical records fulfilled our protocol. Cases of others cardiac diseases were not included. RESULTS--The pathological findings were: myocarditis in 33 (11 had severe myocarditis) and degenerative hystological lesions in 17. The etiologic agents detected were: Toxoplasma in 11, Cryptococcus in 7 and Cytomegalovirus in 3. In 12 cases we could not find any agent. In 15 cases occurred others lesions: endocarditis, pericarditis and sarcoma of Kaposi. It was noted tachycardia in 15 cases, decrease of heart sounds in 12, arterial hypotension in seven, systolic murmur in 8, galop rhythm in 7, pericardial friction rub in 3, arrhythmia in 2. Four patients had congestive heart failure. The EKG showed sinus tachycardia in 18, ST and T changes in 10, low voltage in 5, ST segment elevation in 5 and extrasystoles in 3 cases. The echocardiogram findings were: pericardial effusion in 9 cases and 9 had ventricular dysfunction. CONCLUSION--The cardiac lesions were very important even in patients without clinical signals. We need others prospective studies with viral identification trying to detect specific lesions of HIV

Objetivo - Analisar as alterações miocárdicas na síndrome da imunodeficiência adquirida e correlacionar os achados clínicopatológicos. Métodos - Foram selecionados, retrospectivamente, 50 pacientes entre 4 meses e 40 anos de idade, que apresentavam lesões miocárdicas à histologia e cujos prontuários continham os dados do protocolo. Foram in cluídos aqueles com lesões cardíacas de outra etiologia. Resultados - Os achados anatomopatológicos foram miocardite em 33 (66%) casos, sendo grave em 11 e lesões degenerativas em 17. Os agentes etiológicos foram Toxoplasma em 11, Criptococcus em 7, Citomegalovírus em 3 e inespecífica em 12. Em 15 casos havia também outras lesões como endocardite, pericardite e sarcoma de Kaposi. Quanto aos achados clínicos observamos taquicardia em 15 casos, hipofonese de bulhas em 12, hipotensão arterial em 7, sopro sistólico em 8, ritmo de galope em 7, atrito pericárdico em 3 e arritmia cardíaca em 2. Quatro pacientes tiveram sinais de insuficiência cardíaca congestiva. O ECG mostrou taquicardia sinusal em 18, distúrbio de repolarização em 10, baixa voltagem em 5, supradesnivelamento de ST em 5 e extra-sistolia em 3. Ao ecocardiograma 9 apresentaram derrame pericárdico e 9 diminuição de contratilidade ou da função ventricular. Conclusão - As lesões cardíacas foram expressivas mesmo em pacientes sem sinais clínicos para tal. São necessários mais estudos com métodos de identificação viral para tentar detectar as lesões miocárdicas pelo HIV.

Insuficiência tricúspide severa por infarto do músculo papilar anterior do ventrículo direito secundário à hipóxia neonatal / Critical tricuspid insufficiency due to papillary muscle infarction of the right ventricle in a distressed newborn infant

Os autores relatam um caso fatal de insuficiência tricúspide severa observada no período neonatal, devida a infarto do músculo papilar anterior do ventrículo direito (VD), secundário à hipóxia. Logo após o nascimento o bebê necessitou de manobras de ressuscitaçäo e, ao exame do precórdio, havia sopro sistólico. O exame ecocardiográfico evidenciou falta de coaptaçäo do folheto anterior da válvula. O exame macroscópico do coraçäo revelou ruptura da corda tendínea entre os folhetos anterior e posterior e a microscopia mostrou, nesta área, necrose e depósito de cálcio. A anóxia no período perinatal, na maioria dos casos, leva a alteraçöes cardíacas transitórias, mas em alguns, pode ser fatal e, por isso, é importante a avaliaçäo cardiológica em todos os recém-nascidos com sofrimento prolongado

A fatal case of a stressed newborn baby who developed tricuspid insufficiency due to an anterior papillary muscle infarction of the right-ventricle, related to perinatal anoxia is reported. The baby needed resuscitation management and had a systolic murmur soon after birth. The echocardiographic examination showed aflail anterior leaflet of the tricuspid valve due to an avulsed anterior papillary muscle. There was rupture of chordae tendineae between anterior and posterior leaflet. Necrosis and calcinum deposit were found in the area. The conclusion was that the anoxia in perinatal period, in most cases, causes transient lesions, but infew cases might be severe and fatal. It is important a complete cardiac evaluation in every case of prolonged perinatal stress