[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.

[Postprandial hypotension]. / Hipotensão pós-prandial.

INTRODUCTION: A decrease in blood pressure (BP) 30 to 60 minutes after food ingestion is a physiologic and asymptomatic event, and is about 10 to 16 mm Hg in elderly subjects, but only 3 to 4 mm Hg in youths. PATIENTS AND METHODS: Sixteen women referred to our hospital with complains of lipothymia were studied. They were compared with a control population of 20 healthy subjects. Clinical, laboratory and electrocardiographic (12 leads and 24 hour "Holter" monitoring) evaluation, and 24 hour BP monitoring were performed. In the BP register, the period between the beginning and until 4 hours after the meal was analysed separately. RESULTS: The systolic and diastolic BP between the two populations was not significantly different (120.6 +/- 14.6 mm Hg and 76.5 +/- 8.9 mm Hg in the study group and 126.8 +/- 10.9 mm Hg and 77.8 +/- 7.2 mm Hg in the controls). The average of the mean BP was also not significantly different (78.7 +/- 11.7 mm Hg vs. 86.8 +/- 5 mm Hg, patients and controls). During the 4 hours after the meal there was a significant decrease (p < 0.01) in the average of the mean BP of the patients, which did not occur in the controls (65.4 +/- 7.3 mm Hg vs. 88.5 +/- 2.5 mm Hg, patients and controls). This postprandial decrease in BP correlated with the patients' symptomatology. CONCLUSIONS: Although physiologic in some individuals, the decrease in postprandial BP can be exaggerated and symptomatic. Outpatient BP monitoring can become a useful instrument in the evaluation of syncope/lipothymia.

[Subisthmic aortic coarctation. Apropos a rare case of arterial hypertension]. / Coarctação subístmica da aorta. A propósito de um caso raro de hipertensão arterial.

An uncommon case of high blood pressure secondary to subisthmic aortic coarctation and cured surgically by arterial revascularization is reported. It is probably a congenital coarctation, because the extensive clinical evaluation and condition of the patient ruled out an acquired disease of the aorta, confirmed by the morphologic operative findings and pathological examinations of the aortic wall. In this case, the clinical diagnosis was initially suggested due to an abdominal systolic-diastolic bruit, associated to hypertension and weak femoral pulses. Although doppler ultrasonography and nuclear magnetic resonance were useful diagnostic tools, a complete angiography should be performed because it is currently the most informative technique to evaluate the aorta and its collaterals, frequently involved in association with subisthmic aortic coarctation. Surgical exploration revealed a hypoplastic descending thoracic aorta and histological data confirmed the nonexistence of acquired pathology of the aortic wall. Surgical management was accomplished successfully and the patient was asymptomatic 41 months after the operation with normal blood pressure, no treatment, and a normal pattern of life. Based on this presentation, the authors describe the etiology, morphology and anatomic classification, clinical manifestations, diagnosis and management of subisthmic aortic coarctation.

[Heart failure at an internal medicine department: a retrospective study]. / Insuficiência cardíaca num serviço de medicina interna: estudo retrospectivo.

The files of 222 patients (112 men) admitted to a Medical Department (Medicina 1) of the Hospital de Santa Maria (Lisbon) between 1/1/87 and 21/6/88 with the diagnosis of congestive heart failure (CHF) were studied retrospectively. The next parameters were considered: sex, age, cause of cardiac disease, duration of CHF, presence of diabetes, predispondent factors of CHF episodes, cardiac rhythm and blood pressure on admission, presence of rales, ascitis and edema, echocardiographic findings and evolution. Ischemic heart disease (IHD) (50%) and hypertensive heart disease (HHD) (31%) were the most frequent causes of CHF in this study. The mean age was 70 years, being higher in women (74 versus 66 years). Men were predominant in the younger groups. The rheumatic heart disease (RHD) group had the lowest mean age (54) while the cardiac diseases of unknown origin had the highest mean age (79). Patients with RHD were those with longer CHF (16 years) while patients with IHD, idiopathic cardiomyopathy and cor pulmonale had a shorter duration of CHF (less than 5 years). The respiratory infection was the most frequent predisponent factor (40%). In a high number of cases (31%) it was not possible to find the presumable cause of the CHF episode. Atrial fibrillation was the predominant disarrhythmia (44%) on admission, specially in patients with RHD. Patients with HHD isolated or associated to other causes were those with higher initial blood pressure. Echocardiographic studies were suggestive that HHD can be associated with CHF without a significant increase in left atrium and ventricle dimensions nor impairment of left ventricle systolic function. Echocardiographic analysis of larger numbers of patients and the study of left ventricular diastolic function and Doppler flow patterns will eventually contribute to a better understanding of CHF physiopathology.