Antonio Carlos Carvalho

Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction

BACKGROUND It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI). METHODS Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days. RESULTS The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups. CONCLUSIONS Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).

Self-expandable aortic stent-grafts for treatment of descending aortic dissections

BACKGROUND Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality. METHODS Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension. RESULTS The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive. CONCLUSIONS Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.

Qualidade de vida de pacientes hipertensos em tratamento ambulatorial

BACKGROUND: The main cause of mortality in braziliam population is the cardiovascular disease and arterial hypertension (AH) the most prevalent one. The antihypertensive treatment is effective however it is not well known how affects the quality of life (QOL) in patients afterwards. OBJECTIVE: To comparatively assess the QOL in patients submitted to an antihypertensive treatment. METHODS: One-hundred patients with AH were studied of which 46 had complied with a standard treatment regimen (group A) and 54 (group B control) were about to start the same regimen. We collected clinical and sociodemographic data and questions focusing sexuality, self-perception of QOL, number and types of medication taken and their influence on sex life. The questionnaire SF-36 was also administered. The data were analyzed using the tests chi-square, Students t, Pearson correlation and Tukey. RESULTS: No differences were detected between group A and B in any of the SF-36 domains. There was an association between the question on self-perception of QOL and the SF-36 domains, emotional aspects excepted. As regards sexuality, there was difference in the quality of sex life between the groups, which was less satisfactory for group A. CONCLUSION: When the SF-36 was administered no changes in QOL were detected between the groups because it is an asymptomatic chronic disease. The SF-36 did not properly assess emotional aspects in our case series of hypertensive patients that had high behavior variability. Group A showed lower quality sex life; however, this was not related to the number and type of medication used.

Importance of intraoperative transesophageal echocardiography during coronary artery surgery without cardiopulmonary bypass

The goal of this study was to assess left ventricular segmental wall motion (SWM) abnormalities during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), and its impact on the immediate postoperative outcome. Transesophageal echocardiography was used intraoperatively in 27 patients (mean age 57 years) who had CABG without CPB. Images obtained with a 5-MHz biplane transesophageal echocardiographic probe in the transgastric and transesophageal planes were recorded before, during, and after 48 coronary artery clampings for saphenous vein or internal mammary artery anastomosis. Transthoracic echocardiography was performed 1 day before surgery and on the seventh postoperative day. During the 48 coronary artery clampings, 31 (64%) new SWM abnormalities were found. At the time of chest closure, complete recovery occurred in 16 (50%) segments, partial recovery in 10 (33%), and no recovery in 5 (17%). On the seventh postoperative day the new SWM abnormalities persisted in all 5 segments without recovery at the end of the surgery and in 2 of 10 (20%)segments with partial recovery (group 1). Group 1 had higher variation on the echocardiographic point score index between the beginning and end of surgery, higher enzymatic levels, more ST-T changes on the electrocardiogram, and more clinical problems than group 2 (patients without new SWM abnormalities on the seventh postoperative day) (P < .05). We concluded that new SWM abnormalities of the left ventricle occur during CABG without CPB as assessed by intraoperative transesophageal echocardiography. Persistence of these abnormalities at the end of surgery may be a predictor of SWM dysfunction and clinical problems in the immediate postoperative period.

Incremental shuttle and six-minute walking tests in the assessment of functional capacity in chronic heart failure

BACKGROUND The incremental shuttle test presents some theoretical advantages over the six-minute walk test in chronic heart failure (CHF), including better standardization and less dependency on collaboration. OBJECTIVES The present study evaluated test-retest repeatability, test accuracy in predicting a peak oxygen consumption (VO(2)) of 14 mL/kg/min or less, as well as the prognostic value of both walking tests in stable CHF patients. METHODS Sixty-three patients (44 men; New York Heart Association functional class II to IV) underwent an incremental treadmill exercise test and, on another day, the walk test in duplicate. RESULTS Patients showed well-preserved functional capacity according to the distance walked in both tests (six-minute walk test 491+/-94 m versus incremental shuttle walk test 422+/-119 m; P<0.001). Interestingly, the six-minute and incremental shuttle walk test differences in distance walked were higher in more disabled patients. The mean bias +/-95% CI of the within-test differences were similar (7+/-40 m and 8+/-45 m, respectively). Peak VO(2), but not distance walked in either test, was associated with survival (P<0.05). CONCLUSIONS The incremental shuttle walk test showed similar repeatability and accuracy in estimating peak VO(2) compared with the six-minute walk test in CHF patients. Direct measurement of peak VO(2), however, remains superior to either walking test in predicting survival--at least in patients with well-preserved functional capacity.

Efeitos do local de inserção do dreno pleural na função pulmonar no pós-operatório de cirurgia de revascularização do miocárdio

OBJECTIVE: To analyze the pulmonary function changes and pain in patients undergoing off-pump coronary artery bypass grafting utilizing a left internal thoracic artery graft, comparing the pleural drain insertion through the intercostal space and subxyphoid approach. METHODS: Twenty eight patients (mean age 57.4 ± 8.4 years) were divided into two groups, according to the pleural drain site. Group IL (n=15) had the pleural drain inserted through the sixth left intercostal space at the mid-axillary line and in the IM group (n=13) the drain was placed through the subxyphoid region. All the patients underwent pre- and post-operative evaluation of pulmonary function tests as well as arterial blood gas analysis. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were recorded in the preoperative period, and in the first, third and fifth postoperative days. The pain sensation was evaluated using a standard score from 0 to 10. RESULTS: In both groups falls in FVC and FEV1 were noted, up to the fifth postoperative day (P<0.001). However, the decrease was higher in the IL group, when compared to the IM group (p<0.05). Also arterial blood gas analysis showed a decline of the partial oxygen pressure in both groups on the fist postoperative day, but more significantly in the IL group (p=0.021). The pain sensation was higher in the IL group (p=0.002). CONCLUSION: Off-pump coronary artery bypass grafting with using of left internal thoracic artery, disregarding the pleural drain site, leads to a significant decrease of postoperative pulmonary function. However, the subxyphoid technique of drain insertion has shown a better preservation of the lung function when compared to the intercostal drain site.

Performance of two-dimensional Doppler echocardiography for the assessment of infarct size and left ventricular function in rats

Although echocardiography has been used in rats, few studies have determined its efficacy for estimating myocardial infarct size. Our objective was to estimate the myocardial infarct size, and to evaluate anatomic and functional variables of the left ventricle. Myocardial infarction was produced in 43 female Wistar rats by ligature of the left coronary artery. Echocardiography was performed 5 weeks later to measure left ventricular diameter and transverse area (mean of 3 transverse planes), infarct size (percentage of the arc with infarct on 3 transverse planes), systolic function by the change in fractional area, and diastolic function by mitral inflow parameters. The histologic measurement of myocardial infarction size was similar to the echocardiographic method. Myocardial infarct size ranged from 4.8 to 66.6% when determined by histology and from 5 to 69.8% when determined by echocardiography, with good correlation (r = 0.88; P < 0.05; Pearson correlation coefficient). Left ventricular diameter and mean diastolic transverse area correlated with myocardial infarct size by histology (r = 0.57 and r = 0.78; P < 0.0005). The fractional area change ranged from 28.5 +/- 5.6 (large-size myocardial infarction) to 53.1 +/- 1.5% (control) and correlated with myocardial infarct size by echocardiography (r = -0.87; P < 0.00001) and histology (r = -0.78; P < 00001). The E/A wave ratio of mitral inflow velocity for animals with large-size myocardial infarction (5.6 +/- 2.7) was significantly higher than for all others (control: 1.9 +/- 0.1; small-size myocardial infarction: 1.9 +/- 0.4; moderate-size myocardial infarction: 2.8 +/- 2.3). There was good agreement between echocardiographic and histologic estimates of myocardial infarct size in rats.

Prevalência e variáveis associadas ao hábito de fumar em crianças e adolescentes

OBJETIVO: Identificar a prevalencia do habito de fumar e a ocorrencia de variaveis associadas ao habito em criancas e adolescentes de 7 a 17 anos, de ambos os sexos e provenientes da cidade de Maceio. METODOS: Estudo epidemiologico transversal, baseado na populacao de alunos da rede de ensino publico e privada, niveis fundamental e medio. Calculo da amostra baseado na menor prevalencia esperada de inumeras variaveis, incluindo tabagismo. Amostragem por conglomerados. Questionario sobre o habito de fumar; entrevista individual com cada estudante. Considerado fumante atual aquele que admitiu ter fumado em 1 ou mais dias nos ultimos 30 dias. Variaveis analisadas: relacionadas ao estudante (idade, sexo, experimentacao previa de cigarros e trabalho remunerado), a sua condicao na escola (publica/privada, turno, nivel e repetencia) e a familia (classificacao economica, pais fumantes e pais separados). RESULTADOS: Foram avaliados 1.253 estudantes (547 do sexo masculino, media de idade 12,4±2,9 anos). Identificou-se uma prevalencia de tabagismo de 2,4%. A analise estatistica multivariada demonstrou associacao significante do habito de fumar com: maior idade (odds ratio de 1,31); experimentacao previa de cigarros (odds ratio de 33,96); estudar no periodo noturno (odds ratio de 5,43). Observou-se que 286 estudantes (22,8%) admitiram haver experimentado cigarros (9% de 7 a 9 anos; 21% de 10 a 14 anos; 36% de 15 a 17 anos). CONCLUSOES: A prevalencia de tabagismo em criancas e adolescentes da rede de ensino da cidade de Maceio e de 2,4%, sendo mais frequente em estudantes de 15 a 17 anos, do curso noturno. Estudantes que experimentaram cigarros apresentam 34 vezes mais chances de se tornarem fumantes.

Monitoring of intragraft and peripheral blood TIRC7 expression as a diagnostic tool for acute cardiac rejection in humans

T-cell immune response cDNA 7 (TIRC7) is a recently described T-cell costimulatory molecule that exhibits a central role in T-cell activation in vitro and in vivo. The present study was undertaken to investigate association between intragraft and peripheral blood mononuclear cell (PBMC) TIRC7 mRNA levels and cardiac allograft rejection in humans. TIRC7 gene expression levels were determined by a quantitative-competitive reverse transcriptase-polymerase chain reaction (QC-RT-PCR) in endomyocardial biopsies and in PBMC from cardiac transplant recipients. Biopsies collected during rejection or up to 15 days before rejection showed heightened TIRC7 mRNA expression in comparison with biopsies without rejection. All prerejection and rejection biopsies showed TIRC7 mRNA upregulation, while this was present in only 30% of the biopsies without rejection. Regarding TIRC7 mRNA in PBMC, transplant recipients showed lower levels than healthy individuals and, in contrast to the results obtained in biopsies, the levels were lower during rejection than in rejection-free periods. In summary, TIRC7 mRNA expression levels increase in biopsies and decrease in peripheral blood during acute cardiac rejection. We conclude that intragraft detection of TIRC7 transcripts is a useful tool not only for the diagnosis but also for the prediction of acute heart allograft rejection episodes.

Relação da obesidade com a pressão arterial elevada em crianças e adolescentes

FUNDAMENTO: Excessos de peso e de gordura corporal sao atualmente reconhecidos como os maiores determinantes da elevacao da pressao arterial em criancas e adolescentes. OBJETIVO: Identificar associacao e correlacao entre obesidade - identificada por meio da circunferencia da cintura (CC), da prega cutânea do triceps (PCT) e do indice de massa corporal (IMC) - pressao arterial elevada (PAE) em criancas e adolescentes. METODOS: Estudo epidemiologico transversal, de base populacional escolar, em criancas e adolescentes de ambos os sexos, com idades entre 7 e 17 anos, selecionados aleatoriamente. Protocolo: questionario estruturado; medidas de peso, altura, espessura da prega tricipital, circunferencia da cintura, pressao arterial; diagnostico de obesidade por meio de IMC, PCT e CC; diagnostico de PAE. Analise estatistica: qui-quadrado. RESULTADOS: Foram avaliados 1.253 estudantes (547 do sexo masculino, media de idade 12,4 ± 2,9 anos), e identificou-se uma prevalencia de obesidade (IMC, PCT, CC), respectivamente, de 13,7%, 14,8% e 9,3%. A PAE foi identificada em 7,7% dos jovens. Houve associacao significante de obesidade (IMC, PCT, CC) com PAE (*p < 0,0001). Observou-se correlacao forte (*p < 0,01) entre CC e IMC; moderada entre CC e PCT, CC e PAS, IMC e PAS (*p < 0,01); fraca entre PAD e CC, PCT e IMC, e entre PAS e PCT (*p < 0,05). CONCLUSAO: A associacao e correlacao significantes entre PAE e excesso de gordura corporal por qualquer dos metodos utilizados estabelecem a importância de sua utilizacao na avaliacao de criancas e adolescentes, com vistas a prevencao da HAS nessa faixa etaria, sugerindo-se, para isso, a utilizacao do IMC associado a, pelo menos, um outro metodo antropometrico.