Eulógio Emílio Martinez Filho

Screening for significant coronary artery disease in high-risk renal transplant candidates.

BackgroundRenal transplant candidates are at an increased risk for coronary artery disease (CAD), a strong predictor of cardiovascular events [major adverse coronary events (MACE)]. Coronary angiography is a costly, risky, invasive procedure. We sought to determine clinical predictors of significant CAD (stenosis ≥70%) in high-risk renal transplant candidates. MethodsClinical evaluation and coronary angiography were performed in 301 patients (57±8 years, 73% men) on hemodialysis for 32 months (median). Patients were followed-up for 22 months (median). Inclusion criteria were diabetes (type 1 or 2), evidence of cardiovascular disease, or age ≥50 years. Risk factors included hypertension (93.7%), overweight/obesity (54.3%), dyslipidemia (44.9%), diabetes (42.1%), and smoking (24.3%). Cardiovascular disease was found as follows: peripheral arterial disease (PAD) (31.2%), angina (28.1%), stroke (12.9%), myocardial infarction (MI) (10.3%), and heart failure (9.3%). ResultsSignificant CAD was found in 136 individuals (45.2%). Diabetes [odds ratio (OR)=1.82; 95% confidence interval (CI)=1.08–3.07], PAD (OR=2.50; 95% CI=1.44–4.37), and previous MI (OR=7.75; 95% CI=3.03–23.98) were associated with significant CAD. The prevalence of significant CAD increased with the number of clinical predictors from 26% (none) to 100% (all present) (P<0.0001). The incidence of fatal/nonfatal MACE increased two, four, and sixfold in those with diabetes, PAD, or previous MI, respectively (P<0.0001). ConclusionsIn high-risk patients with end-stage renal disease, the prevalence of CAD and the incidence of MACE were high. Significant CAD or cardiovascular complications were not related to the majority of classic risk factors. Patients with diabetes, PAD, or previous MI are at higher risk of CAD, MACE, or both and, thus, must be referred for invasive diagnostic procedures.

Dietary magnesium improves endothelial dependent relaxation of balloon injured arteries in rats

The purpose of the present study was to examine the importance of magnesium in endothelial function after arterial balloon injury. Male Wistar rats were fed normal, high or low concentrations of magnesium. Three weeks later the animals underwent endothelial injury of the thoracic aorta by a balloon catheter or a sham operation. Biochemical, histological and endothelial function analysis were performed 15 days after the surgical treatment. The animals fed a low magnesium diet presented the lowest level of serum magnesium and the highest ionized blood calcium levels. Histomorphometric analysis revealed no differences among groups neither regarding the magnitude of intimal thickening nor the recovery of endothelial coverage. However, when vasoreactivity responses were compared in the balloon-injured group, those animals fed a high magnesium diet had the better endothelium-dependent vascular relaxation. In conclusion, a higher magnesium level in the diet was beneficial to vessels that underwent endothelial injury by balloon catheter.

Estudo comparativo entre os efeitos terapêuticos da revascularizacão cirúrgica do miocárdio e angioplastia coronária em situacões isquêmicas equivalentes: análise através da cintilografia do miocárdio com 99mTc-Sestamibi

OBJECTIVE To assess the myocardial ischemic load to previous and after myocardial revascularization. METHODS Ninety-six randomized patients, carriers of multivessel coronary artery disease, stable angina, preserved left ventricular function, and exercise-induced myocardial ischemia treated with revascularization (SMR) or coronary angioplasty (TCA). Myocardial scintigraphy with 99mTc-Sestamibi was performed prior to and 6 months after myocardial revascularization. RESULTS The SMR determined a significant greater index of complete revascularization (p=0.001), an increase in the number of maximum ergometric tests (p=0.001) and reduction in the number of positive ergometric tests with exercise angina (p=0.018). Both procedures provided an important improvement in the functional class of angina (p=0.001), an increase in the average value of double peak product (p=0.009), and the time of exercise tolerance (p<0.001), besides the reduction in the average value of the summed of exercise score (p<0.001) and the difference of the summed of scores (p<0.001) in both groups. CONCLUSION TCA and SMR did not differ significantly concerning the reduction of myocardial ischemic load 6 months after the procedure. The myocardial revascularization was more complete with the SMR than the TCA, but it did not represent a significant factor for the reduction myocardial ischemic load.

Angiographic geometric predictors of myocardial infarction are not associated with ultrasonographic markers of plaque vulnerability

OBJECTIVE Some angiographic geometric features of coronary lesions have recently been described as independent predictors of myocardial infarction. The purpose of this study was to correlate these geometric markers with intravascular ultrasound findings known to be associated with greater vulnerability to plaque rupture. METHODS A total of 30 patients with stable coronary syndromes and de novo lesions (31 lesions) underwent coronary angiography and intravascular ultrasound (IVUS). For each lesion, angiographic geometric features (degree of symmetry, degree of stenosis, lesion length, and outflow angle) were correlated with the following ultrasound variables: type of plaque (soft, fibrous, mixed, or calcified), plaque burden and remodeling index. RESULTS Mean lesion length was 9.2 +/- 4.4 mm, percent stenosis was 50.0% to 89.0% (mean 67.7 +/- 12.1%), inflow angles ranged from 8.48 degrees to 48.78 degrees (mean 24.0 +/- 11.4 degrees), outflow angles ranged from 8.30 degrees to 53.03 degrees (mean 23.8 +/- 11.7 degrees), and the symmetry index ranged from 0 to 1 (mean 0.56 +/- 0.32). On ultrasound evaluation, frequency of soft or calcified plaques, positive remodeling, and magnitude of plaque burden were not associated with any angiographic geometric feature (p > 0.05 for all analysis). CONCLUSION Angiographic geometric features that predispose to acute occlusion do not correlate with IVUS morphologic and quantitative findings associated with plaque vulnerability.

Fatal myocardial infarction in a 88-year-old woman

Editor da Secao: Alfredo Jose Mansur (ajmansur@incor.usp.br) Editores Associados: Desiderio Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Correspondencia: Paulo Sampaio Gutierrez InCor Av. Dr. Eneas de Carvalho Aguiar, 44 05403-000 Sao Paulo, SP E-mail: anppaulo@incor.usp.br Mulher de 88 anos de idade procurou atendimento medico (29/12/2003) com queixa de dor epigastrica de 4 horas de duracao acompanhada de vomitos. A paciente sabia ser portadora de hipertensao arterial de longa data. Ha dois anos havia sofrido acidente vascular cerebral, sem sequelas motoras. Ha tres meses surgiu dispneia desencadeada por esforcos moderados e edema de membros inferiores. Negava sincope. O exame fisico (3/10/2003) revelou frequencia cardiaca 68 bpm, pressao arterial 180x80 mmHg. O exame dos pulmoes foi normal. O exame do coracao revelou bulhas normofoneticas e sopro sistolico leve em area mitral. O exame do abdome foi normal e havia edema ++/4 em membros inferiores. A paciente fazia uso de losartan 50 mg, hidroclorotiazida 50 mg e acido acetilsalicilico 100 mg diarios. O eletrocardiograma (30/09/2003) revelou dissociacao atrioventricular com ritmo juncional, frequencia de 50 bpm, duracao de QRS de 80 mseg, com baixa voltagem no plano frontal (fig. 1). Os exames laboratoriais revelaram hemoglobina 15 g/dl, hematocrito 45%, potassio de 5,8 mEq/l (sangue hemolisado) e sodio 138 mEq/l. Foi feito o diagnostico de doenca do no sinusal e prosseguiu a avaliacao laboratorial, incluindo monitorizacao eletrocardiografica ambulatorial. A monitoracao eletrocardiografica ambulatorial de 24 horas de duracao pelo sistema Holter (18/11/2003) revelou ritmo predominante sinusal, tres extra-sistoles ventriculares em taquicardia ventricular e uma extra-sistole ventricular isolada. Havia frequentes extra-sistoles atriais (645/h), das quais 570 isoladas, 36 pareadas e um episodio de taquicardia atrial com tres batimentos. Foram diagnosticadas varias pausas sinusais de 4,3 seg em vigilia, entre 20 e 21 horas (figs. 2 e 3). Na evolucao apresentou (29/12/2003) dor epigastrica de 4 horas de duracao acompanhada de vomitos. O exame fisico (19/12/2003) revelou frequencia cardiaca 80 bpm, pressao arterial 180x100 mmHg, estertores crepitantes em bases de ambos hemitorax. O restante do exame fisico nao revelou dados positivos. O eletrocardiograma (29/12/2003) demonstrou ritmo sinusal, frequencia de 72 bpm; area eletricamente negativa ântero-septal e supradesnivelamento de segmento ST de V1 a V3 e infradesnivelado em derivacoes II, III, aVF, V5 e V6. As alteracoes persistiram apos o uso de 5 mg de dinitrato de isossorbida administrado por via sublingual (fig. 4). Os exames laboratoriais revelaram 1 mg/dl de creatinina, 43 mg/dl de ureia, 139 mEq/l de sodio, 5,8 mEq/l de potassio, 49,4 ng/ml de CKMB e 7,8 ng/ml de troponina. Foi feito o diagnostico de infarto do miocardio e foram administrados 200 mg de acido acetilsalicilico por via oral e nitroglicerina por via endovenosa. Houve controle da pressao arterial e a paciente foi encaminhada para a cinecoronariografia para reperfusao coronaria mecânica por angioplastia. A cineangiografia, realizada 60 minutos apos a chegada da paciente ao hospital, nao revelou obstrucoes em coronarias, apesar da presenca de area discinetica em paredes ântero-lateral e apical de ventriculo esquerdo. Apresentou parada cardiorrespiratoria em assistolia, sem resposta as manobras de ressuscitacao e faleceu (30/12/2003).