Francisco Manes Albanesi Fº

Cardiac tamponade in systemic lupus erythematosus. Report of four cases

OBJECTIVE To report and assess the incidence of cardiac tamponade in systemic lupus erythematosus as a cardiac manifestation of the disease. METHODS We reviewed the medical records of 325 patients diagnosed with systemic lupus erythematosus according to the American Rheumatism Association and their complementary laboratory tests compatible with cardiac tamponade. RESULTS In the 325 medical records reviewed, we found 108 patients with pericardial effusions corresponding to 33.2% of the total and 54% of the patients studied in the active phase of the disease. Clinical assessment and transthoracic echocardiogram allowed the clinical diagnosis of cardiac tamponade in only 4 (1.23%) patients, 3 of whom were females, white, with ages ranging from 25 to 44 years. The pericardial fluid was hemorrhagic or serosanguineous with high levels of FAN and positivity for LE cells. In the treatment, we successfully used pericardiocentesis associated with high doses of corticosteroids. In clinical and laboratory follow-up performed for a period of 3 years, neither recrudescence of the pericardial effusion nor evolution to constriction occurred. CONCLUSION Even though rare (1.23%), cardiac tamponade in patients with systemic lupus erythematosus has a benign evolution when properly treated, according to our experience.

O eletrocardiograma de alta resoluçäo no domínio da frequencia. Utilizaçäo de técnicas estatísticas de correlaçäo espectral para identificaçäo de pacientes com taquicardia ventricular monomórfica sustentada

PURPOSE: To evaluate the diagnostic accuracy of monomorphic ventricular tachycardia (MVT), in patients with structural heart diseases and episodes of sustained MVT, using the signal-averaged ECG (SAECG) in the time (TD) and the frequency domain (FD) with statistical techniques of spectral correlation. METHODS: Twenty seven patients with at least one episode of sustained MVT, 30 patients with structural heart diseases and no evidence of ventricular arrhythmias and 80 subjects with no evidence of heart disease have been studied. SAECG was performed in all patients with the following parameters: duration of the filtered QRS, RMS 40 and LAS40 in TD and the mean and the standard deviation of both signal energy intersegmentar spectral correlation and energy frequency edge track in FD. RESULTS: The sensitivity(S) and positive predict value (PPV) of the SAECG in TD, in FD and combined analysis of both domains were: S = 59.3%, 63.0%, 81.5% and PPV = 80.0%, 81.0%, 84.6%, respectively. CONCLUSION: The combined analysis of SAECG in TD and in FD improves the diagnostic accuracy in patients with S sustained MVT.PURPOSE To evaluate the diagnostic accuracy of monomorphic ventricular tachycardia (MVT), in patients with structural heart diseases and episodes of sustained MVT, using the signal-averaged ECG (SAECG) in the time (TD) and the frequency domain (FD) with statistical techniques of spectral correlation. METHODS Twenty seven patients with at least one episode of sustained MVT, 30 patients with structural heart diseases and no evidence of ventricular arrhythmias and 80 subjects with no evidence of heart disease have been studied. SAECG was performed in all patients with the following parameters: duration of the filtered QRS, RMS 40 and LAS40 in TD and the mean and the standard deviation of both signal energy intersegmentar spectral correlation and energy frequency edge track in FD. RESULTS The sensitivity(S) and positive predict value (PPV) of the SAECG in TD, in FD and combined analysis of both domains were: S = 59.3%, 63.0%, 81.5% and PPV = 80.0%, 81.0%, 84.6%, respectively. CONCLUSION The combined analysis of SAECG in TD and in FD improves the diagnostic accuracy in patients with S sustained MVT.

Endocardite infecciosa em adolescentes. Análise dos fatores de risco de mortalidade intra-hospitalar

PURPOSE To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old (mean 15.5). METHODS Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied. RESULTS Infective endocarditis mortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p = 0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm3 and functional class, both at admission (p = 0.01 and p = 0.004, respectively), and the occurrence of embolic complications (p = 0.03) as independent predictors of in-hospital mortality. CONCLUSION Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S. aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.

Ambulatory blood pressure monitoring and microalbuminuria in normotensive subjects with insulin-dependent diabetes mellitus

OBJECTIVE To assess the association between microalbuminuria with ambulatory blood pressure monitoring in normotensive individuals with insulin-dependent diabetes mellitus. METHODS Thirty-seven patients underwent determination of the rate of urinary excretion of albumin through radioimmunoassay and ambulatory blood pressure monitoring. Their mean age was 26.5+/-6.7 years, and the mean duration of their disease was 8 (1-34) years. Microalbuminuria was defined as urinary excretion of albumin > or =20 and <200 microg/min in at least 2 out of 3 urine samples. RESULTS Nine (24.3%) patients were microalbuminuric. Ambulatory blood pressure monitoring in the microalbuminuric patients had higher mean pressure values, mainly the systolic pressure, during sleep as compared with that in the normoalbuminuric patients (120.1+/-8.3 vs 110.8+/-7.1 mmHg; p=0.007). The pressure load was higher in the microalbuminuric individuals, mainly the systolic pressure load during wakefulness [6.3 (2.9-45.9) vs. 1.6 (0-16%); p=0.001]. This was the variable that better correlated with the urinary excretion of albumin (r(S)=0.61; p<0.001). Systolic pressure load >50% and diastolic pressure load > 30% during sleep was associated with microalbuminuria (p=0.008). The pressure drop during sleep did not differ between the groups. CONCLUSION Microalbuminuric normotensive insulin-dependent diabetic patients show greater mean pressure value and pressure load during ambulatory blood pressure monitoring, and these variables correlate with urinary excretion of albumin.

Natural course of subsequent pregnancy after peripartum cardiomyopathy

OBJECTIVE: To assess the effect of subsequent pregnancy after peripartum cardiomyopathy (PPCM) on maternal and fetal outcome. METHODS: Prospective study of 34 patients with the diagnosis of PPCM (mean age= 26years). At the time of first diagnosis 5 were in NYHA functional class (FC) II for heart failure, one in FC III and 28 in FC IV. After clinical treatment, patients were advised to avoid new pregnancies and a follow-up was obtained. RESULTS: There were 12 (35.3%) subsequent pregnancies in patients (pt) aged 19 to 44 years (mean 32), divided into two groups: GI: 6 pts who had normalized their heart size and GII: 6 pts with persistent cardiomegaly. GI had initially mild clinical manifestations ( 3 were in FC II, 1 in FC II and 2 in FC IV) and complete recovery of cardiac function (FC I). A new pregnancy was well-tolerated in 5 (83.3%); 1 pt presented with preeclampsia, and progressed to FC II. Presently, 5 pt are in FC I and 1 in FC II. GII pts had more severe heart failure at the onset of PPCM (1 pt in FC II and 5 in FC IV); during follow-up, 4 pt were in FC I and 2 in FC II. A new pregnancy was well tolerated in all of them, but the eldest, who had had 2 pregnancies and had a progressive worsening of clinical status, dying 8 years after the last pregnancy and 13 years after the diagnosis of PPCM. The remaining 5 pt are still alive, 3 in FC I and 2 in FC II, with worsening of FC in 1. Subsequent pregnancies occurred 3-7 years after clinical treatment of PPCM and no fetal distress was observed. CONCLUSION: Subsequent pregnancies are well-tolerated after PPCM, but not devoid of risk. No fetal distress was observed. A minimum interval of 3 years after the recovery of function seems to be safe for subsequent pregnancies.

Meningococcemia complicada por miocardite

We report a case of a 26-year old man with meningococcemia complicated with myocarditis (ventricular dysfunction and myocardial ischemia), that required treatment for heart failure. Regression of myocardial dysfunction was observed six months after the infection.

É a cardiomiopatia hipertrófica apical vista em uma amostra na cidade do Rio de Janeiro similar à encontrada no oriente

PURPOSE: To investigate the differences between clinical aspects and evolution of apical hypertrophic cardiomyopathy (AHCM) seen in Rio de Janeiro and the Oriental form, which was the first described. METHODS: In 156 patients with AHCM diagnosed in our institution, there were 13 (8.34%) with the apical form of the disease, whose clinical settings, diagnostic procedures and evolution were studied. RESULTS: There were 8 males and 5 females, between 19 and 75 years old, all white. Electrocardiogram (EKG) showed giant T waves in precordial leads in 10 (76.92%), echocardiogram (ECHO) demonstrated apical hypertrophy in all, 10 (76.92%) had only in the left ventricle, 2 in right ventricle and one involving both. Cineangiography corroborated ECHO findings. Follow-up ranged from 6 to 294 months (x= 95.4). Two deaths occurred in patients with RV involvement, due to large atria, atrial fibrillation, tricuspid or mitral insufficiency and thromboembolism. Among the survivors, the patient with RV disease has diastolic restriction and the ones with LV involvement, 9 are asymptomatic using either propranolol (8) or amiodarone (1), and one uses no medication. CONCLUSION: A HCM seen in Rio de Janeiro is similar to that found in the Orient (Japan) regarding presentation, diagnosis and evolution; but in 3 patients we have found RV disease, not described in Japan, characterizing a distinct group with a worse evolution.

O significado da abstinência do álcool na cardiomiopatia alcoólica com disfunção ventricular moderada

OBJETIVO: Avaliar o papel da abstencao alcoolica, no periodo de 12 meses, na cardiomiopatia alcoolica (CMA) com disfuncao ventricular de grau moderado, em pacientes tratados com esquema anticongestivo. METODOS: Estudo observacional prospectivo com 20 pacientes com CMA, 9 (45%) na classe funcional (CF) II e 11(55%) na CF III, 16 (80%) homens, predominio de negros (55%), de 35 a 56 (x=45) anos, com consumo pesado de alcool (>80g etanol/dia), por periodo de 51 a 112 (x=85) meses, que concordaram, inicialmente, em participar de programa de apoio, com psicoterapia de grupo, alem do acompanhamento clinico com realizacao de exames nao invasivos, antes do inicio do programa e apos 12 meses da terapia, e foram divididos em dois grupos, o 1 (G-I) constituido pelos que atingiram a abstinencia e o 2 (G-II) pelos nao abstemios. RESULTADOS: Apos 12 meses, 11 (55%) pacientes permaneciam em terapia de apoio, 8 (72,72%) no G-I, enquanto os 9 (45%) que nao se mantiveram no programa, apenas 2 (22,22%) tinham logrado abstinencia (G-I). Ao fim da avaliacao, alcancamos numero igual de pacientes entre os grupos. Comparando os grupos observamos: a) menores valores medios dos diâmetros sistolico (DSVE) e diastolico (DDVE) do ventriculo esquerdo no G-I; b) maior numero de internacoes no G-II (3) em relacao ao G-I (1); c) na evolucao clinica, maior numero de pacientes do G-I, entre os que apresentaram melhoras (3 G-I e 1 G-II) e que permaneceram inalterados (6 G-I e 3 G-II), alem do maior numero de pioras entre o G-II (1 G-I e 5 G-II). CONCLUSAO: Apesar do desejo inicial favoravel, a abstinencia so foi obtida em 50% dos pacientes com CMA e disfuncao ventricular moderada, porem, quando alcancada, apresentou melhor evolucao (melhoras + inalterados = 90%), com maior reducao do DSVE e do DDVE (p<0,001), devendo sempre ser perseguida mesmo na presenca de moderada disfuncao ventricular.

Cardiomiopatia hipertrófica apical associada a doença arterial coronária

A fifty-nine year old man, known to have hypertrophic cardiomyopathy, presented worsening of angina. Multivessel coronary artery disease was diagnosed, and he underwent myocardial revascularization (mammary and two safenous grafts were implanted) with good evolution and reduction of left atrium dimension.