Maria Júlia Maciel

Infectious Thoracic Aortitis: A Literature Review

Infectious thoracic aortitis (IA) remains a rare disease, especially after the appearance of antibiotics. However, if left untreated it is always lethal. It usually affects patients with atherosclerotic aortic disease and/or infective endocarditis. Mycotic aneurysm is the most common form of presentation, although a few reports of nonaneurysmal infectious thoracic aortitis have also been described. Various microorganisms have been associated with infectious thoracic aortitis, most commonly Staphylococcal, Enterococcus, Streptococcus, and Salmonella species. It is extremely important to establish an early diagnosis of IA, because this condition is potentially life‐threatening. However, diagnosis is frequently delayed since clinical manifestations are usually nonspecific. Antibiotherapy in combination with complete surgical excision of the infected aorta is the best choice of treatment. Copyright

Iron deficiency status irrespective of anemia: a predictor of unfavorable outcome in chronic heart failure patients.

Objective: To assess the prognostic significance of iron deficiency (ID) in a chronic heart failure (CHF) outpatient population. Methods and Results: We prospectively evaluated 127 patients with stable CHF and left ventricular ejection fraction ≤45%. Clinical and analytical data as well as information regarding the occurrence of the composite endpoint of overall mortality and nonfatal cardiovascular events were assessed. Among the 127 patients enrolled [81% men, median age: 62 years (25th-75th percentile: 53-68)], 46 (36%) patients had ID. Women, patients with higher plasma brain natriuretic peptide levels (>400 pg/ml) and with right ventricular systolic dysfunction presented ID more frequently (p < 0.05 for all). At 225 ± 139 days of follow-up, the composite endpoint occurred in 15 (12%) patients. It was more frequent in ID (24 vs. 5%, p = 0.001) and anemic patients (25 vs. 8%, p = 0.014). In a Cox regression analysis, ID was associated with a higher likelihood of composite endpoint occurrence (HR 5.00, 95% CI 1.59-15.78, p = 0.006). In a multivariable analysis adjusted for clinical variables, including the presence of anemia, ID remained a significant predictor of the composite endpoint (HR 5.38, 95% CI 1.54-18.87, p = 0.009). Conclusion: In a CHF outpatient population, ID carried a higher risk of unfavorable outcome, irrespectively of the presence of anemia.

Acute Myocardial Infarction: Psychosocial and Cardiovascular Risk Factors in Men:

Background Controversy still exists over the independent role of psychosocial factors in acute myocardial infarction (AMI). This study aimed to compare psychometric indices in Portuguese patients surviving a first episode of AMI and a community sample free of AMI. Design A community-based, case–control study. The study sample included 153 male patients with a first episode of AMI and 156 male controls randomly selected from the community. Methods Information on demographic, social, medical and behavioural characteristics was obtained using a structured questionnaire; anthropometric, blood pressure, and serum measurements were performed, and the psychometric evaluation was obtained using a self-evaluation questionnaires (Bortner scale, Beck Depression Inventory, SCL-90-R, Psychological General Well-Being and the Nottingham Health Profile). Results Cases of AMI more often exhibited type A behaviour (15.4 ±3.0 versus 14.7 ±2.7, P = 0.041), had more depressive symptoms (10.8 ±8.0 versus 8.6 ±8.0, P = 0.005) and showed worse scores on general well-being (68.4 ± 17.7 versus 76.6 ± 16.2, P < 0.001) than controls. Cases were significantly different from controls in terms of years of education (6.7 ±4.4 versus 9.0 ± 4.7 years, P < 0.001), hypertension (43.1% versus 30.1%, P = 0.024), dislipidaemia (43.8% versus 34.0%, P = 0.038), type I obesity (53.6% versus 42.3%, P = 0.045), smoking (54.1% versus 26.5%, P < 0.001), no practise of exercise (68.5% versus 50.3%, P = 0.002) and presence of non-insulin-dependent diabetics (16.3% versus 6.4%, P = 0.010). After adjusting for such factors a similar set of significant psychometric results was found. Conclusion Type A behaviour, depression and lower levels of well-being and quality of life, independent of other cardiovascular risk factors, were significant features of AMI cases.

Short and Long-Term Outcome of Stress-Induced Cardiomyopathy: What Can We Expect?

Background Stress-induced/Takotsubo cardiomyopathy (TC) is an increasingly recognized diagnostic entity. Objective This study was aimed to assess the prevalence and clinical predictors of short and long-term outcome of patients (pts) diagnosed with TC. Methods We included all consecutive pts admitted in our department, from November 2006 to August 2011, who met the Mayo Clinic criteria for TC diagnosis. Results We evaluated 37 pts (35 women) with a mean age of 63 ±13 years. TC was precipitated by a stressful emotional event in the majority (57%) and chest pain was the most common symptom (89%). Twelve pts (32%) had ST-segment elevation and 15 pts (41%) had T-wave inversion on the electrocardiogram at admission. Severe left ventricular (LV) dysfunction was found in 16 pts (43%) and the mean troponin I level was 2.6±1.8 ng/mL. The in-hospital complication rate was 30%, with cardiogenic shock being the most common situation. Physical stress, severe LV systolic dysfunction and peak brain natriuretic peptide (BNP) were predictors of acute complications. On the other hand, we found no association between peak troponin I and electrocardiographic presentation. Thirty-five pts were followed for a mean time of 482 ± 512 days, without clinic recurrence. Conclusion In our cohort of pts, TC was associated with a high in-hospital complications rate. Physical stress, LV dysfunction and peak BNP could predict acute adverse outcomes.

Troponin I in atrial fibrillation with no coronary atherosclerosis.

A number of reports have raised the possibility that myocardial strain could be associated to increased plasma levels of troponin I. A 69-year-old, male, Caucasian, patient was admitted with prolonged chest pain and dyspnoea.The electrocardiogram showed atrial fibrillation with a ventricular rate of about 120 to 150/minute. After treatment with digoxin and amiodarone, the patient returned to sinus rhythm. An elevation in the plasma levels of troponin I was noted, with a maximum value of 0.66 ng/ml. Coronary angiography showed absence of coronary artery atherosclerotic lesions. Atrial fibrillation of recent onset and with a relatively high heart rate may be yet another situation in which acute myocardial strain could be the cause of the abnormal release of cardiac troponin I.

Telemonitoring in heart failure: A state-of-the-art review

Heart failure is associated with high costs which are mainly the result of recurrent hospital admissions. New strategies to detect early decompensation and prevent heart failure-related hospitalizations and reduce total health care costs are needed. Telemonitoring is a novel tool based on the use of recent communication technologies to monitor simple clinical variables, in order to enable early detection of heart failure decompensation, providing an opportunity to prevent hospitalization. From conventional telemonitoring to more recent strategies using implantable cardiac devices or implantable hemodynamic monitors, the subject is under active investigation. Despite the beneficial effects reported by meta-analyses of small non-controlled studies, major randomized controlled trials have failed to demonstrate a positive impact of this strategy. Additionally, evidence regarding the value of newer monitoring devices is somewhat contradictory, as some studies show benefits in prognosis which are not confirmed by others. This paper provides an overview of the existing evidence on telemonitoring in heart failure and a comprehensive state-of-the-art discussion on this topic.

The Natural History of Congenital Subaortic Stenosis

BACKGROUND Congenital subaortic stenosis (SAS) has a high recurrence rate after surgical correction. Aortic valve disease frequently coexists with SAS, being its occurrence and progression unpredictable. We aimed to assess predictors of SAS recurrence and aortic valve disease occurrence and progression. METHODS Retrospective analysis of 51 patients with SAS followed in a congenital heart disease clinic of a tertiary care hospital from July 1982 to October 2009. RESULTS The mean age at SAS diagnosis was 15 years and 28 patients (54.9%) were men. Aortic regurgitation was present in 23 (45.1%) patients. Thirty-four (66.7%) patients were submitted to SAS surgical correction, six (17.6%) of them also with aortic valve repair/replacement. Eighteen (52.9%) patients had SAS recurrence and eight patients (23.5%) underwent reoperation. A shorter time from diagnosis to surgery (odds ratio [OR] 0.98 [95% confidence interval, CI 0.96-1.00]; P= 0.04) and a left ventricular outflow tract (LVOT) peak pressure gradient at diagnosis > 50 mm Hg (OR 2.63 [95% CI 1.52-4.53]; P= 0.05) were independent predictors of SAS recurrence. At the end of follow-up, 37 patients (72.5%) had some form of aortic valve disease and 24 patients (47.1%) had progression for or of the aortic valve disease. Higher LVOT peak pressure gradient at diagnosis (OR 1.10 [95% CI 1.01-1.21]; P= 0.05) and higher left ventricular mass (OR 1.04 [95% CI 1.01-1.07]; P= 0.014) were independent predictors of aortic valve disease. Predictors of aortic valve disease progression were not found. CONCLUSIONS SAS recurrence occurred mainly in patients operated sooner and with a high LVOT peak pressure gradients, suggesting a more severe form of disease. A more turbulent systolic jet at LVOT was probably one of the main causes of aortic valve damage. Aortic valve disease progression occurred independently of surgery and SAS recurrence. All LVOT morphological anomalies should be detected and corrected in order to prevent SAS recurrence and aortic valve disease.

The usefulness of the head-up tilt test in patients with suspected epilepsy.

PURPOSE It is estimated that approximately 20-30% of patients diagnosed with epilepsy have been misdiagnosed, and neurocardiogenic syncope (NCS) might frequently be the real cause of transient loss of consciousness (TLOC) episodes. We assessed the role of the head-up tilt test (HUTT) in patients previously diagnosed with refractory epilepsy to evaluate the ability of this test to correctly diagnose patients with NCS. METHOD We retrospectively analysed the clinical records of 107 consecutive patients with a previous diagnosis of refractory epilepsy that were taking antiepileptic drugs and who were referred for HUTT between January 2000 and December 2010. During the subsequent follow-up, we recorded the treatments performed and the recurrence of symptoms. RESULTS Complete follow-up data were available for 94 (88%) patients, and the mean follow-up period was 80±36 months. The HUTT was positive in 54% of patients. Thirty-one (33%) patients were misdiagnosed with epilepsy, and 20 (21%) patients had a dual diagnosis of NCS and epilepsy. The recurrence of TLOC was reported in 55% of the patients, but it was significantly lower in the misdiagnosed group (42% versus 64%; P=0.039). CONCLUSION NCS is an important cause of epilepsy misdiagnosis. The HUTT is often critical for making an accurate diagnosis and subsequently selecting the appropriate treatment for patients presenting with TLOC. The diagnostic overlap between epilepsy and NCS is not uncommon, suggesting that electroencephalographic monitoring during a HUTT may play an important role in diagnosing patients with recurrent, undiagnosed TLOC episodes.

Prognostic Significance of Applying the European Society of Cardiology Consensus Algorithm for Heart Failure With Preserved Systolic Function Diagnosis

The diagnosis of heart failure with preserved left ventricular ejection fraction (HFpEF) is challenging. Although diagnostic criteria have been proposed, limited information exists concerning its implication on prognosis. We aimed to evaluate the prognostic significance of applying the European Society of Cardiology algorithm for HFpEF diagnosis, namely the tissue Doppler imaging information, in patients with acute heart failure (HF).

Early Diagnosis of Nonaneurysmal Infectious Thoracic Aortitis Using Transesophageal Echocardiogram in a Patient with Purulent Meningitis

Infectious thoracic aortitis is a rare entity in the antibiotic era and usually appears in patients with prior aortic disease and/or associated infective endocarditis. Infected nonaneurysmal aorta will likely progress to mycotic aneurysm if left untreated. In most of the reports, infectious thoracic aortitis presents with a mycotic aneurysm. We report the case of a patient with a nonaneurysmal infectious thoracic aortitis, probably secondary to purulent meningitis, early diagnosed by transesophageal echocardiogram.