Newton Fernando Stadler de Souza Filho

Acute myocardial infarction in elderly patients: comparative analysis of the predictors of mortality. The elderly versus the young.

OBJECTIVE To study the in-hospital evolution of patients aged 65 years and older, with acute myocardial infarction, who were treated by direct coronary angioplasty with no fibrinolytic therapy. METHODS We studied 885 patients divided into 2 groups as follows: group I (GI) - 293 (33.4%) patients aged >/= 65 years (72+/-5 years), and group II (GII) - 592 patients aged < 65 years (57+/-9 years). Multivessel disease was more frequent in GI (63.5% x 49.7%; p=0.001). A greater number of GII patients were class I or II of the clinical Killip-Kimball classification (K) (80.2% x 67.2%; p=0.00002), while a significant number of GI patients were KIII and KIV (24.3% x 12.8%; p=0.00003). RESULTS Group I had a lower index of success (84.6% x 94%; p=0.0002) and a greater in-hospital mortality (12.2% x 4.7%; p=0.00007). The predictors of mortality in GI were as follows: previous infarction (20.5% x 6.3%; p=0.02), anterior location (13.4% x 6.4%; p=0.03), and male sex (10.4% x 4.4%; p=0.007). CONCLUSION Elderly patients had more severe acute myocardial infarction and more extensive disease, a lower index of success, and greater in-hospital mortality. Previous infarction, anterior location and male sex were identified as predictors of mortality in the elderly group (GI).

Reduced Progression of Cardiac Allograft Vasculopathy with Routine Use of Induction Therapy with Basiliximab

Background Cardiac allograft vasculopathy (CAV) is a major limitation for long-term survival of patients undergoing heart transplantation (HT). Some immunosuppressants can reduce the risk of CAV. Objectives The primary objective was to evaluate the variation in the volumetric growth of the intimal layer measured by intracoronary ultrasound (IVUS) after 1 year in patients who received basiliximab compared with that in a control group. Methods Thirteen patients treated at a single center between 2007 and 2009 were analyzed retrospectively. Evaluations were performed with IVUS, measuring the volume of a coronary segment within the first 30 days and 1 year after HT. Vasculopathy was characterized by the volume of the intima of the vessel. Results Thirteen patients included (7 in the basiliximab group and 6 in the control group). On IVUS assessment, the control group was found to have greater vessel volume (120–185.43 mm3 vs. 127.77–131.32 mm3; p = 0.051). Intimal layer growth (i.e., CAV) was also higher in the control group (27.30–49.15 mm3 [∆80%] vs. 20.23–26.69 mm3 [∆33%]; p = 0.015). Univariate regression analysis revealed that plaque volume and prior atherosclerosis of the donor were not related to intima growth (r = 0.15, p = 0.96), whereas positive remodeling was directly proportional to the volumetric growth of the intima (r = 0.85, p < 0.001). Conclusion Routine induction therapy with basiliximab was associated with reduced growth of the intima of the vessel during the first year after HT.

Tronco de coronária esquerda ocluso secundário a Lues terciária

A 27-year-old patient with tertiary syphilis, manifested as myocardial ischemia, presenting unstable angina, secondary to left coronary trunk occlusion. The diagnosis was confirmed by the serological findings and the pathological assessment of the aorta fragment.

Transseptal coronary angioplasty in patients with severe peripheral vascular disease

It is estimated that six thousand diagnostic cardiac catheterizations and two thousand coronary angioplasties are performed per million inhabitants per year1, all by retrograde approach. Roughly, for every six thousand procedures, one patient has diffuse injury of the arterial system, with involvement of the four extremities2. Despite the difficulty of arterial access, the anatomical diagnosis of coronary artery disease today is no longer a barrier. It is currently possible to conduct anatomical studies without the need for invasive study, especially due to the improved image quality of coronary CT angiography. However, coronary intervention is still a barrier, as larger profile catheters are used and anticoagulation is needed.

Acesso Radial vs. Acesso Femoral em Pacientes com Idade Avançada Submetidos à Intervenção Coronária Percutânea

Background: Studies demonstrate that radial artery access reduces the risk of vascular and bleeding complications associated to percutaneous coronary intervention. Our objective was to evaluate in-hospital results of the transradial approach in elderly patients undergoing percutaneous coronary intervention. Methods: Prospective registry including patients ≥ 70 years of age; safety and efficacy endpoints were compared for the radial and femoral artery access groups. Results: We included 255 patients, 117 (52%) treated using the radial approach and 108 using the femoral approach. Except for age, the remaining clinical characteristics did not show differences between groups. Male patients prevailed (60%), 36.7% were diabetic and over one third were diagnosed with acute coronary syndrome. Angiographic and procedure-related variables did not show differences between groups. When vascular complication rates were compared only hematomas < 5 cm (5.1% vs. 17.6%; p < 0.01) were more prevalent with the femoral access. Major bleedings, according to the ACUITY criteria (zero vs. 5.6%; p = 0.01) and minor bleedings, according to the TIMI criteria (zero vs. 7.4%; p < 0.01), were also more frequent in the femoral group. In-hospital clinical endpoints, death (0.9% vs. 5.6%; p = 0.06) and non-fatal infarction (zero vs. 3.7%; p = 0.05) were more frequent in patients treated by the femoral access. Conclusions: In a non-selected patient population ≥ 70 years of age, percutaneous coronary intervention by radial access was associated to a lower incidence of in-hospital clinical endpoints, especially of bleeding events related to the vascular access route.

Infarto agudo do miocárdio de parede inferior sem lesão obstrutiva coronária

ABSTRACT Inferior Acute Myocardial Infarctionwithout Coronary Lesions We describe the case of a 70-year-old patient admittedwith acute myocardial infarction, with clinical, electrocar-diographic, enzymatic and left ventricular regional wallmotion abnormalities. Coronary angiography showed noobstructive lesions, which was confirmed by intravascularultrasound (IVUS). Different hypothesis are raised to explainmyocardial infarction with normal coronary arteries inthis patient. DESCRIPTORS: Myocardial infarction. Coronary disease.Coronary angiography. Ultrasonography, interventional. O infarto agudo do miocardio e a principal causade morbidade e mortalidade em todo o mun-do 1 . A maioria dos casos decorre da instabili-zacao de uma placa aterosclerotica com trombosesobrejacente. Varios outros mecanismos foram identi-ficados como causa de sindrome coronaria aguda,como obstrucao dinâmica, inflamacao, obstrucao me-cânica e aumento de consumo miocardico de oxige-nio. Descrevemos a seguir um caso de infarto agudodo miocardio com coronarias normais.

Evolução clínica da enxaqueca após oclusão percutânea de forame oval patente

INTRODUCAO: A enxaqueca atinge aproximadamente 18% das mulheres e 6% dos homens. Cerca de 50% dos pacientes com enxaqueca com aura (MA+) e 30% dos sem aura (MA-) sao portadores de forame oval patente (FOP), incidencia maior que na populacao geral. Este estudo teve como objetivo avaliar a evolucao clinica de pacientes com MA+ e MA- submetidos a oclusao percutânea. METODO: Foram incluidos pacientes portadores de enxaqueca cronica refrataria a tratamento clinico encaminhados ao Laboratorio de Hemodinâmica do Hospital Ecoville, entre agosto de 2006 e maio de 2007, para oclusao do FOP. A cefaleia foi caracterizada clinicamente quanto a intensidade, frequencia, duracao e presenca de aura, bem como foram avaliados os fatores de co-morbidade. A avaliacao complementar foi realizada por meio de ressonância magnetica de crânio (RMC), ecocardiografia Doppler transesofagica (ETE) e Doppler transcraniano (DTC), os dois ultimos metodos com injecao de microbolhas e manobra de Valsalva. Foram, entao, realizados cateterismo cardiaco e oclusao do FOP com protese. Os pacientes foram acompanhados com reavaliacao dos mesmos criterios pre-operatorios. RESULTADOS: No total, foram avaliados sete pacientes (seis do sexo feminino), entre 18 e 65 anos de idade, cinco deles portadores de MA+ (enxaqueca classica) e outros dois portadores de MA-. Em quatro pacientes foram observadas crises moderadas e em tres, crises graves. Todos, exceto um, apresentavam alteracoes isquemicas a RMC, quatro apresentavam associacao com depressao e um, com doenca de Behcet. Todos tinham resultados de ETE e DTC positivos, que foram negativados ate tres meses apos a oclusao. Apenas um paciente nao apresentou melhora apos o tratamento. CONCLUSAO: Apesar do numero ainda pequeno de pacientes, a oclusao percutânea do FOP com protese parece ser metodo promissor para o tratamento complementar da enxaqueca.

Fístula da artéria descendente anterior para ventrículo direito pós-implante de stent

aciente do sexo masculino, 73 anos de idade, na-tural de Curitiba, admitido na Unidade de Dor To-racica da Santa Casa de Curitiba com quadro dedor toracica tipica em repouso, de inicio recente. Eletro-cardiograma mostrava infradesnivelamento do segmentoST, em parede anterior. Exames laboratoriais sem anor-malidades. Submetido a cineangiocoronariografia, quemostrou lesao moderada no terco medio da arteriadescendente anterior – DA – (Figura 1). Em analiseretrospectiva, nota-se discreta constricao no terco medio,sugestivo de trajeto intramiocardico da DA. A ultra-sonografia intracoronaria mostra area de 2,8mm

Terapia trombolítica no tratamento da embolia pulmonar maciça

aciente de 44 anos, sexo feminino, admitida naUnidade de Dor Toracica da Santa Casa de Mise-ricordia de Curitiba, com quadro de dispneia deinicio subito, com piora progressiva nos ultimos 5 dias,associada a dor ventilatoria-dependente. Relatode empastamento do membro inferior esquerdo e usode contraceptivo oral, nega outros fatores de risco paraembolia pulmonar. A admissao, encontrava-se taquip-neica, hipoxemica (Sat O

The use of abciximab associated with primary angioplasty for treating acute myocardial infarction

OBJECTIVE To assess the benefit resulting from the use of abciximab associated with primary angioplasty. The following parameters were analyzed in-hospital, at 30 days, and 6 months: (a) flow in the culprit artery; (b) ventricular function; (c) combined outcome of death, acute myocardial infarction, and additional revascularization. METHODS From November 1997 to June 1999, a longitudinal nonrandomized study with historical data of 137 patients with acute myocardial infarction within the first 12 hours. Patients undergoing primary angioplasty and were divided into 2 groups: those receiving (A) abciximab (26) or (B) conventional therapy (111). TIMI flow and regional ventricular function estimated by the standard deviation (SD)/chordis index were analyzed. RESULTS At the end of angioplasty, TIMI 3 flow was observed in 76.9% and 83.8% of the patients in groups A and B, respectively (P=0.58). In the reevaluation, patients with TIMI flow <3 showed a 100% improvement in group A and a 33% in group B (P<0.0001). A significant improvement (P<0.0001) in regional ventricular function, by SD/chordis index, occurred in each group; no significant difference between groups however, was observed (29.9% x 20.2%; P=0.58). A nonsignificant reduction in the combined outcome in the in-hospital phase (3.85% A x 9.0% B; P=0.34) and on the 30th day (4.0% x 12.0%; P=0.22) was observed in group A. CONCLUSION Abciximab improved blood flow. Primary angioplasty improved regional ventricular function independent of antithrombotic therapy. Abciximab showed a trend toward reducing the combined outcome in the in-hospital phase and on the 30th day.