Paulo Roberto Nogueira

Early infarct artery collateral flow does not improve long-term survival following thrombolytic therapy for acute myocardial infarction

It is known that acutely developed collaterals can prevent the onset of acute myocardial infarction (AMI) in the presence of a total coronary occlusion. However, there still is controversy concerning long-term follow-up of coronary collateral circulation to the infarct-related artery. In this study we analyze the prognostic role of collateral flow (degrees 0 to 3) as well as anterograde flow (degrees 0 to 3) in patients with AMI treated with thrombolytic therapy. Four hundred twenty-two patients (median age 57 years, 355 men) with AMI were treated with intravenous streptokinase and followed prospectively for up to 8 years. At the end of the study period, patients with collateral coronary flow 3 (n = 30) and those with flow <3 (n = 392) at in-hospital coronary arteriography had survival rates of 66% and 85%, respectively (p <0.12). Meanwhile, patients with coronary anterograde flow 3 (n = 189) and those with flow <3 (n = 233) had survival rates of 89% and 80%, respectively (p <0.04). By censored regression analysis, a negative correlation was found between coronary collateral flow degree and survival (p = 0.0498) and, inversely, a positive correlation was found between coronary anterograde flow degree and survival (p = 0.0053). By Cox multivariate analysis, the following variables showed significant correlations with long-term survival: global left ventricular ejection fraction (p = 0.0003), anterograde flow degree (p = 0.0006), collateral flow degree (negative correlation, p = 0.0179), and medical treatment (negative correlation, p = 0.0464). Thus, patients treated with intravenous streptokinase during AMI and with adequate coronary collateral circulation had a worse prognosis than those who developed adequate anterograde flow, probably because of residual myocardial ischemia. Such patients may benefit from coronary revascularization (angioplasty or surgery) to restore anterograde blood flow and minimize myocardium at risk.

The role of gender in the long-term prognosis of patients with myocardial infarction submitted to fibrinolytic treatment.

PURPOSE To determine the role of gender in short- and long-term survival after a thrombolytic-treated myocardial infarction. METHODS A total of 686 consecutive patients with ST-elevation acute myocardial infarction, admitted to a single center and treated with intravenous streptokinase, were studied prospectively and consecutively. Assessment of clinical and in-hospital variables permitted comparison of baseline characteristics and both in-hospital and long-term survival between men and women. RESULTS A significantly (odds ratio=0.48, P=0.009) lower 14-day mortality rate for males (8.5%) relative to females (16%) was noted. However, this difference became non-significant after adjustment for age (odds-ratio male/female=0.62, P=0.097) or age and other variables (odds ratio=0.71, P=0.17). At the end of the follow-up (up to 12 years), survival rates for the whole population were 59.6% and 54.4% for men and women, respectively (chi-square=1.4, P=0.24); excluding in-hospital deaths, the rates were 65.1% and 64.8%, respectively (chi-square=0.21, P=0.65). CONCLUSIONS In the short-term follow-up, women have a significantly higher mortality relative to men in an unadjusted analysis. This difference became non-significant after adjusting for age, or age and other variables. In the long-term follow-up, sex was not correlated with prognosis.

Diltiazem improves left ventricular systolic function following acute myocardial infarction treated with streptokinase

The role of diltiazem on left ventricular systolic function was analyzed in 101 patients with acute myocardial infarction treated with streptokinase, being obtained, for the total of the population, higher LV global ejection fraction (p = 0.022), LV regional shortening (p = 0.046) and LV global shortening (p = 0.064) for the treated group, relative to the placebo group; the p values were, respectively, 0.005, 0.009, and 0.012, for patients that achieved TIMI-3 antegrade coronary flow. It is concluded that diltiazem is useful as adjuvant to streptokinase, especially when antegrade coronary blood flow TIMI-3 is obtained.

Serum ferritin and obstructive coronary artery disease: angiographic correlation

OBJECTIVE To verify the possible association between the levels of serum ferritin and the degree of obstructive coronary artery disease. METHODS 115 patients with coronary arteriography and concomitant evaluation of serum ferritin were studied. The adopted cut-off values were 80 ng/ml for women and 120 ng/ml for men. RESULTS The mean ferritin levels for males and females were 133.9 +/- 133.8 ng/ml and 214.6 +/- 217.2 ng/ml, respectively (p=0.047). It was observed that 44.1% of the women had normal serum ferritin levels in comparison to 30.9% of the men (p=0.254). In the patients without obstructive coronary artery disease or with less severe obstructions (group A) the serum ferritin level was 222.3 +/- 325 ng/ml. On the other hand, for those with moderate (group B) and severe obstructions (group C) the levels were 145.6+-83.7 ng/ml and 188.9 +/- 150.6 ng/ml, respectively. There was no correlation between the degree of coronary artery disease and the mean level of serum ferritin. Regarding the cut-off value, the number of women with serum ferritin level > 80 ng/ml in groups B+C or only C was significantly higher than the number of women in group A (ODDS RATIO 9.71 with 95%CI from 1.63 to 57.72). For males there was no significant difference between the number of cases above or below the cut-off values (ODDS RATIO 0.92 with 95%CI from 0.28 to 2.95). CONCLUSION It was verified that women with serum ferritin levels > 80 ng/mL presented more severe obstructive coronary artery disease than women with lower levels. In men, the serum ferritin level was not a predictor element of the degree of obstruction.

Combination of amlodipine and enalapril in hypertensive patients with coronary disease

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Combinação de anlodipino e enalaprila em pacientes hipertensos com doença coronariana

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Combinación de amlodipino y enalapril en pacientes hipertensos con enfermedad coronaria

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.