Pedro José Negreiros de Andrade

Endocardite infecciosa valvar submetida a tratamento cirúrgico: análise de 64 casos

OBJECTIVE: To identify some aspects of the infective valve endocarditis treated by heart surgery, as well as antibiotic therapy, in a public hospital, in the city of Fortaleza, Ceara state, Brazil, from1988 to 2003. METHOD: A retrospective and observational study of 64 patients with Infective Valve Endocarditis who required aortic and/or mitral valve replacement, tricuspid vegectomy and repair or pulmonary valve valvulectomy, as well as antibiotic therapy, during their in-hospital stay. They were analyzed in respect to gender, age, time elapsed from hospital admission to the surgery, time elapsed from hospital admission to hospital discharge, valve lesion, blood culture result, surgical treatment and mortality. RESULTS: Infective valve endocarditis treated with heart surgery was more frequent in the third decade of life. Most of patients (81.2%) were males. The patients who died spent a shorter time from hospital admission to the surgery than the patients who survived. The aortic valve was affected in 65% of cases. Positivity blood culture were seen in 42% and Staphylococcus aureus was isolated in 52.4% of these cases. Valve replacement was necessary in 93.7% of cases. The in-hospital mortality rate was 14.1% which was not influenced by the age of the patient or the blood culture result. CONCLUSION: Infective valve endocarditis treated by heart surgery was more frequent in men and in the third decade of life. It mostly affected the aortic valve. Staphylococcus aureus was the more common pathogen found. Almost all the patients needed replacement of the infected valve and the in-hospital mortality rate was 14.1%.

Cardiac tumours: clinical, echocardiographic and pathological features

OBJETIVO: Caracterizacao clinica e ecocardiografica dos pacientes com tumores cardiacos, avaliacao da terapeutica cirurgica e da recidiva dos tumores. METODO: Na primeira parte da pesquisa, o delineamento metodologico foi do tipo retrospectivo, atraves da identificacao de tumores cardiacos e coleta de dados dos prontuarios do Hospital Universitario Walter Cantidio (UFCE) e Hospital de Messejana, no periodo de 1981 a 2001, onde foram encontrados 19 casos de tumores cardiacos. Os pacientes foram submetidos a uma reavaliacao clinica, eletro e ecocardiografica durante o periodo de marco a julho de 2002. RESULTADOS: Sintomas congestivos e dor toracica foram os sintomas mais frequentes em nossa serie. A localizacao preferencial dos tumores cardiacos em nossa serie foi no atrio esquerdo. Entre os pacientes submetidos a operacao, todos tiveram o tumor ressecado dos atrios, predominando a localizacao em atrio esquerdo (79%). O tipo histopatologico mais encontrado em nossa serie foi o mixoma (78%). A mortalidade cirurgica foi de 14%. Detectamos recidiva de tumor em um paciente. CONCLUSOES: Tumores cardiacos foram mais encontrados no atrio esquerdo. Os tumores benignos foram mais frequentes que os malignos. O tipo histopatologico mais encontrado foi o mixoma.

Dosagem de microalbuminúria em hipertensos e em pacientes portadores de doença coronariana

BACKGROUND The normal 24-hour albumin excretion rate is of 20 mg. A persistent rate of 30 to 300 mg/day is called microalbuminuria and is related to a higher prevalence of cardiovascular disease. OBJECTIVE 1) To determine the prevalence of microalbuminuria in a group of hypertensive patients and in a group of patients with coronary artery disease; 2) To determine the relationship between the presence of microalbuminuria and hypertension, diabetes mellitus, dyslipidemia, smoking and obesity. METHODS The presence of microalbuminuria in a group of hypertensive patients (73 individuals) and in a group of patients with coronary artery disease (39 individuals) was determined and compared with a control group (43 individuals). Microalbuminuria was defined as an albumin/creatinine ratio higher than 30 and lower than 300 in a spot morning urine sample. The chi-square test and the Fishers exact test were used in the statistical analysis. RESULTS Microalbuminuria was present in 9.5% of the hypertensive individuals and in 33% of the patients with coronary artery disease, and was absent in individuals of the control group. When the occurrence of microalbuminuria was analyzed according to the different clinical parameters, regardless of the group involved, a statistically significant correlation was found with age, diabetes and dyslipidemia. CONCLUSION 1) The prevalence of microalbuminuria in hypertensive individuals is high, and is even higher in patients with coronary artery disease; 2) There is a correlation of the presence of microalbuminuria with age, diabetes and dyslipidemia.

Angioplastia coronariana versus cirurgia de revascularização: revisão de estudos randomizados

Realizamos uma revisao com agregacao de resultados dos ensaios randomizados que compararam intervencao coronariana percutânea (ICP) com cirurgia de revascularizacao miocardica (CRM). Os 25 ensaios selecionados envolveram 12.305 pacientes dos quais 11.103 pertenciam a estudos em multiarteriais e 1.212 pertenciam a estudos em lesao unica de descendente anterior (DA). Nos estudos em multiarteriais a ICP mostrou uma tendencia a menor mortalidade precoce (1,2% versus 2%) e menor incidencia de acidente vascular cerebral (AVC): 0,7% versus 1,65%. Nao houve diferenca na mortalidade intermediaria (3,8% versus 3,8%). Houve tendencia a superioridade da CRM na mortalidade tardia (10,5% versus 9,6%). A diferenca deveu-se exclusivamente aos estudos da era balao, tendendo a inverter-se na era stent (9,6% versus 9,9%). Nos estudos de lesao unica de DA nao houve diferenca significativa em nenhum desfecho. A agregacao de resultados de nove estudos que avaliaram a mortalidade tardia em diabeticos mostrou diferenca favoravel a cirurgia (21,3% versus 15,9%). Dois estudos que avaliaram lesao de tronco nao mostraram diferenca significativa na mortalidade em um ano (3,9% versus 4,7%). A incidencia de nova revascularizacao foi consistentemente maior na ICP, apesar de progressiva melhora dos resultados na era stent.

Drug-eluting stents Versus Coronary Artery Bypass Grafting in Multivessel Disease and Left Main Obstruction: Meta-analysis of Randomized Clinical Trials

Fundamento: A escolha entre intervencao coronaria percutânea (ICP) e cirurgia de revascularizacao miocardica (CRM) continua controversa. Objetivo: Realizar uma meta-analise dos estudos randomizados que compararam stents farmacologicos (SF) a cirurgia de revascularizacao miocardica (CRM) em multiarteriais ou obstrucao de tronco de coronaria esquerda. Metodo: Bases de dados eletronicas foram pesquisadas sistematicamente com objetivo de avaliar resultados de estudos aleatorizados que compararam ICP com uso de SF a CRM em multiarteriais e obstrucao de tronco de coronaria esquerda. Dez estudos foram identificados. Resultados: Na agregacao de resultados (n = 9268) a mortalidade em 30 dias e a incidencia de acidente vascular encefalico (AVE) favoreceram a ICP (0,8% versus 1,5%, p = 0,005; 0,4% versus 1,5%, p < 0,0001). Nao houve diferenca na mortalidade em um ano (3,4% versus 3,5%. p = 0,50). A /mortalidade tardia favoreceu a CRM (10,1% versus 8,5%, p = 0,01). Em diabeticos de quatro estudos (n = 3830); a mortalidade tardia favoreceu a CRM (12,5% versus 9,7% p < 0,0001). Em seis estudos de obstrucao de tronco (n = 4700) a incidencia de AVE favoreceu a ICP (0,3% versus 1,5%; p < 0,001); nao houve diferenca na mortalidade em 30 dias (0,8% versus 1,3%. p = 0,15), na mortalidade em um ano nem na mortalidade tardia (8,1% versus 8,1%). Escore de SYNTAX elevado e diabete foram os subgrupos que influenciaram mais fortemente de forma adversa os resultados da ICP. Conclusao: CRM foi superior a ICP na mortalidade tardia e inferior na mortalidade em 30 dias e na incidencia de AVE. Diabete e escore de SYNTAX impactaram fortemente nos resultados. (Int J Cardiovasc Sci. 2018;31(2)152-162)

Physiological changes from walking and time of stay after heart surgery

1Instituto Nobre de Cardiologia – Setor de Fisioterapia – Feira de Santana, BA – Brazil 2Grupo de Pesquisa em Fisioterapia Cardiovascular – Salvador, BA – Brazil 3Instituto Nobre de Cardiologia – Setor de Cirurgia Cardiaca – Feira de Santana, BA – Brazil 4Universidade Salvador – Hospital Alianca Unidade de Terapia Intensiva – Salvador, BA – Brazil 5Centro Medico Pulmonar Diagnostico – Joao Pessoa, PB – Brazil 6Hospital Encore – Aparecida de Goiânia, GO – Brazil

About the use of DES (Drug-Eluting Stents) in real life: the importance of registries

1. Ribeiro EE, Ribeiro HB. Uso de stents farmacológicos na ‘vida real” : a importância dos registros. Arq Bras Cardiol. 2010; 95 (1): 131-4. 2. Kirtane AJ, Gupka A, Iyengar S, Moses JW, Leon MB, Applegate R, et al . Safety and eficacy of drug-eluting stents and bare metal stents: comprehensive meta-análisys of randomized trials and observational studies. Circulation. 2010; 119 (25): 3198-206. Referencias Sobre el Uso de Stents Farmacológicos en la Vida Real: la Importancia de los Registros

Sobre el uso de Stents farmacológicos en la vida real: la importancia de los registros

1. Ribeiro EE, Ribeiro HB. Uso de stents farmacológicos na ‘vida real” : a importância dos registros. Arq Bras Cardiol. 2010; 95 (1): 131-4. 2. Kirtane AJ, Gupka A, Iyengar S, Moses JW, Leon MB, Applegate R, et al . Safety and eficacy of drug-eluting stents and bare metal stents: comprehensive meta-análisys of randomized trials and observational studies. Circulation. 2010; 119 (25): 3198-206. Referencias Sobre el Uso de Stents Farmacológicos en la Vida Real: la Importancia de los Registros

Sobre o uso de Stents farmacológicos na vida real: a importância dos registros

1. Ribeiro EE, Ribeiro HB. Uso de stents farmacológicos na ‘vida real” : a importância dos registros. Arq Bras Cardiol. 2010; 95 (1): 131-4. 2. Kirtane AJ, Gupka A, Iyengar S, Moses JW, Leon MB, Applegate R, et al . Safety and eficacy of drug-eluting stents and bare metal stents: comprehensive meta-análisys of randomized trials and observational studies. Circulation. 2010; 119 (25): 3198-206. Referencias Sobre el Uso de Stents Farmacológicos en la Vida Real: la Importancia de los Registros

Angioplasty versus medical treatment in oligosymptomatic patients: is it time to stop it?

The long-awaited BARI 2-D 1 study has just been published in the New England Journal of Medicine. In the part that would be of interest to cardiologists, 2,368 patients with type 2 diabetes and coronary artery disease were randomized into two groups: optimal treatment for diabetes, and revascularization therapy, either by surgery or angioplasty. The randomization was performed independently of the selecting of optimal therapy for each patient, which was left at the discretion of the physicians; the study was not a comparison between angioplasty and surgery. Analyzing the publication of supplements, we observed that most patients were mildly symptomatic. Of the total, 17% were asymptomatic; and 21.4% did not have angina, but what the researchers considered to be an “angina equivalent”. Of the patients with angina, most were in functional class I or II; only 8.6 % were in angina class III or IV; and only 9.5% had unstable angina. Demonstrating the predominantly nonsurgical conditions of the patients, only 17% had an ejection fraction of less than 50%; only 30% had three-vessel disease; and only 13% had a proximal left anterior descending artery obstruction. It was thus a sample of patients with generally minor angiographic changes, in many of whom myocardial revascularization, by any method, would be questionable: surgical revascularization would be questionable because they did not meet the traditional angiographic indication criteria (left main, three vessels with poor ventricular function, or three vessels with proximal left anterior descending obsctruction); and coronary angioplasty would be questionable because they were diabetic, and especially because they were mildly symptomatic. The results were as the expected by anyone accompanying such studies over the past 27 years 2-8 . The 5-year mortality was 11.7% in the revascularization therapy group, and 12.2% in the clinical treatment group (NS). There was no difference in major events, deaths, heart attacks, or strokes: 22.8% in the revascularization group, and 24.1% in the clinical treatment group (NS). Angioplasty did not reduce mortality (10.8% versus 10.2%) or events (21.1% versus 23%). Surgery has not significantly reduced mortality (13.4% versus 16.4%), although it has reduced events (22.4% versus 30.4%), possibly because it was indicated for a subgroup of patients with more extensive lesions. On learning the results of the study, the American Society of Interventional Cardiology issued a statement reminding that drug-eluting stents are the best option for diabetics with coronary artery disease, and that they have been used in a minority (30%) of patients. Actually the limited use of drug-eluting stents may have contributed to the poor outcome of angioplasty in terms of reducing events, but not in terms of reducing mortality. Moreover, there is evidence of the existence of subgroups of stable patients in whom the benefits of PCI were higher than those found in the patients of the Bari-2D study 9 . But it is worth questioning something much simpler: Does this study add anything to what we already know? After the results of six randomized studies (seven with the COURAGE study, totaling more than 5,000 patients) which uniformly showed no benefit of angioplasty in patients with mild symptoms, why test it once more in patients with so few symptoms, often non-surgical patients, and with the aggravating circumstance of diabetes? Given all that is already known, hasn’t the time come to stop randomized studies like this, especially when confronted with the certainty that the clinical judgement tend to better separate the treatment options as universally agreed and already proven by the MASS II study? 10