Rogério Silva de Paula

Effects of chlorthalidone and diltiazem on myocardial ischemia in elderly patients with hypertension and coronary artery disease

OBJECTIVE Antihypertensive therapy with thiazides decreases coronary events in elderly patients. However, the influence of diuretics on myocardial ischemia has not been fully investigated. The aim of this study was to compare the effect of chlorthalidone and diltiazem on myocardial ischemia. METHODS Following a randomized, double-blind, crossover protocol, we studied 15 elderly hypertensive patients aged 73.6+/-4.6 years with myocardial ischemia. All patients had angiographically documented coronary artery disease. We measured patients using 48- hour ambulatory electrocardiogram monitoring and exercise testing. After a 2-week period using placebo, patients received chlorthalidone or diltiazem for 4 weeks. RESULTS Both treatments lowered systolic and diastolic blood pressures. The number of ischemic episodes on ambulatory electrocardiogram recordings was reduced with the use of chlorthalidone (2.5+/-3.8) and diltiazem (3.2+/-4.2) when compared with placebo (7.9+/-8.8; p<0.05). The total duration of ischemic episodes was reduced in both treatments when compared with placebo (chlorthalidone: 19.2+/-31.9min; diltiazem: 19.3+/-29.6min; placebo: 46.1+/-55.3min; p<0.05). CONCLUSION In elderly hypertensive patients with coronary artery disease, chlorthalidone reduced myocardial ischemia similarly to diltiazem. This result is consistent with epidemiological studies and suggests that reduction of arterial blood pressure with thiazide therapy plays an important role in decreasing myocardial ischemia.

Prevalência e preditores de embolia pulmonar em pacientes com insuficiência cardíaca agudamente descompensada

FUNDAMENTO: Nao existe descricao da prevalencia de Embolia Pulmonar (EP) em pacientes internados por quadro classico de Insuficiencia Cardiaca descompensada (IC). OBJETIVO: Em pacientes internados por IC, (1) descrever a prevalencia de EP, e (2) avaliar a acuracia diagnostica dos Escores de Wells e de Genebra. METODOS: Pacientes internados primariamente por IC realizaram sistematicamente cintilografia pulmonar de ventilacao/perfusao, sendo EP definida por laudo de alta probabilidade. Para fins de interpretacao, definimos baixa probabilidade clinica de EP como prevalencia < 5%, de acordo com dados da literatura. No calculo do tamanho amostral, 49 pacientes seriam necessarios para fornecer um intervalo de confianca 95% com ± 10% de precisao, estimando uma prevalencia a priori de 15%. RESULTADOS: Em 51 pacientes estudados, seis apresentaram cintilografia de alta probabilidade, resultando em prevalencia de 12% (95% IC = 5% - 23%). Os Escores de Wells e de Genebra apresentaram area abaixo da curva ROC de 0,53 (95% IC = 0,27 - 0,80; p = 0,80) e 0,43 (95% IC = 0,13 - 0,73; p = 0,56), respectivamente, indicando ausencia de acuracia para o diagnostico de EP. Alternativamente, variaveis relacionadas a IC mostraram tendencia a associacao com EP e um modelo exploratorio formado por esse tipo de variavel apresentou acuracia diagnostica para EP (ROC = 0,81; 95% IC = 0,66 - 0,96; p = 0,01). CONCLUSAO: (1) A despeito da ausencia de suspeita primaria, pacientes internados com IC possuem probabilidade clinica intermediaria de EP concomitante; (2) Os escores usualmente utilizados para estimar a probabilidade clinica de EP nao se aplicam a populacao com IC e futuros modelos preditores devem contemplar variaveis relacionadas a esta sindrome.

Time Domain Analysis of the Signal Averaged Electrocardiogram to Detect Late Potentials in Heart Failure Patients with Different Etiologies

OBJECTIVE To evaluate the frequency, clinical correlations and prognosis influence of late potentials on the of heart failure patients with different etiologies using the signal averaged electrocardiogram. METHODS A 42 month study of the signal averaged electrocardiograms of 288 heart failure patients with different etiologies was conducted. The group of patients included 215 males (74.65%) and 73 females (25.35%) between the ages of 16 and 70 (mean 51.5, standard deviation 11.24). The heart failure etiologies were: hypertensive heart disease (78 patients, 27.1%); idiopathic dilated cardiomyopathy (73 patients, 25.4%); ischemic cardiomyopathy (65 patients, 22.6%); Chagas disease (42 patients, 14.6%); alcoholic cardiomyopathy (9 patients, 3.1%); peripartum cardiomyopathy (6 patients, 2.1%); valvular heart disease (2 patients, 4.2%) and viral myocarditis (3 patients, 1.04%). The variables included the duration of the standard QRS complex, duration of the filtered QRS complex, duration of the signal below 40 microV and the root mean square of the last 40 ms which were analyzed in regard to age, gender, etiology and mortality as well as the findings of the 12-lead electrocardiogram at rest, echocardiogram and ambulatory electrocardiogram. The statistical analysis tests used were: the Fisher exact probability test, Students t-test, Mann Whitney test, variance analysis, Log-Hank and the Kaplan-Meyer method. RESULTS Late potentials were diagnosed in 90 patients (31.3%) and there was no association with the etiologies. The presence of this condition is associated with: a lower maximum oxygen uptake during the ergospirometry (p=0.001); sustained and non-sustained ventricular tachycardia during Holter monitoring (p=0.001), sudden death and mortality (p<0.05). Patients that did not present late potentials had a higher overlife rate. CONCLUSION The presence of late potentials was not associated with the etiologies and proved to be an indication of a worse prognosis.

Case 1/2017 - 26-Year-old Male with Rapidly Progressive Heart Failure

Mailing Address: Vera Demarchi Aiello • Avenida Dr. Enéas de Carvalho Aguiar, 44, subsolo, bloco I, Cerqueira César. Postal Code 05403-000, São Paulo, SP Brazil E-mail: demarchi@cardiol.br, vera.aiello@incor.usp.br