HB - Cardiologia
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- Non-coronary sinus of Valsalva aneurysm diagnosed after a road traffic accidentPublication . Ribeiro, A; Fernandes, F; Costeira, A; Simões, A; Rodrigues, PA 38 year old man with a huge unruptured sinus of Valsalva aneurysm, complicated with severe valvar aortic regurgitation, is described. The aneurysm was detected by echocardiography in the asymptomatic patient who presented with an intense precordial diastolic rumble after a road traffic accident. The patient had successful surgery for the aneurysm and aortic valve replacement. Possible aetiologies for the aneurysm and a brief revision of clinical aspects and treatment are discussed.
- Sudden death and variant anginaPublication . Costa, J; Pereira, MA; Correia, A; Rebelo, A; Araúlo, AOVariant angina is defined by chest pain occurring at rest associated with transitory ST segment elevation on ECG, and is caused by a spasm of a coronary artery. Frequently, variant angina is associated with atherosclerotic coronary obstruction and patients with normal coronary arteries are rare. Patients with variant angina and normal coronary arteries have good prognosis, and the development of ventricular arrhythmias or sudden death is rare. The authors present two cases of sudden cardiac death in patients with variant angina and normal coronary arteries.
- Congenitally corrected transposition of the great arteries and aortic coarctation--an uncommon associationPublication . Brandão, A; Magalhães, S; Correia, ACongenitally corrected transposition of the great arteries, L-TGA, is a rare abnormality accounting for less than 0.5% of clinically apparent congenital heart disease. Age at time of diagnosis and survival rate are variable and depend mostly on associated anomalies. The authors present a clinical case of a twenty-four-year-old woman in whom, in a routine echocardiogram, congenitally corrected transposition of the great arteries and aortic coarctation were diagnosed, an unusual association. They describe the results of complementary exams (echocardiography, chest X-ray, electrocardiogram and cardiac angiography) that they believe to be useful for the correct diagnosis of this clinical situation. Additionally, the authors make a brief review of the literature relevant to the case.
- Heart failure after acute coronary syndrome: identify to treat better!Publication . Rocha, S; Nabais, S; Magalhães, S; Azevedo, A; Torres, M; Marques, J; Pereira, MA; Correia, AINTRODUCTION: The development of heart failure (HF) following acute coronary syndromes (ACS) significantly worsens short- and long-term prognosis. The present study aimed to identify clinical characteristics, detectable at admission for ACS, that could predict HF development during hospitalization, and to evaluate its impact on in-hospital mortality. METHODS: This was a retrospective cohort study that included 601 patients consecutively admitted with ACS. Demographic, clinical and laboratory data at admission were collected and HF was defined as maximum Killip class II or III. Logistic regression analysis was performed to identify independent predictors of HF and, additionally, in-hospital death. RESULTS: 29.3% of the population developed HF, mostly older patients (69.52+/-11.9 years vs. 61.81+/-12.4 years, p<0.0001), women, hypertensive, diabetic and non-smokers. On admission, this subgroup of patients presented with higher heart rate and glycemia, and lower glomerular filtration rate (eGFR) and hemoglobin. The percentage of patients with left ventricular systolic dysfunction (LVSD) was significantly higher in the group of patients with HF (74.4% versus 48.7%, p<0.0001); however, no significant differences were found in the type of ACS or its location. In the present study, we found that patients with HF were stratified less invasively (less likely to undergo cardiac catheterization or percutaneous coronary intervention). The development of HF was associated with longer hospitalization and higher in-hospital mortality (7.4% versus 2.1%, p=0.004) on univariate analysis, but not on multivariate analysis. On multivariate analysis, only age (OR=1.04; 95% CI 1.02-1.06), diabetes mellitus (OR=1.77; 95% CI 1.05-2.96), glycemia (OR=1.05; 95% CI 1.01-1.08), eGFR <60 ml/min/1.73m2 (OR=2.90, 95% CI 1.73- 4.84), heart rate (OR=1.03, 95% CI 1.02-1.04) and LVSD (OR=2.48, 95% CI 1.59-3.85) were independent predictors of HF. CONCLUSIONS: HF is a frequent complication in ACS and is associated with higher in-hospital mortality. Identifying risk of HF development on admission, through easily acquired clinical characteristics (older age, diabetes and/or elevated glycemia, renal failure and higher heart rate), will certainly influence immediate therapeutic choices and permit an individualized approach to each patient.
- Admission glycemia: a predictor of death after acute coronary syndrome in non-diabetic patients?Publication . Rocha, S; Nabais, S; Magalhães, S; Salgado, A; Azevedo, P; Marques, J; Torres, M; Pereira, MA; Correia, ABACKGROUND: Previous studies have demonstrated that acute phase hyperglycemia is associated with increased in-hospital mortality in diabetic patients admitted with acute coronary syndrome (ACS), but this has not been clearly demonstrated in non-diabetic patients. The present study was designed to determine whether admission hyperglycemia (AG) is an independent predictor of in-hospital and six-month mortality after ACS in non-diabetic patients. METHODS: This was a retrospective cohort study of 426 non-diabetic patients consecutively admitted with ACS. The patients were stratified into quartile groups according to AG, which was also analyzed as a continuous variable. Vital status was obtained at six-month follow-up in 96.8% of the patients surviving hospitalization. Logistic regression analysis was used to identify independent predictors of in-hospital and six-month death. RESULTS: Of the 426 patients included in the study (age 62.6 years+/-13.1, 77% male), 22 (5.4%) patients died during hospitalization and 20 (5.2% of the patients surviving hospitalization) within six months of ACS. Mean AG was 134.89 mg/dl+/-51.95. The higher the AG, the more probable was presentation with ST-segment elevation ACS (STEMI), anterior STEMI, higher heart rate, Killip class higher than one (KK >1), higher serum creatinine and greater risk of in-hospital and six-month death. In multivariate analysis, only age (OR=1.10; 95% CI 1.04-1.17), STEMI (OR=3.02; 95% CI 1.07-8.50), AG (OR=1.073; 95% CI 1.004-1.146), serum creatinine (OR=1.10; 95% CI 1.009-1.204) and KK >1 on admission (OR=4.65; 95% CI 1.59-13.52) were independently associated with in-hospital death. Age (OR=1.07; 95% CI 1.03-1.12), serum creatinine (OR=1.09; 95% CI 1.01-1.18) and in-hospital development of heart failure (OR=2.34; 95% CI 1.07-5.10) were independently associated with higher risk of death within six months of ACS. CONCLUSIONS: AG is an independent predictive factor of in-hospital death after ACS in non-diabetic patients. Although it did not show an independent association with higher risk of six-month death, AG appears to contribute to it, since the risk is greater the higher the AG. Its predictive value may have been blunted by the insufficient power of the sample and/or by the time interval between acquisition of AG and the evaluated endpoint.
- Toxicidade cardiovascular da cocaína de natureza iatrogénica: caso clínicoPublication . Torres, M; Rocha, S; Rebelo, A; Marques, J; Nabais, S; Azevedo, P; Magalhães, S; Costa, J; Correia, AThe use of cocaine as an illicit drug is associated with various cardiovascular events. In recent decades, because of growing levels of consumption, there has been an increasing incidence of these complications. At the same time, cocaine is also widely used as a local anesthetic, mainly in nasal surgery. Its application in this context is controversial due to the potential associated adverse effects. The authors report the case of a 29-year-old patient, with no known cardiovascular risk factors, admitted for elective nasal surgery, under general anesthesia combined with topical application of cocaine. During surgery the patient developed hemodynamic instability in the context of ventricular arrhythmias, after which she presented evolving electrocardiographic changes and increased levels of myocardial necrosis markers, diagnostic of non-ST-segment elevation acute coronary syndrome. The authors review the cardiovascular complications associated with cocaine use and the underlying pathophysiologic mechanisms and discuss the role of cocaine as a topical anesthetic.
- O “paradoxo dos fumadores” revisitado.Publication . Gaspar, A; Nabais, S; Torres, M; Rocha, S; Brandão, A; Azevedo, P; Álvares-Pereira, M; Correia, AIntrodução: O termo “paradoxo dos fumadores” surgiu na sequência de vários estudos que descreveram uma menor mortalidade a curto prazo nos doentes com história de tabagismo, internados com Síndrome Coronário Agudo (SCA). No entanto, trabalhos mais recentes têm contestado a existência deste fenómeno. Objectivo: Avaliar a ocorrência do “paradoxo dos fumadores” na nossa população de doentes internados por SCA. Métodos: Foram analisados 1228 doentes admitidos consecutivamente por SCA de Janeiro 2004 a Março 2007. Os doentes foram classificados em 2 grupos, o grupo I incluindo os doentes sem história de tabagismo (n=778) e o grupo II os doentes com história de tabagismo (n=450). Os “endpoints” foram a morte no internamento e morte total aos 6 meses. Resultados: Verificou-se que os doentes sem história de tabagismo eram mais idosos (68,25 ± 12,22 anos contra 58,13 ± 11,91 anos), mais frequentemente do sexo feminino, e apresentavam com maior frequência diabetes mellitus (DM), hipertensão arterial (HTA) e insuficiência renal (p <0,05). Os doentes que nunca fumaram tiveram mais frequentemente enfarte agudo do miocárdio (EAM) sem supra de ST enquanto os doentes com história de tabagismo tiveram mais EAM com supra de ST (p <0,05). Os doentes sem história de tabagismo eram mais frequentemente medicados com nitratos, diuréticos e antagonistas de cálcio e menos com β – bloqueadores (p <0,05), não se tendo encontrado diferenças quanto à restante terapêutica médica. Os doentes com história tabágica foram mais frequentemente submetidos a coronariografia (p <0,01). Apesar de se observar, na análise univariável, maior mortalidade intra-hospitalar e aos 6 meses nos doentes sem antecedente de tabagismo (p <0,05), a análise multivariável, com o ajuste para os factores de risco mais reconhecidos (idade, classe KK na admissão, pressão arterial sistólica e frequência cardíaca na admissão, disfunção ventricular esquerda, presença de insuficiência renal) não permitiu confirmar esta associação. Conclusão: Na nossa população de doentes internados por SCA, não se verificou nenhum “paradoxo dos fumadores”. A ocorrência de maior mortalidade observada entre os doentes sem história de tabagismo correlaciona-se provavelmente com as diferenças das características basais dos doentes, nomeadamente idade mais avançada e maior número de co-morbilidades (DM, HTA e insuficiência renal).
- Coexistence of coronary cameral fistulae and cor triatriatum sinister in an elderly patientPublication . Nabais, S; Salomé, N; Brandão, A; Simões, A; Marques, J; Costa, J; Basto, L; Costeira, A; Correia, ACoronary cameral fistulae are unusual congenital or acquired anomalous communications between an epicardial coronary artery and a cardiac chamber. There are no reported cases of the association of coronary cameral fistulae and cor triatriatum, a rare congenital cardiac anomaly in which a fibromuscular membrane divides the left atrium into two chambers. We report the case of an 82-year-old man presenting with recurrent anterior chest pain. Echocardiographic examination identified non-obstructive cor triatriatum, mitral valve prolapse resulting in significant mitral regurgitation, dilated coronary arteries, and established the entry site of coronary artery fistulae at the apex of the left ventricle (Figure 1). Coronary angiography confirmed the existence of a plexiform fistula between the left anterior descending coronary artery and the left ventricle. Tetrofosmine scintigraphy revealed the presence of stress-induced ischaemia in the apex. To our knowledge, we report the oldest person with coronary cameral fistulae presenting with angina only at this stage, and the interesting case of the coexistence of two, although unconnected, congenital conditions in an elderly patient. In addition, this report highlights the important role of transthoracic and transoesophageal echocardiography to the characterization of these unusual anomalies, and the complementary information offered by three-dimensional transthoracic echocardiography.
- Prognostic impact of moderate renal dysfunction in acute coronary syndromesPublication . Nabais, S; Rocha, S; Costa, J; Marques, J; Torres, M; Magalhães, S; Pereira, MA; Correia, AINTRODUCTION: End-stage renal disease is associated with high cardiovascular mortality. The prognostic importance of milder degrees of renal impairment in patients who have had an acute coronary syndrome (ACS) is less well defined. The purpose of this study was to evaluate the impact of baseline renal dysfunction assessed by estimated glomerular filtration rate (GFR) on mortality in patients admitted with an ACS. METHODS: We studied all patients with an ACS consecutively admitted to an Intensive Cardiac Care Unit over 18 months. The GFR was estimated by means of the four-component Modification of Diet in Renal Disease study equation. Patients were grouped according to their estimated GFR (less than 45.0; 45.0 to 59.9; 60.0 to 74.9; and at least 75.0 ml/min/1.73 m2). Primary outcome was death from any cause. RESULTS: The mean age of the 589 study patients was 64.1 years, 73.7% were male, and 49.2% had an ACS with ST-segment elevation. Arterial hypertension, diabetes mellitus, prior myocardial infarction, and Killip class > I were incrementally more common across increasing renal dysfunction strata (p < 0.01). The use of reperfusion therapy, beta-blockers, and coronary angioplasty was lower in groups with reduced estimated GFR (p < 0.001). Overall six-month mortality was 13.6%. Using the group with an estimated GFR of at least 75.0 ml/min/1.73 m2 as the reference group yielded odds ratios for six-month mortality that increased with the degree of renal impairment. After adjusting for baseline characteristics, impaired renal funtion remained associated with increased mortality. The multivariable-adjusted odds ratio for six-month mortality in patients with mild renal impairment (GFR 60.0 to 74.9 ml/min/1.73 m2) was 2.71 (95% confidence interval [CI] 1.09 to 6.69), compared with 7.53 (95% CI, 3.21 to 17.71) and 8.10 (95% CI, 3.18 to 20.60) in patients with moderate and more severe renal dysfunction, respectively. CONCLUSIONS: Baseline renal dysfunction, as assessed by estimated GFR, is a potent and easily identifiable determinant of outcome after an ACS. Even mild levels of renal impairment are independently associated with increased mortality after an ACS.
- Prognostic value of in-hospital worsening of renal function in patients with acute coronary syndromePublication . Gaspar, A; Nabais, S; Torres, M; Rocha, S; Brandão, A; Azevedo, P; Álvares-Pereira, M; Correia, APurpose: The association between a history of renal insufficiency and poor outcome in patients with acute coronary syndrome (ACS) is well known. However, little information is available about in-hospital worsening of renal function. Our goal was to determine the prognostic impact of in-hospital worsening of renal function in patients with ACS. Methods: A total of 1228 patients consecutively admitted with ACS from January 2004 to March 2007 were reviewed. Patients deceased in hospital and patients with < 2 analysis and/or without creatinine value on admission were excluded. The selected patients were classified into 2 groups. Group I included patients with an increase in creatinine <0,5 mg/dL. Group II included patients with an increase in creatinine ≥ 0,5 mg/dL. The primary endpoint was 6-month mortality from any cause. Results: Of the 1134 patients finally selected, 1028 belonged to group I and 106 to group II. Patients of group II were older (74,08±8,8 vs 63,2±12,9; p <0,001), more frequently women (39,6% vs 26,1%; p= 0,003) and more often had diabetes mellitus (42,5% vs 25,7%; p=0,001), arterial hypertension (77,4% vs 62,0%; p=0,001) and renal insufficiency (63,5% vs 19,8%; p <0,001). Patients of group II had higher 6-month mortality compared with patients in group I (24,5% vs 5,0%; p <0,001). After adjustment for known risk factors by multivariate analysis (age, history of renal insufficiency, diabetes mellitus, creatinine value on admission, history of myocardial infarction, Killip class on admission, heart rate on admission, systolic blood pressure on admission and left ventricular systolic dysfunction), an increase in creatinine remained a independent predictor of 6-month mortality (OR=2,45; 95% confidence interval 1,42 to 4,24; p=0,0013). Conclusions: In-hospital worsening of renal function is associated with increased 6-month mortality in patients with ACS.