Cardiologia
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- 18F-FDG-PET/CT in diagnosis of Q fever endocarditisPublication . Domingues, CM; Ferreira, MJ; Silva, R; Gonçalves, V; Silva, AM; Gonçalves, L
- Abordagem Invasiva versus Conservadora nas Síndromes Coronárias Agudas sem Supradesnivelamento do Segmento ST – Contributo para o Conhecimento e Avaliação da Realidade NacionalPublication . Teixeira, R; Lourenço, C; Baptista, R; Jorge, E; António, N; Monteiro, S; Gonçalves, F; Monteiro, P; Freitas, M; Providência, LABACKGROUND: In addition to medical therapy, revascularization plays an important role in determining prognosis in the acute setting of unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI). OBJECTIVE: To compare in-hospital and medium-term outcome of an invasive versus a conservative strategy in the setting of UA/ NSTEMI. METHODS: We carried out a prospective study of 802 consecutive patients admitted to a single coronary unit between May 2004 and December 2006 with UA/NSTEMI. Patients were divided into two groups: A (n=418)--invasive strategy; B (n=384)--conservative strategy. All-cause mortality and major adverse cardiovascular events (MACE) were assessed at one year. RESULTS: Group B patients were older (73.0 [29-93] vs. 64.0 [27-86] years, p < 0.001), more frequently female and diabetic (35.9 vs. 26.0%, p = 0.002), and were more likely to have a history of myocardial infarction and heart failure. They also presented with worse renal function, lower hemoglobin levels and lower left ventricular ejection fraction (53.0 [45-59] vs. 57.0% [50-60]%, p < 0.001). In hospital mortality was significantly higher for this group (5.7 vs. 1.9%, p = 0.004). Group A had more smokers, more frequent history of percutaneous coronary intervention, higher total and LDL cholesterol, lower Killip class on admission and lower TIMI scores. They were more frequently treated with anti-platelet therapy and at discharge were more often under beta-blocker and dual anti-platelet therapy. Female gender (adjusted OR 0.46; 95% CI 0.27-0.78) and older age (adjusted OR 0.55; 95% CI 0.31-0.99), were independent predictors for a conservative strategy during hospital stay. One-year survival was higher for the invasive strategy patients (95.9% vs. 86.2%, log rank p < 0.001), as was one-year MACE-free survival (88.3% vs. 75.7%, log rank p < 0.001). According to two multivariate Cox regression analyses, opting for an invasive strategy during hospital stay conferred a 57% reduction in relative risk of death (HR 0.43; 95% CI 0.20-0.94), and a 56% reduction in relative risk of MACE (HR 0.44; 95% CI 0.26-0.77) at one year. CONCLUSIONS: Despite some imbalances between the groups, in our population an invasive strategy during hospital stay independently predicted a favorable one-year outcome.
- Accelerated age-related olfactory decline among type 1 Usher patientsPublication . Ribeiro, JC; Oliveiros, B; Pereira, P; António, N; Hummel, T; Paiva, A; Silva, EUsher Syndrome (USH) is a rare disease with hearing loss, retinitis pigmentosa and, sometimes, vestibular dysfunction. A phenotype heterogeneity is reported. Recent evidence indicates that USH is likely to belong to an emerging class of sensory ciliopathies. Olfaction has recently been implicated in ciliopathies, but the scarce literature about olfaction in USH show conflicting results. We aim to evaluate olfactory impairment as a possible clinical manifestation of USH. Prospective clinical study that included 65 patients with USH and 65 normal age-gender-smoking-habits pair matched subjects. A cross culturally validated version of the Sniffin' Sticks olfaction test was used. Young patients with USH have significantly better olfactory scores than healthy controls. We observe that USH type 1 have a faster ageing olfactory decrease than what happens in healthy subjects, leading to significantly lower olfactory scores in older USH1 patients. Moreover, USH type 1 patients showed significantly higher olfactory scores than USH type 2, what can help distinguishing them. Olfaction represents an attractive tool for USH type classification and pre diagnostic screening due to the low cost and non-invasive nature of the testing. Olfactory dysfunction should be considered among the spectrum of clinical manifestations of Usher syndrome.
- Acquired left coronary artery fistulae to pulmonary artery and superior vena cavaPublication . Faustino, A; Paiva, LV; Mota, P; Catarino, R
- Acute onset pulmonary toxicity associated to amiodaronePublication . Ferreira, PG; Saraiva, F; Carreira, CAmiodarone is a potent anti-arrhythmic drug with a well-known potential chronic pulmonary toxicity. We describe a case of acute pulmonary toxicity (APT) induced by amiodarone in a 57 year old patient submitted to a perfusion of 900 mg in just 6 hours, to control an auricular flutter with rapid ventricular response. During the administration, the patient developed hemodynamic instability and oxygen dessaturation that led to an electrical cardioversion with return of sinus rhythm. Still, the patient continued in progressive respiratory deterioration with acute bilateral infiltrates on chest x-ray and apparent normal cardiac filling pressures confirmed by echocardiography. Anon-cardiogenic pulmonar edema progressing to clinico-physiological ARDS criteria was diagnosed. Expeditive therapeutic measures were undertaken, namely by initiation of non-invasive positive airway pressure support, that attained a good result.Albeit rare, amiodarone-induced APT might have severe consequences, namely progression to ALI/ARDS with a high mortality index.As it is a frequently prescribed drug, there should be a high clinical suspicion towards this phenomenon, allowing precocious therapeutic measures to be taken in a timely fashion to prevent the associated unfavorable outcome.
- An unusual cause of acute cardiogenic shock in the operating roomPublication . Baptista, R; Fonseca, J; Marconi, L; Furriel, F; Prieto, D; Bento, C; Antines, MJ; Figueiredo, AA 51-year-old man with a renal carcinoma with inferior vena cava (IVC) invasion was referred to our hospital for the performance of a radical nephrectomy with IVC thrombus excision. To prevent embolism, an IVC filter was implanted the day before surgery below the suprahepatic veins. On nephrectomy completion, the clinical status of the patient started to deteriorate and an unsuccessful attempt was made to excise the IVC thrombus. The patient developed profound refractory hypotension without significant bleeding and worsening splanchnic stasis was noted. A transesophageal echocardiogram was immediately performed in the operating room, revealing a hemispheric mass protruding from the IVC ostium to the right atrium, completely blocking all venous return. Volume depletion was evident by low left and right atrial volumes and increased septum mobility. No other abnormalities were found that could explain the shock, namely ventricular dysfunction or valvular disease. Cardiac surgery consultation was immediately obtained, ultimately deciding to perform a median sternotomy with direct exploration of right atrium. Under cardiopulmonary bypass, a 6-cm long thrombotic mass was identified, involving the IVC filter, blocking all lower body venous return; the removal of the mass reversed the shock. The patient had an uneventful recovery. Adverse outcomes associated with IVC filters are common. Our case highlights the importance of a team approach to rapid changes in hemodynamic status in the operating room, including the surgeon, the anesthesiologist, and the cardiologist. It also emphasizes the pivotal role of transesophageal echocardiogram in the clinical evaluation of severely unstable patient
- Anemia: apenas marcador ou preditor independente de mortalidade na insuficiência cardíaca avançadaPublication . Saraiva, F; Martins, H; Costa, S; Franco, F; Gonçalves, L; Providência, LAINTRODUCTION AND OBJECTIVES: Advanced heart failure (HF) remains a major cause of mortality. Identification of new prognostic risk factors is therefore a priority. Anemia, a frequent comorbidity in HF patients and a recognized trigger of symptoms, has recently received considerable attention in this context. Several studies have demonstrated an association between anemia and increased mortality in stable chronic HF patients. However, the prognostic impact of this comorbidity on the survival of advanced HF patients remains unclear. Our aim was to assess whether anemia is not only a marker of advanced HF, but also an independent predictor of mortality. METHODS: We performed a retrospective study of 391 consecutive patients admitted to a single advanced HF care unit and divided into two groups according to the presence or absence of anemia at admission. Demographic, clinical, laboratory and therapeutic data were compared between the groups. Anemia was defined as hemoglobin at admission of <12 g/dl for women and <13 g/dl for men. Appropriate statistical tests and multivariate analysis were used to identify independent predictors of one-year and overall mortality. Median follow-up was 3.2 years. RESULTS: Group A, anemic patients (n=169, 43.2%), were older (61.7 +/- 14.7 vs. 58.0 +/- 14.5 years, p = 0.01) and included a higher number of patients with ischemic cardiomyopathy (40.7% vs. 28.6%, p = 0.01), but fewer with dilated cardiomyopathy (41.0% vs. 55.8%, p = 0.004). At admission, group A had lower systolic blood pressure (110.1 +/- 24.8 mmHg vs. 115.2 +/- 22.0 mmHg, p = 0.03) and higher mean C-reactive protein (1.90 +/- 3.6 mg/dl vs. 1.19 +/- 2.6 mg/dl, p = 0.004) and creatinine (1.50 +/- 0.9 mg/dl vs. 1.20 +/- 0.5 mg/dl, p < 0.001). Gender, prevalence of cardiovascular risk factors, previous medication and left ventricular ejection fraction were not statistically different between the groups. At discharge, fewer anemic patients received digoxin (71.1% vs. 81.8%, p = 0.03). Mortality rates at 3 months (13.6% vs. 6.7%, p = 0.05), one year (22.9% vs. 11%, p = 0.006) and during follow-up (39.8 % vs. 23.8%, p = 0.002) were significantly higher in Group A. Multivariate analysis demonstrated that anemia was an independent predictor of mortality at one year (p = 0.035) and during median follow-up: (p = 0.014). In the anemic group a linear relationship between hemoglobin levels and mortality was also detected. CONCLUSIONS: In our population, anemia was a frequent comorbidity and had an independent and negative impact on long-term mortality. Its correction could improve outcomes in advanced HF patients.
- Angiogenic growth factors: potential new treatment for acute myocardial infarction?Publication . Gonçalves, LIn models of hind-limb ischemia and progressive coronary artery occlusion, angiogenic growth factor proteins and genes expressing growth factors have been shown to induce the development of collateral vessels and remodeling of existing collaterals. The therapeutic potential of growth factors in the setting of acute myocardial infarction may be related to non-angiogenic properties of growth factors as well, and is the focus of this review.
- Angioplastia Coronária Electiva e Primária em Hospitais sem Cirurgia Cardíaca On-sitePublication . Pereira, H; Canas da Silva, P; Gonçalves, L; Baptista, JINTRODUCTION: Current European clinical guidelines do not restrict interventional cardiology at centers without on-site surgical backup, but disagreement still exists whether hospitals with cardiac catheterization laboratories, but without on-site cardiac surgery, should develop percutaneous coronary intervention (PCI) programs. Technical improvements in equipment and pharmacologic adjunctive therapy have increased the safety margins of diagnostic and therapeutic cardiac catheterization and more than half of the patients treated by PCI in Portugal are treated at hospitals without on-site cardiac surgery. OBJECTIVES: We set out to compare clinical outcomes of elective and primary PCI for ST-segment elevation myocardial infarction at centers without on-site cardiac surgery with those at centers with on-site cardiac surgery. METHODS: Based on the Portuguese Registry of Interventional Cardiology, we retrospectively reviewed a total of 13,235 PCI procedures performed from January 2002 to June 2006 and compared the results for 7,112 patients treated at hospitals without on-site cardiac surgery with 6,123 patients treated at hospitals with on-site cardiac surgery. RESULTS: Demographic data were similar, with a mean age of 64 (55-72) vs. 63 (54-71) years, 75% vs. 76% male and 25.0% vs. 24.2% with diabetes respectively at centers without and with on-site surgical backup. Hospital mortality at centers without and with on-site surgical backup respectively was: chronic angina: 0.3% vs. 0.3% (NS); acute coronary syndromes: 1.5% vs. 1.0% (NS); acute myocardial infarction with ST elevation and without cardiogenic shock: 4.0% vs. 5.0% (NS); cardiogenic shock: 50.9% vs. 53.4% (NS). CONCLUSIONS: Similar clinical outcomes for interventional cardiology were achieved at hospitals without on-site cardiac surgery and those with on-site cardiac surgery. In the era of coronary stents, adjunctive therapy and experienced operators, elective and primary PCI can safely be performed without on-site surgical backup.