This study evaluates the association between the presence of diagonal earlobe creases (ELC) and c... more This study evaluates the association between the presence of diagonal earlobe creases (ELC) and coronary artery disease (CAD). One thousand four hundred twenty-four patients (760 men and 664 women, aged 30 to 80 years) were examined for the presence of ELC and classified into 2 groups: group I control--1,086 consecutive patients who denied symptoms of myocardial ischemia and were admitted to a general hospital for other reasons; group II CAD--338 patients with documented CAD (presence of > or = 70% coronary diameter stenosis at angiography). ELC was present in 304 patients (28%) in group I and 220 (65%) in group II (p < 0.0001). The patients were stratified in age groups to isolate the influence of age because the prevalence of ELC and CAD increased with advancing age (p < 0.0001 for both). This association remained statistically significant in all decades, except for patients aged > 70 years. To further remove the confounding effect of different age and sex distributions between the groups, a direct adjustment of the ELC prevalence was performed. When adjusted for age and sex, the prevalence of creases was still 58% higher in patients with CAD than in control subjects (p < 0.001). The presence of ELC was also related to the extent of CAD as measured by the number of major arteries narrowed (p = 0.015). The observed sensitivity of the sign for the diagnosis of CAD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%.
Purpose: Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis w... more Purpose: Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis with success. Material and methods: Thirty-five patients with acute myocardial infarction, 32 (91.4%) male with ages varying from 33 to 68 (mean 52.6). Thrombolysis was obtained during cinecoronarography with intravenous infusion "in bolus" of doses of 50 mg, 60 mg and 70 mg of rt-PA, with a new bolus of 30 mg at 60 minutes after the procedure. A new angiographic study was performed 12-48 hours late. The high resolution ECG was taken with the ART system model 1200 EPX, before, after and 72 hours later. The presence of electrical activity in the last 40 ms of the QRS complex with less than 20 mu volts in amplitude and more than 35 ms in duration characterized the LP. Results: LP was observed in 16 (46%) patients during the phase of arterial occlusion. LP was recorded only in 23% after recanalization and in 26% when the infarcted related artery (IRA) remain opened. The reduction in the LP was 43.5%. Only one patient with LP had threatening arrhythmia. Conclusion: In patients with demonstrated thrombotic occlusion of the IRA, the recanalization diminished the incidence of LP in 43.5% of the patients. Further studies are necessary to achieve the exact clinical importance of these findings.
To the Editor: The results of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress... more To the Editor: The results of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) study (Current Controlled Trials number, ISRCTN83738615) reported on by Schouten et al. (Sept. 3 issue)1 should be interpreted carefully. The reduction of cardiac complications observed in the fluvastatin group cannot be generalized to all patients undergoing vascular surgery. Indeed, inclusion criteria required at least 51 points on a prespecified risk index. This requirement excluded 356 patients from the study. In addition, 798 patients who were already receiving statins were excluded; this was probably an initial response to the guidelines on perioperative evaluation from the American College of Cardiology and the American Heart Association which recommended the use of these drugs.2 These guidelines were published after the results of our randomized, controlled trial on this subject.3 In that trial, we found that the use of 20 mg of atorvastatin reduced cardiac events in all patients referred for vascular surgery. Despite the fact that we did not have prespecified risk index as an exclusion criterion, we conclude that the available evidence does not provide support for the use of statins to reduce the risk of cardiac events among all patients.
Constrictive pericarditis is typically a chronic and progressive condition characterised by debil... more Constrictive pericarditis is typically a chronic and progressive condition characterised by debilitating chronic right heart failure and surgical pericardiectomy remains the treatment of choice. Although most cases of acute pericarditis are self-limiting, an uncommon but known complication is a transient form of constrictive pericarditis that shares the same clinical features with the chronic form but resolves without surgical intervention.We report a case of a 29-year-old man with acute idiopathic pericarditis complicated with overt signs of constriction with complete recovery after medical treatment. The knowledge of this transient pattern of cardiac constriction complicating acute pericarditis may avoid unnecessary morbidity and mortality related to surgical procedure in a pericardium with acute inflammatory reaction.
The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) coul... more The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) could lead to a dangerous decrease in blood pressure coronary perfusion. To evaluate the safety aspects and haemodynamic effects of this combination, we studied 36 first 'Q wave' thrombolysed anterior wall AMI patients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusion of nitroglycerin and were submitted to pulmonary artery catheterization. Those patients with mean arterial pressure (MAP) > or = 70 mmHg, cardiac index > or = 2.2 l.min-1.m-2, and wedge pressure > or = 10 mmHg were included and randomized to receive 6.25 mg of captopril every 6 h on the first day and 12.5 mg qid on the second if MAP > or = 70 mmHg (group 1). A second group (group 2) received a placebo. Haemodynamic parameters were determined after 1, 6 and then every 6 h up to 48 h after basal measurements. Significant differences were observed only for the MAP and the rate-pressure product (reduction in group 1 values, P < 0.05). However, MAP was maintained within acceptable limits. Our data support the fact that the combination of captopril and nitroglycerin in the early hours of a non-complicated anterior wall AMI is safe, and could guarantee its use in large clinical trials to determine the effects on left ventricle remodelling and survival after AMI.
Perioperative Anemia: How Low Can We Tolerate? To the Editor We read with great interest the stud... more Perioperative Anemia: How Low Can We Tolerate? To the Editor We read with great interest the study by Spolverato and colleagues1 recently published in JAMA Surgery. They elegantly explore the effect of acute anemia on the perioperative period of major abdominal surgery, showing that a lower nadir hemoglobin (Hb) level and a higher percentage of individual hemoglobin loss are correlated with an increased risk of cardiovascular events among patients without preoperative anemia. Most of the evidence for the management of anemia after noncardiac surgery comes from the extrapolation of results obtained from cardiac surgery trials, with important limitations. While cardiac surgery patients are potentially more vulnerable to hemoglobin fluctuations owing to an underlying cardiomyopathy, myocardial revascularization or a valve replacement could obviate the oxygen supply-demand mismatch, attenuating the incidence of cardiac events. We believe that the rate of perioperative complications for patients with a change in the Hb level (ΔHb) of 50% or greater and/or a nadir Hb level of less than 7 g/dL (to convert to grams per liter, multiply by 10.0) observed by Spolverato and colleagues1 would be even greater if the population were older (median age, 59 years; interquartile range, 49-69 years) and had a greater prevalence of cardiac disease, such as heart failure (only 2.2% in their study1). Actually, we have previously observed in our cohort of 286 vascular surgery patients with a median age of 68 years (interquartile range, 61-74 years), 24% with heart failure and 36% with known coronary artery disease, that the degree of acute anemia was more important than the preoperative hemoglobin level for the occurrence of ischemic complications (15.7%).2 The degree of acute anemia was independently associated with cardiovascular events, so that patients with a postoperative nadir Hb level below 9 g/dL had more than twice the events than did patients with a nadir Hb level above or equal to 9 g/dL (odds ratio, 2.3 [95% CI, 1.074.96]; P = .03). The mean (SD) ΔHb was higher in patients with ischemic complications than in patients without (30% [13%] vs 26% [13%]; P = .05). Preoperative anemia was present in 25.5% of patients, but it was not related to cardiovascular events. Whether or not packed red blood cell transfusion can modify the effect of acute anemia on the prognosis of surgical patients3 remains to be determined, but there is no doubt that studies such the one by Spolverato and colleagues1 are important steps toward the answer. Future studies in noncardiac surgery are still needed to guide transfusion practice and cardioprotective measures in the very particular scenario of perioperative acute anemia.
Purpose: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA ... more Purpose: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA for myocardial infarction (MI). Methods: Thirty-eight MI patients, 28 male, mean age 51 +/- 9 years, submitted to thrombolysis with rt-PA, divided in two groups according the result of the thrombolysis: A) Successful, B) Failure. Serum fibrinogen (SF) was assessed before and 90 minutes after treatment. Lp (a) levels were determined six months later. These parameters were analyzed in both groups. Results: Lp (a) levels were similar in groups A and B (p = 0.45). The SF levels were not different in the groups. Conclusion: Lp (a) seems to have no influence in thrombolysis with rt-PA for MI.
This study evaluates the association between the presence of diagonal earlobe creases (ELC) and c... more This study evaluates the association between the presence of diagonal earlobe creases (ELC) and coronary artery disease (CAD). One thousand four hundred twenty-four patients (760 men and 664 women, aged 30 to 80 years) were examined for the presence of ELC and classified into 2 groups: group I control--1,086 consecutive patients who denied symptoms of myocardial ischemia and were admitted to a general hospital for other reasons; group II CAD--338 patients with documented CAD (presence of > or = 70% coronary diameter stenosis at angiography). ELC was present in 304 patients (28%) in group I and 220 (65%) in group II (p < 0.0001). The patients were stratified in age groups to isolate the influence of age because the prevalence of ELC and CAD increased with advancing age (p < 0.0001 for both). This association remained statistically significant in all decades, except for patients aged > 70 years. To further remove the confounding effect of different age and sex distributions between the groups, a direct adjustment of the ELC prevalence was performed. When adjusted for age and sex, the prevalence of creases was still 58% higher in patients with CAD than in control subjects (p < 0.001). The presence of ELC was also related to the extent of CAD as measured by the number of major arteries narrowed (p = 0.015). The observed sensitivity of the sign for the diagnosis of CAD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%.
Purpose: Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis w... more Purpose: Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis with success. Material and methods: Thirty-five patients with acute myocardial infarction, 32 (91.4%) male with ages varying from 33 to 68 (mean 52.6). Thrombolysis was obtained during cinecoronarography with intravenous infusion "in bolus" of doses of 50 mg, 60 mg and 70 mg of rt-PA, with a new bolus of 30 mg at 60 minutes after the procedure. A new angiographic study was performed 12-48 hours late. The high resolution ECG was taken with the ART system model 1200 EPX, before, after and 72 hours later. The presence of electrical activity in the last 40 ms of the QRS complex with less than 20 mu volts in amplitude and more than 35 ms in duration characterized the LP. Results: LP was observed in 16 (46%) patients during the phase of arterial occlusion. LP was recorded only in 23% after recanalization and in 26% when the infarcted related artery (IRA) remain opened. The reduction in the LP was 43.5%. Only one patient with LP had threatening arrhythmia. Conclusion: In patients with demonstrated thrombotic occlusion of the IRA, the recanalization diminished the incidence of LP in 43.5% of the patients. Further studies are necessary to achieve the exact clinical importance of these findings.
To the Editor: The results of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress... more To the Editor: The results of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) study (Current Controlled Trials number, ISRCTN83738615) reported on by Schouten et al. (Sept. 3 issue)1 should be interpreted carefully. The reduction of cardiac complications observed in the fluvastatin group cannot be generalized to all patients undergoing vascular surgery. Indeed, inclusion criteria required at least 51 points on a prespecified risk index. This requirement excluded 356 patients from the study. In addition, 798 patients who were already receiving statins were excluded; this was probably an initial response to the guidelines on perioperative evaluation from the American College of Cardiology and the American Heart Association which recommended the use of these drugs.2 These guidelines were published after the results of our randomized, controlled trial on this subject.3 In that trial, we found that the use of 20 mg of atorvastatin reduced cardiac events in all patients referred for vascular surgery. Despite the fact that we did not have prespecified risk index as an exclusion criterion, we conclude that the available evidence does not provide support for the use of statins to reduce the risk of cardiac events among all patients.
Constrictive pericarditis is typically a chronic and progressive condition characterised by debil... more Constrictive pericarditis is typically a chronic and progressive condition characterised by debilitating chronic right heart failure and surgical pericardiectomy remains the treatment of choice. Although most cases of acute pericarditis are self-limiting, an uncommon but known complication is a transient form of constrictive pericarditis that shares the same clinical features with the chronic form but resolves without surgical intervention.We report a case of a 29-year-old man with acute idiopathic pericarditis complicated with overt signs of constriction with complete recovery after medical treatment. The knowledge of this transient pattern of cardiac constriction complicating acute pericarditis may avoid unnecessary morbidity and mortality related to surgical procedure in a pericardium with acute inflammatory reaction.
The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) coul... more The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) could lead to a dangerous decrease in blood pressure coronary perfusion. To evaluate the safety aspects and haemodynamic effects of this combination, we studied 36 first 'Q wave' thrombolysed anterior wall AMI patients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusion of nitroglycerin and were submitted to pulmonary artery catheterization. Those patients with mean arterial pressure (MAP) > or = 70 mmHg, cardiac index > or = 2.2 l.min-1.m-2, and wedge pressure > or = 10 mmHg were included and randomized to receive 6.25 mg of captopril every 6 h on the first day and 12.5 mg qid on the second if MAP > or = 70 mmHg (group 1). A second group (group 2) received a placebo. Haemodynamic parameters were determined after 1, 6 and then every 6 h up to 48 h after basal measurements. Significant differences were observed only for the MAP and the rate-pressure product (reduction in group 1 values, P < 0.05). However, MAP was maintained within acceptable limits. Our data support the fact that the combination of captopril and nitroglycerin in the early hours of a non-complicated anterior wall AMI is safe, and could guarantee its use in large clinical trials to determine the effects on left ventricle remodelling and survival after AMI.
Perioperative Anemia: How Low Can We Tolerate? To the Editor We read with great interest the stud... more Perioperative Anemia: How Low Can We Tolerate? To the Editor We read with great interest the study by Spolverato and colleagues1 recently published in JAMA Surgery. They elegantly explore the effect of acute anemia on the perioperative period of major abdominal surgery, showing that a lower nadir hemoglobin (Hb) level and a higher percentage of individual hemoglobin loss are correlated with an increased risk of cardiovascular events among patients without preoperative anemia. Most of the evidence for the management of anemia after noncardiac surgery comes from the extrapolation of results obtained from cardiac surgery trials, with important limitations. While cardiac surgery patients are potentially more vulnerable to hemoglobin fluctuations owing to an underlying cardiomyopathy, myocardial revascularization or a valve replacement could obviate the oxygen supply-demand mismatch, attenuating the incidence of cardiac events. We believe that the rate of perioperative complications for patients with a change in the Hb level (ΔHb) of 50% or greater and/or a nadir Hb level of less than 7 g/dL (to convert to grams per liter, multiply by 10.0) observed by Spolverato and colleagues1 would be even greater if the population were older (median age, 59 years; interquartile range, 49-69 years) and had a greater prevalence of cardiac disease, such as heart failure (only 2.2% in their study1). Actually, we have previously observed in our cohort of 286 vascular surgery patients with a median age of 68 years (interquartile range, 61-74 years), 24% with heart failure and 36% with known coronary artery disease, that the degree of acute anemia was more important than the preoperative hemoglobin level for the occurrence of ischemic complications (15.7%).2 The degree of acute anemia was independently associated with cardiovascular events, so that patients with a postoperative nadir Hb level below 9 g/dL had more than twice the events than did patients with a nadir Hb level above or equal to 9 g/dL (odds ratio, 2.3 [95% CI, 1.074.96]; P = .03). The mean (SD) ΔHb was higher in patients with ischemic complications than in patients without (30% [13%] vs 26% [13%]; P = .05). Preoperative anemia was present in 25.5% of patients, but it was not related to cardiovascular events. Whether or not packed red blood cell transfusion can modify the effect of acute anemia on the prognosis of surgical patients3 remains to be determined, but there is no doubt that studies such the one by Spolverato and colleagues1 are important steps toward the answer. Future studies in noncardiac surgery are still needed to guide transfusion practice and cardioprotective measures in the very particular scenario of perioperative acute anemia.
Purpose: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA ... more Purpose: To evaluate the influence of lipoprotein (a) (Lp (a)) levels in thrombolysis with rt-PA for myocardial infarction (MI). Methods: Thirty-eight MI patients, 28 male, mean age 51 +/- 9 years, submitted to thrombolysis with rt-PA, divided in two groups according the result of the thrombolysis: A) Successful, B) Failure. Serum fibrinogen (SF) was assessed before and 90 minutes after treatment. Lp (a) levels were determined six months later. These parameters were analyzed in both groups. Results: Lp (a) levels were similar in groups A and B (p = 0.45). The SF levels were not different in the groups. Conclusion: Lp (a) seems to have no influence in thrombolysis with rt-PA for MI.
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Papers by Bruno Caramelli