Beneficial effect of long-term use of a beta-blocker in patients before acute myocardial infarction

The outcome of 38 beta-blocker users (group BB, 28 men and 10 women with a mean age of 56 +/- 4 years) was compared to that of 100 non-users (group NU, 69 men and 31 women with a mean age of 57 +/- 8 years) after acute myocardial infarction (AMI). The two groups were compared in terms of electrocardiographic (EKG) location of the AMI (anterior, inferior and lateral), EKG Q and non-Q wave infarction, clinical functional class of Forrester, serum creatine phosphokinase MB fraction (CKMB) peak release and intrahospital mortality. There were no differences between groups concerning sex or severity of coronary artery disease but arterial hypertension was 2-fold more prevalent in group BB. The EKG location of the AMI was similar in the two groups. Non-Q infarction was significantly more prevalent in group BB (37%) than in group NU (6%). The incidence of clinical functional class IV of Forrester and the serum CKMB peaks were significantly lower in group BB (2.6% vs 16.0% and 53 +/- 3 vs 68 +/- 9 IU/l, respectively). Intrahospital mortality was also significantly lower in group BB (2.6%) than in group NU (10%). These data suggest the beneficial effect of previous long-term use of beta-blockers as indicated by a lower incidence of cardiogenic shock and a significant decrease in intrahospital mortality after AMI.

Cardiac and neurologic complications in malignant hypertension due to oral contraceptive use

Malignant hypertension is a rare consequence of contraceptive use. We report here on two young women with malignant hypertension secondary to contraceptive use whose main symptomatology was neurological. Both patients had renal failure, severe left ventricle hypertrophy, and hemorrhagic stroke, all reversible after control of blood pressure and discontinuation of the contraceptive pill.

[Hemodynamic behavior of the right ventricle in acute inferior wall myocardial infarction: comparison between patients with and without cardiogenic shock]

PURPOSE

To evaluate the hemodynamic profile of patients (pts) with acute inferior wall myocardial infarction (AMI) and dysfunction of right ventricle (RV).

METHODS

Ninety nine consecutive pts (aged 56.6 +/- 3.4 years), 47 men, with inferior AMI and RV dysfunction were studied. RV infarction was diagnosed based on ST segment elevation (> lmm) in precordial V4R lead and RV abnormalities found in echocardiography. All pts were undergone to bedside hemodynamic studies, by measuring mean right atrial (RAP), pulmonary artery (PAP), wedge pulmonary (PWP), and radial artery (AP) pressures and cardiac output (CO). Cardiac index (CI), pulmonary (PAR) and systemic arterial resistance (SAR) were calculated in dynes x sec x cm-5. Left ventricle (LV) ejection fraction (EF) and RV-EF were obtained by contrast ventriculography. Cardiogenic shock was diagnosed based on AP < or = 70 mmHg, RAP > or = 7 mmHg, PWP < or = 20mm Hg, CI < or = 1.8l/min/m2 and oliguria. Pts were then subdivided in 2 groups: with cardiogenic shock (group A, n = 41) with a mean age of 55.4 +/- 2.1 and without shock (group B, n = 58) with a mean age of 57.2 +/- 1.7.

RESULTS

No significant differences between groups regarding RAP, PWP, AP and LVEF were observed, but compared to group B, group A had lower CI (1.3 +/- 0.3 vs 2.6 +/- 0.5 l/min/m2, p < 0.05), higher SVR (2314 +/- 252 vs 1324 +/- 324 dynes.sec.cm-5, p < 0.01), and lower RVEF (0.27 +/- 0.08 vs 0.41 +/- 0.11%, p < 0.05).

CONCLUSION

Pts with inferior AMI and RV dysfunction, cardiogenic shock depends on of RV failure and is independent of a preserved LV function.

[Percutaneous angioplasty and surgical revascularization in renovascular hypertension: experience in treatment and long-term follow up in 124 patients]

PURPOSE

To report the experience in the treatment and long-term follow-up of patients with renovascular hypertension submitted to angioplasty and/or surgical revascularization, and to compare blood pressure and renal function responses to both treatment.

METHODS

One hundred and twenty-four patients diagnosed with renovascular hypertension, divided, according to the etiology, as atherosclerosis (76 patients), fibromuscular dysplasia (32) and arteritis (16), were submitted to isolated or associated treatment of renal revascularization by percutaneous transluminal angioplasty (71 patients) or surgery (84). The patients were followed-up during 2.5 +/- 1.5 years and we evaluate blood pressure response and renal function preservation. In relation to blood pressure control, the patients were considered as cured when normotensives without antihypertensives, improved when normotensives with fewer drugs than previously, and unchanged, when out of these criteria.

RESULTS

From 124 patients, 20% were considered cured, 54% improved and 26% unchanged, after a mean follow-up of 2.5 +/- 1.5 years. Patients with atherosclerosis and fibromuscular dysplasia presented a higher rate of care and improvement after surgery. The blood pressure and the number of antihypertensive drugs decreased significantly during the follow-up among patients that cured or improved arterial hypertension, either after angioplasty (190 +/- 26/115 +/- 14 mmHg vs 130 +/- 34/85 +/- 7 mmHg. 2.70 vs 1.60 drugs) or after surgery (194 +/- 17/115 +/- 16 mmHg vs 143 +/- 18 mmHg vs 88 +/- 8 mmHg, 1.88 vs 1.51 drugs). It was also observed a significant decrease of serum creatinine among these patients.

CONCLUSION

Renal revascularization in patients with renovascular hypertension, either by angioplasty or surgery, is beneficial to control blood pressure and to preserve renal function in the majority of patients.

[Primary hyperaldosteronism and adrenal tumors. Clinico-surgical experience with 9 patients]

PURPOSE

To report seven patients with diagnosis of primary aldosteronism, five of them due to aldosterone-producing adenoma (APA) and two due to idiopathic hyperaldosteronism (IHA), and two patients with adrenal non-producing tumors in order to discuss our experience on differential diagnosis and treatment of this hypertensive disease.

METHODS

Hypokalemia and higher values of urinary potassium in the absence of diuretics were useful to the screening diagnosis of primary aldosteronism, reinforced by suppressed plasma renin activity either at rest and after deambulation and by higher values of plasma aldosterone. Computerized tomography in all patients and selenium-cholesterol scintigraphy were used to make the localization of tumors and differential diagnosis between APA and IHA.

RESULTS

The patients with adrenal tumors were submitted to surgical treatment and the two patients with IHA were submitted to spironolacone therapy. After 1 to 5 years of follow-up, we observed cure of hypertension and hypokalemia in three patients after surgery and improvement of blood pressure control and normalization of serum potassium in the six others.

CONCLUSION

The diagnosis of primary aldosteronism is important, besides its rarity, because surgical or appropriated clinical treatment provide cure of hypertension or improvement of blood pressure control in most of patients.

[Proteinuria in patients with congestive heart failure. Role of arterial hypertension]

PURPOSE

To evaluate the role of arterial hypertension (AH) in the development of proteinuria in patients with decompensated congestive heart failure (CHF).

METHODS

Twenty-four-hour urinary protein determinations were obtained from 30 patients with decompensated CHF, before and after therapy of CHF. The patients were divided in two groups according with the presence of AH as cause of CHF: group A, 18 patients with CHF due to AH and group B, 12 patients with CHF due to idiopathic dilated or chagasic cardiomyopathy without previous AH.

RESULTS

There was no differences between the groups concerning age, sex, renal function and duration of CHF. Before treatment, 88% of group A presented proteinuria exceeding 150 mg/24h compared to 25% of group B (p < 0.01). After treatment of CHF, proteinuria > 150 mg/24 h remained in 38% of group A and in none of group B. Proteinuria did not reverse after 6 months of follow-up in 2 patients, one of them showed benign nephrosclerosis in renal biopsy.

CONCLUSION

Patients with decompensated CHF, unrelated to AH, presented mild proteinuria reversible after the treatment, that improved renal function. In patients with CHF due to AH, proteinuria was more frequent, more severe and did not improve after the treatment, suggesting renal lesion.

Ventricular function by radionuclide ventriculography in malignant hypertension

Malignant hypertension is a unique and natural model for the study of abnormalities of left ventricular function due to arterial hypertension, because the development and regression of these abnormalities can be observed in a short period. Studies of ventricular function by radionuclide ventriculography, either before or after therapy, have not been previously reported in malignant hypertensive patients. We used this methodology to study left ventricular function in 17 malignant/accelerated hypertensive patients at the time of admission to the hospital and 3, 6, and 9 months after discharge. Seventy percent of patients (12 of 17) had symptoms of congestive heart failure at admission. We compared these data with those obtained in 12 normotensive subjects and 13 mild-to-moderate untreated hypertensive patients. Blood pressure of malignant hypertensive patients was 213 +/- 26/140 +/- 17 mm Hg at admission and 165 +/- 23/101 +/- 15 after 9 months of therapy. Radionuclide ventriculography at admission showed that peak filling rates of malignant hypertensive patients (2.13 +/- 0.21 end-diastolic volume [counts] [EDV]/sec) were significantly lower than those in normotensive subjects (2.40 +/- 0.41) and in mild-to-moderate hypertensive patients (2.46 +/- 0.21). In contrast, peak ejection rates were significantly higher in malignant hypertensive patients (3.44 +/- 0.38 EDV/sec) than in the two control groups (3.01 +/- 0.32 and 3.10 +/- 0.43, respectively). Ejection fractions were similar in the three groups of patients. After 9 months of therapy, peak filling rates of malignant hypertensive patients increased to 2.38 +/- 0.35 EDV/sec, whereas peak ejection rates decreased to 2.89 +/- 0.43 EDV/sec, both not significantly different from data in controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Infective endocarditis related to acute cholecystitis

A 30-year-old woman with a homologous dura-mater valve prosthesis developed infective endocarditis related to acute purulent cholecystitis occurring in chronic cholelithiasis. During anti-bacterial treatment refractory heart failure ensued which compelled replacement of the infected prosthesis. She died in the post-operative period. Autopsy revealed endocarditis on the implanted bioprosthesis, purulent cholecystitis and a gallbladder stone. It is warningly concluded that the surgical treatment of endocarditis was unsuccessful because of persistence of purulent cholecystitis that led to reinfection of the inserted prosthesis.