A 23-year-old man presented with cough and progressive shortness of breath. Echocardiogram showed a biscupid aortic valve with a large vegetation causing severe regurgitation. Blood cultures were positive for Neisseria gonorrhoeae sensitive to cefotaxime and penicillin. Despite direct antibiotherapy, the patient required cardiac surgery with aortic valve replacement.
Background and Aims There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. Methods A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0–4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. Results At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12–2.26) and 2.92 (1.99–4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93–1.87) and 1.97 (1.33–2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Conclusions Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.
Thoracic outlet syndrome results from neurovascular compression at the thoracic outlet. Clinical presentation varies according to the predominantly compressed structure, determining its subtype: neurogenic, venous, or arterial. The neurogenic subtype is the most common, affecting 90% of patients, while the vascular subtype is rarely found in practice. We present two case reports of young patients with upper extremity deep vein thrombosis in the setting of venous thoracic outlet syndrome: one due to an anatomic variant, the second an effort thrombosis due to repeated upper arm exercise. These reports depict uncommon clinical scenarios, which imply significant morbidity if not identified and timely treated.
Oliveira et al. Achados cardiovasculares na esclerose tuberosa ReferênciasEste é um artigo de acesso aberto distribuído sob os termos da licença de atribuição pelo Creative Commons Potencial Conflito de InteresseDeclaro não haver conflito de interesses pertinentes. Fontes de FinanciamentoO presente estudo não teve fontes de financiamento externas. Vinculação AcadêmicaNão há vinculação deste estudo a programas de pós-graduação.
Background Chronotropic incompetence (CI) is defined as the inability to increase heart rate (HR) in response to increased activity. It is common in patients (pts) with cardiovascular (CV) disease, being a predictor of major adverse CV events; however, its importance is often underestimated in clinical practice. Purpose Evaluate the prognostic value of CI in pts with known coronary artery disease (CAD) who performed Bruce protocol treadmill testing. Methods Unicentric, retrospective analysis of consecutive pts with known CAD who underwent Bruce protocol treadmill testing between 2009 and 2010. Chronotropic index (ChI) was calculated as:(peak HR–resting HR)/(220–age–resting HR). CI was defined as ChI < 80% (< 62% in pts prescribed with beta-blockers). Pts were divided in two groups-G1: CI and G2: normal chronotropic response. Events were defined as: de novo heart failure (HF), CAD progression, myocardial infarction (MI), stroke, all-cause mortality and CV mortality. Results A total of 471 pts were included (87.3% male, mean age 69 ± 9.8 years). Mean follow-up was 9.7 years. The groups were similar regarding sex, age, body mass index, diabetes, arterial hypertension, dyslipidemia, MI and left ventricle ejection fraction (P > 0.050). CI was identified in 27.4% pts. Comparing G1 vs. G2, no differences were found related to all-cause mortality, de novo HF, CAD progression, MI and stroke (P > 0.050). However, statistically significant differences were found regarding CV mortality (P = 0.028). Conclusion CI is a simple an easily available parameter that shows a clear association with CV mortality in a long-term follow-up of pts with CAD.
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