Cardiac allograft vasculopathy is still a major issue, with significative mortality in heart transplant patients, and the best therapeutic options are not yet established. The progressively higher survival rates after transplantation have made it a major concern. This is a case report about a patient who underwent cardiac transplantation due to chagasic cardiomiopathy. During an endomyocardial biopsy more than 2 years after the transplant, the patient arrested in ventricular fibrillation, with ST-elevation in anterior leads after defibrillation. The angiography showed total occlusion of proximal left anterior descending artery, promptly treated with primary angioplasty, with excellent angiographic and clinical results.
Much has been achieved in one century after Carlos Chagas discovery. However, there is surely much to be done in the next decades. At present, we are witnessing many remarkable efforts to monitor the epidemiology of the disease, to better understand the biology of the T. cruzi and its interaction with human beings as well as the pathogenesis and pathophysiology of the complications in the chronic phase, and deal more appropriately and effectively with late cardiac and digestive manifestations. Although the vector and transfusion-derived transmission of the disease has been controlled in many countries, there remains a pressing need for sustained surveillance of the measures that led to this achievement. It is also necessary to adopt initiatives that enable appropriate management of social and medical conditions resulting from the migration of infected individuals to countries where the disease formerly did not exist. Its also necessary to standardize the most reliable methods of detection of infection with T. cruzi, not only for diagnosis purposes, but more crucially, as a cure criterion. The etiological treatment of millions of patients in the chronic stage of the disease is also to be unraveled. A renewed interest in this area is observed, including prospects of studies focusing on the association of drugs with benznidazole. We also wait for full evidence of the actual effectiveness of the etiological treatment to impact favorably on the natural history of the disease in its chronic phase. Eventually, cardiologists are primarily responsible for improving the clinical management of their patients with Chagas disease, judiciously prescribing drugs and interventions that respect, as much as possible, the peculiar pathophysiology of the disease, wasting no plausible therapeutic opportunities.
A serious complication such as dissection of the left main coronary artery, with significant reduction in coronary blood flow by the true light, requires quick action. Therefore, the immediate choice of stent with appropriate length and size to treat the complication is necessary.
despite the overwhelming evidence of its effectiveness, oral anticoagulation continues to be underused in the elderly, presumably due to physicians misconceptions when estimating bleeding risk and ability to comply with treatment.
The anaerobic threshold (AT) provides information on functional capacity in heart failure (HF). However, the visual determination of the AT by ventilatory methods is subjective, being susceptible to differences between examiners.
In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.
The efficacy and risks of oral anticoagulation are largely associated with maintaining the quality of anticoagulation control. Nevertheless, few studies have addressed which factors, if any, are associated with this control.
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