Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure - demographics, etiologic and pulmonary histologic analysis

OBJECTIVES: Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life. METHODS: This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression. RESULTS: In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema. CONCLUSIONS: For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported

Post-Mortem Histological Pulmonary Analysis in Patients with HIV/AIDS

OBJECTIVES: Certain aspects of pulmonary pathology observed in autopsies of HIV/AIDS patients are still unknown. This study considers 250 autopsies of HIV/AIDS patients who died of acute respiratory failure and describes the demographic data, etiology, and histological pulmonary findings of the various pathologies. METHODS: The following data were obtained: age, sex, and major associated diseases (found at the autopsy). Pulmonary histopathology was categorized as: diffuse alveolar damage; pulmonary edema; alveolar hemorrhage; and acute interstitial pneumonia. Odds ratio of the HIV/AIDS-associated diseases developing a specific histopathological pattern was determined by logistic regression. RESULTS: A total of 197 men and 53 women were studied. The mean age was 36 years. Bacterial bronchopneumonia was present in 36% (91 cases) and Pneumocystis jiroveci pneumonia in 27% (68) of patients. Pulmonary histopathology showed acute interstitial pneumonia in 40% (99), diffuse alveolar damage in 36% (89), pulmonary edema in 13% (33), and alveolar hemorrhage in 12% (29) of patients. Multivariate analysis showed a significant and positive association between Pneumocystis jiroveci pneumonia and acute interstitial pneumonia (Odds ratio, 4.51; 95% CI, 2.46 - 8.24; p < 0.001), severe sepsis and/or septic shock and diffuse alveolar damage (Odds ratio, 3.60; 95% CI, 1.78 -7.27; p < 0.001), and cytomegalovirus and acute interstitial pneumonia (Odds ratio, 2.22; 95% CI, 1.01 - 4.93; p = 0.05). CONCLUSIONS: This report is the first autopsy study to include demographic data, etiologic diagnosis, and respective histopathological findings in patients with HIV/AIDS and acute respiratory failure. Further studies are necessary to elucidate the complete pulmonary physiopathological mechanism involved with each HIV/AIDS-associated disease

Peritonite bacteriana espontânea causada por Listeria monocytogenes em pacientes com cirrose: primeiro relato de caso no Brasil

Two cases of spontaneous bacterial peritonitis (SBP) caused by Listeria monocytogenes in cirrhotic patients are reported. In one of the cases, the microorganism was isolated from pleural effusion and ascites. SBP is a serious and common complication of patients with ascites caused by hepatic cirrhosis and the culture of the ascitic fluid is an important tool for the diagnosis and for the more appropriate treatment. Although a third generation cephalosporin has usually been employed for empiric treatment of SBP, it does not provide adequate coverage against Listeria spp. In such cases the use of ampicillin (with or without sulbactam) or sulfamethoxazole-trimethoprim is recommended. The last one is used for secondary prophylaxis, instead of norfloxacin. To summarize, Listeria monocytogenes infection is a rare cause of SBP, whose treatment should be specific for the bacteria.Foram relatados dois casos de peritonite bacteriana espontânea (PBE) por Listeria monocytogenes em pacientes com cirrose. Em um dos casos isolamos também o agente no líquido pleural. A PBE é uma complicação comum e grave de pacientes com ascite por cirrose e a cultura do líquido ascítico é de grande importância para o diagnóstico e para o tratamento mais adequado. Embora uma cefalosporina de terceira geração seja geralmente utilizada para o tratamento empírico da PBE, ela não oferece cobertura adequada contra a Listeria spp. Nesses casos, recomenda-se o uso de ampicilina (com ou sem sulbactam) ou sulfametoxazol-trimetoprim. Para a profilaxia secundária indica-se o uso deste último, ao invés da norfloxacina. Em resumo, a infecção por Listeria monocytogenes é uma causa rara de PBE e o tratamento específico deve ser administrado

Coronary artery disease in women: a review on prevention, pathophysiology, diagnosis, and treatment

Despite numerous studies on women's cardiac health throughout the past decade, the number of female deaths caused by cardiovascular disease still rises and remains the leading cause of death in women in most areas of the world. Novel studies have demonstrated that cardiovascular disease, and more specifically coronary artery disease presentations in women, are different than those in men. In addition, pathology and pathophysiology of the disease present significant gender differences, which leads to difficulties concerning diagnosis, treatment and outcome of the female population. The reason for this disparity is all steps for female cardiovascular disease evaluation, treatment and prevention are not well elucidated; and an area for future research. This review brings together the most recent studies published in the field of coronary artery disease in women and points out new directions for future investigation on some of the important issues

Demographic, etiological, and histological pulmonary analysis of patients with acute respiratory failure: a study of 19 years of autopsies

INTRODUCTION: Acute respiratory failure has been one of the most important causes of death in intensive care units, and certain aspects of its pulmonary pathology are currently unknown. OBJECTIVES: The objective was to describe the demographic data, etiology, and pulmonary histopathological findings of different diseases in the autopsies of patients with acute respiratory failure. METHOD: Autopsies of 4,710 patients with acute respiratory failure from 1990 to 2008 were reviewed, and the following data were obtained: age, sex, and major associated diseases. The pulmonary histopathology was categorized as diffuse alveolar damage, pulmonary edema, alveolar hemorrhage, and lymphoplasmacytic interstitial pneumonia. The odds ratio of the concordance between the major associated diseases and specific autopsy findings was calculated using logistic regression. RESULTS: Bacterial bronchopneumonia was present in 33.9% of the cases and cancer in 28.1%. The pulmonary histopathology showed diffuse alveolar damage in 40.7% (1,917) of the cases. A multivariate analysis showed a significant and powerful association between diffuse alveolar damage and bronchopneumonia, HIV/AIDS, sepsis, and septic shock, between liver cirrhosis and pulmonary embolism, between pulmonary edema and acute myocardial infarction, between dilated cardiomyopathy and cancer, between alveolar hemorrhage and bronchopneumonia and pulmonary embolism, and between lymphoplasmacytic interstitial pneumonia and HIV/ AIDS and liver cirrhosis. CONCLUSIONS: Bronchopneumonia was the most common diagnosis in these cases. The most prevalent pulmonary histopathological pattern was diffuse alveolar damage, which was associated with different inflammatory conditions. Further studies are necessary to elucidate the complete pathophysiological mechanisms involved with each disease and the development of acute respiratory failure

Avaliação semiquantitativa da biópsia pulmonar cirúrgica: valor preditivo e impacto na sobrevida de pacientes com infiltrado pulmonar difuso

PURPOSE: Surgical lung biopsy has been studied in distinct populations, mostly going beyond clinical issues to impinge upon routine histopathological diagnostic information in diffuse infiltrates; however, detailed tissue analyses have rarely been performed. The present study was designed to investigate the prognostic contribution provided by detailed tissue analysis in diffuse infiltrates. METHODS: Medical records and surgical lung biopsies from the period of 1982 to 2003 of 63 patients older than 18 years with diffuse infiltrates were retrospectively examined. Lung parenchyma was histologically divided into 4 anatomical compartments: interstitium, airways, vessels, and alveolar spaces. Histological changes throughout these anatomical compartments were then evaluated according to their acute or chronic evolutional character. A semiquantitative scoring system was applied to histologic findings to evaluate the intensity and extent of the pathological process. We applied logistic regression to predict the risk of death associated with acute and chronic histological changes and to estimate the odds ratios for each of the independent variables in the model. RESULTS: Impact on survival was found for male gender (P = 0.03), presence of diffuse alveolar damage (P = 0.001), and chronic histological changes (P = 0.0004) on biopsy. Thus, being male was associated with a slightly lower risk (O.R. = 0.18; P=0.03) of dying than being female. Death risk was increased 17 times in the presence of acute histological changes such as diffuse alveolar damage and 2.5 times in the presence of chronic histological changes. CONCLUSION: Detailed analysis of histological specimens can provide more than a nosological diagnosis: this approach can provide valuable information concerning prognosis.PROPOSIÇÃO: A biópsia pulmonar cirúrgica tem sido estudada em populações distintas, geralmente abordando aspectos histopatológicos puramente diagnósticos em infiltrados pulmonares difusos, além de dados clínicos. Contudo, análises teciduais detalhadas em tais casos têm sido pouco exploradas. O presente estudo foi delineado com o intuito de se investigar a contribuição prognóstica fornecida pela análise histológica detalhada em infiltrados difusos. MÉTODOS: Foram examinados retrospectivamente os prontuários e biópsias pulmonares cirúrgicas de 63 pacientes maiores de 18 anos, com infiltrados difusos, de 1982 a 2003. O parênquima pulmonar foi dividido em 4 compartimentos histológicos: interstício, vias aéreas, vasos e espaços alveolares. Alterações histológicas de cada compartimento histológico foram então avaliadas de acordo com seu caráter evolutivo agudo ou crônico. Um escore semiquantitativo foi aplicado a achados histopatológicos com o intuito de se avaliar a intensidade e a extensão do processo patológico. Aplicamos regressão logística para predizer o risco de morte para alterações histológicas agudas e crônicas e para estimar a razão de probabilidades para cada uma das variáveis independentes do modelo. RESULTADOS: O impacto sobre a sobrevida foi observado para o gênero masculino (p=0.03), para a presença de dano alveolar difuso (p=0.001) e para alterações histológicas crônicas (p=0.0004) em biópsias. Assim, homens apresentariam menor chance (O.R. = 0.18; P=0.03) de morrer do que mulheres. O risco de morte foi 17 vezes maior na presença de alterações histológicas agudas como dano alveolar difuso e 2,5 vezes na presença de alterações histológicas crônicas. CONCLUSÃO: A análise detalhada de espécimes histológicos pode proporcionar maiores e mais valiosas informações de valor prognóstico do que o simples diagnóstico nosológico

Mortality associated factors in patients with acute pulmonary edema

Introduction: Risk factors related to acute pulmonary edema are still poorly described. However, they are determinant in the perspective of treatment. Methods: This is a retrospective, unicentric and observational study which aim was to evaluate factors related to mortality in patients with acute pulmonary edema. A total of 142 patients were included between January of 2,015 and 2,016. The following factors were evaluated: age, systolic and diastolic pressures, heart rate, creatinine, C-reactive protein, BNP, left ventricular ejection fraction, left ventricular diastolic diameter, troponin, left atrial diameter and pulmonary arterial systolic pressure.Statistical analysis: Evaluation of factors according to occurrence or not of death was performed through Q-square and T-test, being considered significant p &lt;0.05. The complementary analysis of the factors was done by ROC curve to identify the sensitivity and specificity of the best cut-off point of risk factors as a probability of death discriminator.Results: About 49% of the patients were males and the mean age was 69 years. Hypertensive etiology was the most prevalent (42.3%) followed by valve disease (29.5%) and ischemia (14.8%). The in-hospital mortality rate was 15.5%. There were significant differences between patients who died or not, respectively, in the following factors: age (73.6 x 67.6, p = 0.024), C-reactive protein (64.9 mg/dL x 39.7 mg/dL, p = 0.042), troponin (7.41 ng/dL x 2.58 ng/dL, p = 0.007)and diastolic blood pressure (74.2 mmHg x 88.6 mmHg, p = 0.023). The areas under the ROC curve between risk and death factors were: age = 0.640; C-reactive protein = 0.640; Troponin = 0.660; Diastolic blood pressure = 0.318. Best cut-off points to discriminate the risk of death were: age = 67.5 (sensitivity of 72.7% and specificity of 54%), C-reactive protein = 21.5 mg/dL (sensitivity of 66.7% and specificity of 58%), troponin = 0.73 ng/dL (sensitivity of 63.6% and specificity of 65%) and diastolic blood pressure = 87.5 mmHg (sensitivity of 29.4% and specificity of 49%).Conclusion: Mortality in patients with acute pulmonary edema remains high. Age, C-reactive protein, troponin, and diastolic blood pressure were the factors related to mortality

Effect of &#946;-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction

INTRODUCTION: Oral &#946;-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with &#946;-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of &#946;-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral &#946;-blockers and mortality during the first 24 hours. RESULTS: a) The use of &#946;-blockers was inversely correlated with the presence of atrial fibrillation (&#961; = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5% in patients with atrial fibrillation, 9.2% in those without atrial fibrillation (&#961; < 0.001; Odds Ratio = 4.52), and 17.5% in patients not treated with &#946;-blockers and 6.7% in those who received the drug (&#961; < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, &#961; = 0.002). The use of &#946;-blockers was inversely and independently correlated with mortality (OR = 0.53; &#961; = 0.002). The patients who used &#946;-blockers showed a lower risk of atrial fibrillation (OR = 0.59; &#961; = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral &#946;-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral &#946;-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit

Effect of β-Blockers on the Risk of Atrial Fibrillation in Patients with Acute Myocardial Infarction

INTRODUCTION: Oral &#946;-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with &#946;-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of &#946;-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral &#946;-blockers and mortality during the first 24 hours. RESULTS: a) The use of &#946;-blockers was inversely correlated with the presence of atrial fibrillation (&#961; = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5% in patients with atrial fibrillation, 9.2% in those without atrial fibrillation (&#961; < 0.001; Odds Ratio = 4.52), and 17.5% in patients not treated with &#946;-blockers and 6.7% in those who received the drug (&#961; < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, &#961; = 0.002). The use of &#946;-blockers was inversely and independently correlated with mortality (OR = 0.53; &#961; = 0.002). The patients who used &#946;-blockers showed a lower risk of atrial fibrillation (OR = 0.59; &#961; = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral &#946;-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral &#946;-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit

Cardiac arrhythmias – clinical presentation and physiopathologic mechanisms

Ultimamente o conhecimento sobre arritmias cardíacas tornou-se algo extremamentenecessário a todo médico generalista. É relativamente comum encontrarmos, em todasas especialidades médicas, indivíduos com algum tipo de distúrbio do ritmo cardíaco. Sua altaincidência e potenciais riscos ao paciente fazem com que medidas diagnósticas e terapêuticasdevam ser prontamente realizadas. Neste artigo, relatamos quatro casos clínicos envolvendo odiagnóstico e tratamento de arritmias cardíacas comumente observadas em pronto-socorros,discutindo alguns dos mecanismos fi siopatológicos responsáveis pela sua gênese.The knowledge about cardiac arrhythmias has become something extremelynecessary to all physicians. It is common found people with some kind of cardiac rhythm disturbin all medical specialties. Diagnostic and therapeutic decisions should be quickly done due tothe high incidence and potential damage to the patient. In this article, we present four clinicalcases about cardiac arrhythmias, showing something related to the diagnostic, treatment andphysiopathologic mechanisms