Preclinical studies suggest that in addition to the well-known direct damage to the myocardium, anthracycline antineoplastic drugs exert toxic effects on the cardiovascular autonomic system as well. To investigate whether this phenomenon occurs in the clinic, we carried out noninvasive, widely used tests of cardiovascular autonomic physiology in 55 women with stage II or III breast cancer. In all, 31 were being treated with anthracycline-containing chemotherapy regimens, and 24 who were receiving CMF (cyclophosphamide, Methotrexate, and fluorouracil) served as controls. Of 279 tests conducted in anthracycline (A)-treated patients, 123 were abnormal, vs 54 of 216 tests carried out in 24 controls (44% vs 25%; P less than 0.005). Abnormal variations in heart rate on standing and in diastolic blood pressure during handgrip was found in 25 (81%) and 17 patients receiving A, vs 9 (37%; P less than 0.005) and 5 (21%; P less than 0.0001), respectively, in controls. The incidence of abnormal tests was significantly higher in A-treated patients greater than 60 years of age (41%) vs 67%; P less than 0.05). Radionuclide ventriculography was carried out in 19 patients who showed abnormal tests of cardiovascular autonomic function after greater than or equal to 6 courses of a-containing chemotherapy; only 1 of them had abnormal cardiac contractility (global hypokinesia), suggesting that abnormal tests of cardiovascular autonomic function may occur in the absence of a detectable deterioration in left ventricular ejection fraction. A large number of factors may alter cardiovascular autonomic function in cancer patients, including age, radiation therapy to the chest, and multidrug treatment. Even after correcting for the most obvious of these, chemotherapy with anthracyclines is associated with a significantly higher percentage of abnormal tests for cardiovascular autonomic function. Although indirect and semi-quantitative, our results are compatible with the idea of A-induced cardiac autonomic dysfunction.

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Hypertension control is a difficult goal to achieve in common practice even when its benefits have been widely proved. We assessed the effectiveness of a Complex Antihypertensive Intervention Program in the Elderly (CAPE). A program trial of 500 elderly hypertensive patients was conducted. 250 were followed by primary care physicians and intervened by the CAPE and 250 received usual care. The program included an organizational change with the addition of an office where patients had their blood pressure measured, were appointed to join educational sessions and received verbal and printed advice before medical attendance. Data was systematically recorded in the electronic medical record which functioned as a physician reminder during the visit. Differences in systolic blood pressure level and in percentage of well-controlled (<140/90 mm Hg) patients between groups were measured after 12 months of follow-up. The difference of mean change in systolic blood pressure between groups was 7.1 mm Hg (95% confidence interval, 4-10 mm Hg). Sixty-seven percent of patients in the intervention group were well-controlled, as were 51% of patients in the control group (p < 0.001). Patients who attended educational sessions showed the lowest odd ratio (0.25; 95% confidence interval, 0.11-0.54) for blood pressure above 140/90 mm Hg in multivariate analysis after adjusting for age, sex, initial systolic blood pressure level, and changes in antihypertensive treatment. These results support the effectiveness of our complex intervention program. Routine clinical care of hypertension can be improved with simple strategies that go beyond pharmacotherapy, tending to overcome clinical inertia.

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We report the results of a case-control study of post-surgical mediastinitis, that we conducted for eighteen months. The aim of the study was to detect possible risk factors for mediastinal infection after cardiovascular surgery as well as to analyze related clinical features. Thirty episodes of mediastinal infections over 687 consecutive cardiovascular surgeries (4,4%) were registered during a control period of 18 month at Hospital Italiano of Buenos Aires, Argentina. Among all variables analyzed only the following were significantly associated to mediastinal infection in the postoperative period: time elapsed at the recovery unit (p < 0.01) total time with catheter placed in the pulmonary artery (p: 0.05) and the rate of postoperative complications (p < 0.01). Six patients with mediastinal infection (20%) had undergone reoperation shortly after main surgery compared to only 3 (5%) in the control group (p: 0.05). The association with surgical events may be related to post-surgical causation. The presence of fever, only after 72 hours from surgery, allowed discrimination between patients with and without mediastinal infection. All case patients showed abnormalities in surgical wound, and 28 of these patients (93%) had at least two local signs of infection. Among the 37 types of microorganisms isolated from sternal secretion, 22 (59%) were gram-positive cocci, with Staphylococcus as the predominant genus. While 40% of the recovered gram-positive bacteria were methicillin-resistant, only 50% of the gram-negative bacteria were sensitive to aminoglycosides and ceftazidime. The in-hospital time was significantly longer in patients with mediastinitis compared to control patients (p < 0.001). The mortality rate inpatients mediastinitis was 33%. In conclusion, mediastinal infection actually remains representing a severe and costly complication of cardiovascular surgery due to its high morbidity and mortality rates.