RESUMO
BACKGROUND: Cardiac resynchronization therapy-defibrillator (CRT-D) implantation via the cephalic vein is feasible and safe. Recent evidence has suggested a higher implantable cardioverter-defibrillator (ICD) lead failure in multi-lead defibrillator therapy via the cephalic route. We evaluated the relationship between CRT-D implantation via the cephalic and ICD lead failure. METHODS: Data was collected from three CRT-D implanting centers between October 2008 and September 2017. In total 633 patients were included. Patient and lead characteristics with ICD lead failure were recorded. Comparison of "cephalic" (ICD lead via cephalic) versus "non-cephalic" (ICD lead via non-cephalic route) cohorts was performed. Kaplan-Meier survival and a Cox-regression analysis were applied to assess variables associated with lead failure. RESULTS: The cephalic and non-cephalic cohorts were equally male (81.9% vs. 78%; p = .26), similar in age (69.7 ± 11.5 vs. 68.7 ± 11.9; p = .33) and body mass index (BMI) (27.7 ± 5.1 vs. 27.1 ± 5.7; p = .33). Most ICD leads were implanted via the cephalic vein (73.5%) and patients had a mean of 2.9 ± 0.28 leads implanted via this route. The rate of ICD lead failure was low and statistically similar between both groups (0.36%/year vs. 0.13%/year; p = .12). Female gender was more common in the lead failure cohort than non-failure (55.6% vs. 17.9%, respectively; p = .004) as was hypertension (88.9% vs. 54.2%, respectively, p = .038). On multivariate Cox-regression, female sex (p = .008; HR, 7.12 [1.7-30.2]), and BMI (p = .047; HR, 1.12 [1.001-1.24]) were significantly associated with ICD lead failure. CONCLUSION: CRT-D implantation via the cephalic route is not significantly associated with premature ICD lead failure. Female gender and BMI are predictors of lead failure.
Assuntos
Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Insuficiência Cardíaca , Hipertensão , Dispositivos de Terapia de Ressincronização Cardíaca , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Humanos , Masculino , Resultado do TratamentoRESUMO
BACKGROUND: Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use. METHODS: A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method. RESULTS: A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non-cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P = .0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P < .0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P < .0001). CONCLUSIONS: CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient.
Assuntos
Veia Axilar , Dispositivos de Terapia de Ressincronização Cardíaca , Cateterismo Periférico/métodos , Competência Clínica , Idoso , Terapia de Ressincronização Cardíaca/métodos , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
BACKGROUND: Studies in middle-age and older (masters) athletes with atherosclerotic risk factors for coronary artery disease report higher coronary artery calcium (CAC) scores compared with sedentary individuals. Few studies have assessed the prevalence of coronary artery disease in masters athletes with a low atherosclerotic risk profile. METHODS: We assessed 152 masters athletes 54.4±8.5 years of age (70% male) and 92 controls of similar age, sex, and low Framingham 10-year coronary artery disease risk scores with an echocardiogram, exercise stress test, computerized tomographic coronary angiogram, and cardiovascular magnetic resonance imaging with late gadolinium enhancement and a 24-hour Holter. Athletes had participated in endurance exercise for an average of 31±12.6 years. The majority (77%) were runners, with a median of 13 marathon runs per athlete. RESULTS: Most athletes (60%) and controls (63%) had a normal CAC score. Male athletes had a higher prevalence of atherosclerotic plaques of any luminal irregularity (44.3% versus 22.2%; P=0.009) compared with sedentary males, and only male athletes showed a CAC ≥300 Agatston units (11.3%) and a luminal stenosis ≥50% (7.5%). Male athletes demonstrated predominantly calcific plaques (72.7%), whereas sedentary males showed predominantly mixed morphology plaques (61.5%). The number of years of training was the only independent variable associated with increased risk of CAC >70th percentile for age or luminal stenosis ≥50% in male athletes (odds ratio, 1.08; 95% confidence interval, 1.01-1.15; P=0.016); 15 (14%) male athletes but none of the controls revealed late gadolinium enhancement on cardiovascular magnetic resonance imaging. Of these athletes, 7 had a pattern consistent with previous myocardial infarction, including 3(42%) with a luminal stenosis ≥50% in the corresponding artery. CONCLUSIONS: Most lifelong masters endurance athletes with a low atherosclerotic risk profile have normal CAC scores. Male athletes are more likely to have a CAC score >300 Agatston units or coronary plaques compared with sedentary males with a similar risk profile. The significance of these observations is uncertain, but the predominantly calcific morphology of the plaques in athletes indicates potentially different pathophysiological mechanisms for plaque formation in athletic versus sedentary men. Coronary plaques are more abundant in athletes, whereas their stable nature could mitigate the risk of plaque rupture and acute myocardial infarction.
Assuntos
Atletas , Ciclismo/fisiologia , Doença da Artéria Coronariana/diagnóstico por imagem , Resistência Física/fisiologia , Placa Aterosclerótica/diagnóstico por imagem , Corrida/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Teste de Esforço/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/epidemiologia , Placa Aterosclerótica/fisiopatologia , Prevalência , Fatores de RiscoAssuntos
Embolia Pulmonar/diagnóstico , Taquicardia/diagnóstico , Idoso , Anticoagulantes/uso terapêutico , Biomarcadores/sangue , Angiografia por Tomografia Computadorizada , Diagnóstico Diferencial , Dispneia , Ecocardiografia , Eletrocardiografia , Humanos , Masculino , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/fisiopatologia , Taquicardia/fisiopatologiaRESUMO
We present a 27-year old British nurse admitted to the Kerry Town Ebola Treatment Unit, Sierra Leone, with symptoms fitting suspect-Ebola virus disease (EVD) case criteria. A diagnosis of Plasmodium falciparum malaria and heat illness was ultimately made, both of which could have been prevented through employing simple measures not utilised in this case. The dual pathology of her presentation was atypical for either disease meaning EVD could not be immediately excluded. She remained isolated in the red zone until 72â h from symptom onset. This case highlights why force protection measures are important to reduce the incidence of both malaria and heat illness in deployed military and civilian populations. These prevention measures are particularly pertinent during the current EVD epidemic where presenting with these pathologies requires clinical assessment in the 'red zone' of an Ebola treatment unit.
Assuntos
Erros de Diagnóstico , Epidemias , Transtornos de Estresse por Calor/diagnóstico , Doença pelo Vírus Ebola/diagnóstico , Malária Falciparum/diagnóstico , Enfermeiras e Enfermeiros , Adulto , Exercício Físico , Feminino , Transtornos de Estresse por Calor/complicações , Doença pelo Vírus Ebola/epidemiologia , Doença pelo Vírus Ebola/transmissão , Hospitalização , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional , Malária Falciparum/complicações , Equipamento de Proteção Individual , Serra Leoa/epidemiologia , Reino UnidoRESUMO
INTRODUCTION: For the purposes of patient safety, audit and research, the electronic patient record (EPR) must be accurate and searchable. No evaluation of the accuracy of EPRs compared with paper records has been made. Furthermore, the use of Read codes is known to be heterogeneous. This study was designed to evaluate the EPR used by the UK Armed Forces. METHODS: A cross-sectional study reviewing the paper records and EPRs of 50 consecutive soldiers posted to a British Army Training Regiment. RESULTS: There was a pre-enlistment summary in only 38% of the paper notes, although 24% had some primary care records from prior to enlistment. There were 357 entries that should have been transferred to the EPR. Of these, only 190 (53.2%) were transferred with appropriate Read codes, while only 24% of patients reviewed had all their entries appropriately Read coded. There were 168 secondary care letters discovered with 122 (72.6%) generically Read coded and 46 (27.4%) using an appropriate Read code. Of those letters with more than one potential Read code, 34 (73.9%) were coded using all appropriate Read codes. Several incidental errors in the medical records were also discovered with significant patient safety implications. CONCLUSIONS: The historical paper-based medical record was found to have many data missing. The transfer of these paper records to the EPR has been inaccurate with many records not transferred or transferred ineffectively. These findings have an impact on patient safety, audit and data security and should trigger a review of how the Armed Forces manage their primary care records.
Assuntos
Registros Eletrônicos de Saúde/normas , Medicina Militar , Militares , Atenção Primária à Saúde , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reino Unido , Adulto JovemRESUMO
INTRODUCTION: During previous deployments of the British Armed Forces, a significant proportion of aeromedical evacuations were accounted for with recurrent symptoms from a known disease that had often triggered occupational medical downgrading. Many servicemen and women had deployed inappropriately, and by doing so became a burden on the deployed medical facilities. Commanders performing systematic medical risk assessments prior to departure might have prevented these individuals from deploying. This study was designed to assess the avoidable burden from recurrent disease during the current Afghanistan operation. METHODS: A cross-sectional study reviewing the hospital and computerised primary care medical records of consecutive patients admitted under the General Physicians to the Role 3 Hospital in Camp Bastion over 9â months from April 2011. The occupational medical grading, diagnosis, disposal and whether the disease was recurrent were recorded. RESULTS: Of 270 patients admitted, 14 (5.2%) were medically downgraded. The computerised records were unavailable for 31 (11.5%) patients. All those patients who were medically downgraded were graded 'Medically Limited Deployable'. In the downgraded group, only one patient presented with recurrent symptoms from their pre-existing condition (Crohn's disease). In the non-downgraded group, two patients presented with symptoms relating to their previous diagnoses. One presented with a second heat illness and should have been medically downgraded and not have been deployed, while the other patient had previously been investigated for recurrent syncope and was upgraded 6â months prior to deploying. All three patients underwent aeromedical evacuation but only two of these were considered to have been avoidable. DISCUSSION: The number of general medical admissions to the Role 3 Hospital due to a pre-existing disease is very low.
Assuntos
Hospitais Militares/estatística & dados numéricos , Medicina Interna/estatística & dados numéricos , Militares/estatística & dados numéricos , Adolescente , Adulto , Afeganistão , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cobertura de Condição Pré-Existente/estatística & dados numéricos , Reino Unido , Adulto JovemRESUMO
BACKGROUND: Detailed knowledge of the likely volume and nature of the diseases presenting to deployed secondary care facilities aids operational planning. Now the British operation in Afghanistan has ended and a record of the experience is useful to preserve the lessons learned. METHODS: Over a 2-year period from April 2011, prospective demographic and clinical data were collected on consecutive general internal medicine admissions to the Role 3 Hospital in Camp Bastion, Afghanistan. Up to four different symptoms and diagnoses were coded using the WHO International Classification of Disease, V.10 for each patient. RESULTS: A total of 1368 medical patients were admitted. Of 1131 military admissions, 612 were from the UK (54.1%) and the remainder from 13 allied countries; 237 civilians came from 23 countries. Civilians were older than the military patients (p<0.001) but included five children. The 20 most frequent presenting symptoms were identified and there were 1626 diagnoses made. The 10 most frequent diagnoses were infectious gastroenteritis (12.6%), heat illness (4.3%), pneumonia (3.6%), epilepsy (2.6%), cellulitis (2.7%), migraine (1.8%), peptic ulcer disease (1.2%), myocardial infarction (1.2%), venous thromboembolism (1.2%) and pericarditis (0.7%). In 252 cases (18.4%) a firm diagnosis was not reached and a symptom was recorded. The five most frequent of these were undifferentiated febrile illnesses (4.6%), syncope (3.7%), chest pain (2.8%), headache (0.8%) and palpitations (0.7%). The mean hospital length of stay was 1.59â days and 72.2% of UK military patients were 'returned to unit'. Three civilian patients died in hospital or following aeromedical evacuation and there were no deaths of any military patients. DISCUSSION: This study demonstrates the wide variety of presentations seen by physicians at an established military field hospital. This information informs the core syllabus of military physician training and will help facilitate planning for future medical support to similar military operations. TRIAL REGISTRATION NUMBER: RCDM/Res/Audit/1036/12/0305.
Assuntos
Hospitalização/estatística & dados numéricos , Hospitais Militares/estatística & dados numéricos , Medicina Interna/estatística & dados numéricos , Militares/estatística & dados numéricos , Adolescente , Adulto , Afeganistão , Idoso , Criança , Pré-Escolar , Doenças Transmissíveis/epidemiologia , Feminino , Humanos , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Reino Unido , Adulto JovemRESUMO
When the general public look from the outside at the armed services, their impression is often one of earnest young men and women who are the pinnacle of physical fitness and health, and put their lives on the line for their country. There is usually sadness and respect for those killed on active operations, having put themselves in harm's way. Therefore, when the public discover that more than 1 in 10 deaths in the UK Armed Forces are due to cardiovascular disease, the air of sadness is invariably replaced with surprise and disbelief. These figures, while lower than those due to deaths in accidents, are approaching the numbers of those due to suicide in the armed services; yet deaths from cardiac disease are barely recognised by society, in spite of many of them being avoidable. This article reviews the epidemiology of cardiac disease in the UK Armed Forces, both in terms of morbidity and mortality. It outlines current understanding and gaps in the knowledge regarding the burden of cardiovascular disease in the military population. The particular demographics of the Armed Forces and its influence on cardiac disease burden are discussed. The role of inherited and congenital diseases in younger servicemen and women is highlighted, as is the trend that with increasing age, the burden of disease shifts to ischaemic heart disease, which becomes the dominant cause of both death and disability.
Assuntos
Cardiopatias/epidemiologia , Militares , Feminino , Cardiopatias/mortalidade , Humanos , Masculino , Reino Unido/epidemiologiaRESUMO
The British Army screens potential recruits for disease, including cardiovascular disease, at the pre-employment medical assessment in the Army Selection Centres. The epidemiology of cardiovascular disease in the Armed Forces coupled with the high physical demand placed on the cardiovascular system, often in remote locations make screening desirable. This is particularly pertinent as servicemen and women die from cardiovascular disease each year. To evaluate this particular screening system it is essential to understand the aim of the system, how it is designed and how screening systems in general are evaluated. The efficacy of a screening test is quantified using the measurements of sensitivity, specificity and likelihood ratios. These measurements are defined and the pitfalls associated with evaluating a screening system are described. The different screening tests used to identify cardiac disease and their individual strengths and weaknesses, are illustrated. Finally the article reviews the previous British Army recruit cardiac screening system, that used a stereotyped history and physical examination and the newer system that replaced it, which includes the incorporation of the 12-lead ECG and on site echocardiography in individuals revealing abnormalities on history, examination or ECG.
Assuntos
Cardiopatias/diagnóstico , Programas de Rastreamento/métodos , Seleção de Pessoal , Diagnóstico Precoce , Feminino , Humanos , Masculino , Reino UnidoRESUMO
INTRODUCTION: The British Role 3 Hospital in Camp Bastion, Afghanistan, uses a different electronic patient record (EPR) to Defence Primary Health Care and the two cannot directly communicate. Consequently, hospital discharge information is transferred by printed letter to primary care, introducing a step where information can be lost. This study was designed to test the hypothesis that the primary care EPR contained an accurate summary of the secondary care admission. METHODS: Cross-sectional information on consecutive General Internal Medicine patients at the hospital was collected and compared with the primary care EPR. RESULTS: From April 2011 the hospital records of 270 patients were reviewed. 239 primary care records were available for comparison. Of 185 patients discharged back to their unit the EPR of 43.8% contained a comprehensive summary, 23.2% contained the scanned discharge letter and 50.8% contained an account of their hospital admission but not necessarily a comprehensive summary. Of the 54 patients evacuated to the UK, the EPRs of 48.1% contained a summary, 68.1% contained the scanned discharge letter and 75.9% contained some account of their hospital admission. More of the evacuated group had their admission documented in the primary care EPR (p=0.001). Only 56.5% of all primary care records contained some account of the hospital admission. DISCUSSION: The primary care record is not a reliable record of operational hospital admission and presents an unrecognised potential patient safety issue. The systems responsible for the transfer of discharge summary data need to be appraised to prevent it continuing. Retrospective action should be considered to rectify this problem in former hospital patients.
Assuntos
Registros Eletrônicos de Saúde , Hospitais Militares , Militares , Alta do Paciente , Adolescente , Adulto , Campanha Afegã de 2001- , Afeganistão , Estudos Transversais , Documentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medicina Militar , Reino Unido , Adulto JovemRESUMO
The pericardium is the thin double-walled sac encapsulating the heart which has a number of important physiological roles including fixing the heart in the mediastinum, protecting it from cross-organ infection (eg, lung) and lubricating cardiac contraction. The pericardium is associated with several disease syndromes that occasionally affect the military population. These include acute and recurrent pericarditis, pericardial effusion and tamponade, which may result from a large number of different aetiological agents. Pericardial diseases have a wide range of clinical manifestations and the diagnosis of pericardial diseases can be a challenge. This article reviews the anatomy and pathophysiology of pericarditis and pericardial effusions before outlining their clinical features, recommended investigations and management options. Particular emphasis is placed on the impact of these diseases for patients in a military occupational environment.
Assuntos
Militares , Derrame Pericárdico , Pericardite , Adulto , Diagnóstico Diferencial , Eletrocardiografia , Feminino , Humanos , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/fisiopatologia , Derrame Pericárdico/cirurgia , Pericardite/diagnóstico , Pericardite/fisiopatologiaRESUMO
Myocarditis, simply defined as inflammation of the heart muscle, is a commonly encountered cardiac disease in primary and secondary care, both in the UK and on Operational deployments. In the UK Armed Forces, myocarditis results in deaths as well as the premature termination of military careers on medical grounds. The aetiology is usually the result of a number of infectious aetiologies with viruses being the most common pathogens in the vast majority of cases. However, it may also be the result of autoimmune activation, chemical or pharmacological toxins, environmental insult or hypersensitivity reactions. Particular aetiologies that are more likely to be seen in a military population are discussed and include certain infections, smallpox vaccine, and hyperthermia and hypothermia. The clinical features can be highly variable ranging from an asymptomatic infection to fulminant heart failure. Features pertinent to the military doctor, including the natural history, investigative modalities and management strategies, with a particular emphasis on the occupational impact of myocarditis in the UK Armed Forces are reviewed.
Assuntos
Militares , Miocardite , Adulto , Diagnóstico Diferencial , Eletrocardiografia , Humanos , Masculino , Miocardite/diagnóstico , Miocardite/etiologia , Miocardite/fisiopatologiaRESUMO
OBJECTIVES: To compare heat acclimation adaptations after three and six days of either post-exercise hot water immersion (HWI) or exercise-heat-acclimation (EHA) in recreationally active individuals. DESIGN: Randomised, mixed model, repeated measures. METHODS: Post-exercise HWI involved a daily 40-min treadmill-run at 65% VÌO2peak in temperate conditions (19⯰C, 45% RH) followed by HWI (≤40â¯min, 40⯰C water; nâ¯=â¯9). Daily EHA involved a ≤60-min treadmill-run in the heat (65% VÌO2peak; 33⯰C, 40% RH; nâ¯=â¯9), chosen to elicit a similar endogenous thermal stimulus to HWI. A thermoneutral exercise intervention (TNE, 19⯰C, 45% RH; nâ¯=â¯9), work-matched to EHA, was also included to determine thermoregulatory adaptations to daily exercise in temperate conditions. An exercise-heat-stress-test was performed before and after three and six intervention days and involved a 40-min treadmill-run and time-to-exhaustion (TTE) at 65% VÌO2peak in the heat (33⯰C, 40% RH). RESULTS: ANCOVA, using baseline values as the covariate, revealed no interaction effects but significant group effects demonstrated that compared to EHA, HWI elicited larger reductions in resting rectal temperature (Tre; pâ¯=â¯0.021), Tre at sweating onset (pâ¯=â¯0.011), and end-exercise Tre during exercise-heat-stress (-0.47⯰C; pâ¯=â¯0.042). Despite a similar endogenous thermal stimulus to HWI, EHA elicited a modest reduction in end-exercise Tre (-0.26⯰C), which was not different from TNE (-0.25⯰C, pâ¯=â¯1.000). There were no main effects or interaction effects for end-exercise Tsk, heart rate, physiological strain index, RPE, thermal sensation, plasma volume, or TTE (all pâ¯≥â¯0.154). CONCLUSIONS: Compared with conventional short-term exercise heat acclimation, short-term post-exercise hot water immersion elicited larger thermal adaptations.
Assuntos
Aclimatação , Regulação da Temperatura Corporal , Exercício Físico/fisiologia , Temperatura Alta , Imersão , Transtornos de Estresse por Calor/prevenção & controle , Humanos , Masculino , Fatores de Tempo , Adulto JovemRESUMO
A 59-year-old woman presented with a sudden onset of breathlessness and chest pain. An echocardiography and CT scan showed pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria. For haemodynamically stable patients, the optimal management strategy is poorly defined. Three main strategies were considered: surgical thrombectomy, thrombolysis and anticoagulation. Surgery with reversal of anticoagulation may lead to further coagulation and increased risk of bleeding complications. The significant pulmonary hypertension and right ventricular infarction raised the prospect of difficult weaning from cardiopulmonary bypass following thrombectomy. Thrombolysis, which has significant mortality rate, and systemic embolisation including pulmonary infarction with haemorrhagic transformation were also contraindications. A multidisciplinary approach was adopted and anticoagulation was therefore believed to be the safest and effective approach. Here, the use of anticoagulation alone was fortunately successful but could as easily end in disaster. This approach should be considered the ideal paradigm to yield optimum outcomes.
Assuntos
Anticoagulantes/uso terapêutico , Cardiopatias/tratamento farmacológico , Embolia Pulmonar/tratamento farmacológico , Trombose/tratamento farmacológico , Angiografia por Tomografia Computadorizada , Quimioterapia Combinada , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/tratamento farmacológico , Feminino , Átrios do Coração , Cardiopatias/diagnóstico por imagem , Heparina/uso terapêutico , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/tratamento farmacológico , Trombose/diagnóstico por imagem , Resultado do Tratamento , Varfarina/uso terapêuticoRESUMO
We present the case of a 61-year-old woman admitted with chest pain and an ECG demonstrating ST-segment elevation in the lateral leads. Emergency coronary angiography demonstrated an occluded obtuse marginal branch. Percutaneous intervention was unsuccessful as the lesion could not be crossed with a wire. Left ventriculography and transthoracic echocardiography demonstrated hypokinesis of the entire apex but preserved contractility of the basal segments, consistent with a diagnosis of apical ballooning syndrome (ABS). Cardiac MRI demonstrated myocardial oedema in all mid to apical segments, with a left ventricular ejection fraction (LVEF) of 38%. Repeat study at 5 months demonstrated an infarct in the distribution of the occluded artery with late gadolinium enhancement, consistent with a diagnosis of a lateral wall myocardial infarction and an improvement in the LVEF to 51%. The case illustrates the novel observation that ABS and acute myocardial infarction may rarely occur simultaneously.
Assuntos
Ventrículos do Coração/fisiopatologia , Miocárdio/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Cardiomiopatia de Takotsubo/complicações , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Angiografia Coronária/métodos , Oclusão Coronária , Vasos Coronários/patologia , Ecocardiografia , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Volume Sistólico , Cardiomiopatia de Takotsubo/diagnósticoRESUMO
BACKGROUND: There is increasing evidence that the Brugada ECG pattern is a marker of subtle structural heart disease. OBJECTIVE: The purpose of this study was to characterize patients with Brugada syndrome (BrS) using cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). METHODS: BrS was diagnosed according to international guidelines. Twenty-six percent of patients with BrS carried SCN5A mutations. CMR data from 78 patients with BrS were compared with 78 healthy controls (44 ± 15 vs 42 ± 14 years; P = .434; and 64% vs 64% male; P = 1). RESULTS: Right ventricular (RV) ejection fraction was slightly lower (61 ± 8% vs 64 ± 5%; P = .004) and RV end-systolic volume slightly greater (31 ± 10 mL/m2 vs 28 ± 6 mL/m2; P = .038) in BrS compared with controls. These values remained within the normal range. LGE was demonstrated in 8% of patients with BrS (left ventricular midwall LGE in 5%) but not in controls (P = .028). In patients with BrS with midwall LGE there were no other features of cardiomyopathy at the time of CMR, but genetic testing and follow-up revealed a desmoplakin mutation in 1 patient and evolution of T-wave inversion throughout all precordial ECG leads in another. Neither patient fulfils diagnostic criteria for arrhythmogenic right ventricular cardiomyopathy. CONCLUSION: Some patients with BrS have left ventricular midwall LGE consistent with an underlying cardiomyopathic process. Even cases without LGE show greater RV volumes and reduced RV function. These findings lend further support to the presence of subtle structural abnormalities in BrS. The BrS pattern with LGE may serve as early markers for evolution of a cardiomyopathic phenotype over time. CMR is a potentially useful adjunct investigation in the clinical evaluation of BrS.
Assuntos
Síndrome de Brugada , Ventrículos do Coração , Imagem Cinética por Ressonância Magnética/métodos , Adulto , Síndrome de Brugada/diagnóstico , Síndrome de Brugada/genética , Síndrome de Brugada/fisiopatologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/fisiopatologia , Meios de Contraste/farmacologia , Feminino , Gadolínio/farmacologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Ventrículos do Coração/fisiopatologia , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Mutação , Canal de Sódio Disparado por Voltagem NAV1.5/genética , Tamanho do Órgão , Reprodutibilidade dos Testes , Volume SistólicoRESUMO
BACKGROUND: Cardiac involvement predicts outcome in systemic AL amyloidosis and influences therapeutic options. Current methods of cardiac assessment do not quantify myocardial amyloid burden. We used equilibrium contrast cardiovascular magnetic resonance (EQ-CMR) to quantify the cardiac interstitial compartment, measured as myocardial extracellular volume (ECV) fraction, hypothesizing it would reflect amyloid burden. METHODS AND RESULTS: Sixty patients with systemic AL amyloidosis (65% men, median age 65 years) underwent conventional clinical cardiovascular magnetic resonance, including late enhancement, equilibrium contrast cardiovascular magnetic resonance, and clinical cardiac evaluation, including ECG, echocardiography, assays of N-terminal pro-brain natriuretic peptide and Troponin T, and functional assessment comprising the 6-minute walk test in ambulant individuals. Cardiac involvement in the amyloidosis patients was categorized as definite, probable, or none, suspected by conventional criteria. Findings were compared with 82 healthy controls. Mean ECV was significantly greater in patients than healthy controls (0.25 versus 0.40, P<0.001) and correlated with conventional criteria for characterizing the presence of cardiac involvement, the categories of none, probable, definite corresponding to ECV of 0.276 versus 0.342 versus 0.488, respectively (P<0.001). ECV was correlated with cardiac parameters by echocardiography (eg, Tissue Doppler Imaging [TDI] S-wave R=0.52, P<0.001) and conventional cardiovascular magnetic resonance (eg, indexed left ventricular mass R=0.56, P<0.001). There were also significant correlations with N-terminal pro-brain natriuretic peptide (R=0.69, P<0.001) and Troponin T (R=0.53, P=0.006). ECV was associated with smaller QRS voltages (R=0.57, P<0.001) and correlated with poorer performance in the 6-minute walk test (R=0.36, P=0.03). CONCLUSIONS: Myocardial ECV measurement has potential to become the first noninvasive test to quantify cardiac amyloid burden.