Alterações cardíacas em pacientes durante o primeiro ano de hemodiálise crônica: foco em preditores de fibrilação atrial / Cardiac changes in patients during the first year of chronic hemodialysis: focus on predictors of atrial fibrillation

Objetivos: Detecção precoce de alterações cardíacas, em especial de preditores de fibrilação atrial (FA), em pacientes renais crônicos dialíticos, permitem condutas terapêuticas que podem impactar na morbimortalidade cardiovascular desses pacientes. Descrevemos alterações elétricas e estruturais cardíacas nos pacientes durante o 1º ano de hemodiálise (HD). Métodos: Estudo observacional, transversal, prospectivo, em pacientes entre 20 e 80 anos, renais crônicos, pertencentes a serviços públicos de São Paulo, divididos pelo tempo de início de hemodiálise: grupo 1: 1 a 6 meses; grupo 2: 7 a12 meses. Coletados dados sociodemográficos, mórbidos, eletrocardiograma de repouso, Holter 48h, ecocardiograma transtorácico e exames de sangue pré e pós hemodiálise ( função renal, eletrólitos, bicarbonato e inflamatórios). Analisados por teste T student e Qui-quadrado. Resultados: 73 pacientes, hipertensos, predomínio homens, quinquagenários, escolaridade fundamental, brancos, não solteiros, procedentes da região sudeste metropolitana, com multimorbidades e polifarmácia. Grupo 2 apresentou maior idade (p=0,007), morbidades (p=0,04), medicações (p=0,02), preditores de FA caracterizados por extrassístoles ventriculares ( p=0,02), aumento dos volumes e diâmetros ventriculares e átrio esquerdo (todos p≤0,001), alteração do bicarbonato pré e pós hemodiálise (p<0,01). Grupo 1 apresentou maiores alterações eletrolíticas pós hemodiálise (p≤0,03). Conclusão: Além da hipertensão arterial, tempo de hemodiálise, acidose metabólica próxima dos limites de referência, associaram-se precocemente à progressiva disfunção sisto-diastólica de câmaras esquerdas cardíacas e preditores de fibrilação atrial, em especial o volume sistólico final, predominantemente no 2º semestre do início de hemodiálise. Sugere-se Holter e Ecocardiograma a partir do 7º mês de hemodiálise e controles mais rígidos de acidose para essa população.

Objectives: Early detection of cardiac alterations in chronic renal patients on hemodyalisis (HD), especially atrial fibrillation (AF) predictors, allows therapeutic approaches that can impact their cardiovascular prognosis. We describe electrical and structural cardiac alterations in patients during the 1st year of hemodyalisis. Methods: Observational, cross-sectional, prospective study. Chronic kidney patients on dyalisis aged between 20 and 80 years, wihout atrial fibrillation, from public hemodyalisis services were divided by the time of hemodyalisis onset: group 1: 1 to 6 months; group 2: 7 to 12 months. Sociodemographic and morbid data, electrocardiogram at rest, Holter 48h, transthoracic echocardiogram and pre and post hemodialysis blood tests (kidney function, electrolytes and inflammatory tests) were collected. Data analyzed by Chi-square and Student T tests. Results: 73 hypertensive patients, predominantly men, aged in their fifties, elementary school, white, not single, from the metropolitan southeast region, with multimorbidities and polypharmacy were analyzed. Group 2 presented more age (p<0.01), morbidities (p=0.04), medications (p=0.02), atrial fibrillation, predictors especially ventricular extrasystoles (VES, p=0.02), increased left venticular and atrium volumes and diameters (all p≤0.001) and lower bicarbonate before and after hemodyalisis (both p≤0,01). Group 1 presented more changes in eletrolytes (p≤0.03). Conclusion: In addition to arterial hypertension, hemodyalisis duration was associated to systolic and diastolic dysfunction of the left cardiac chambers, atrial fibrillation predictors especially end-systolic volume (ESV) and mild acidosis, in the 2nd semestre predominantly. Holter and echocardiography are suggested from the 7th month of hemodyalisis onset and tighter metabolic control in this population

Physical fitness and quality of life in adolescents with asthma and fixed airflow obstruction.

Asthma is a disease characterized by reversible bronchoconstriction, but some subjects develop fixed airflow obstruction (FAO). Subjects with FAO present more asthma symptoms and may have increased sedentary behavior; however, the effect of FAO on aerobic fitness and physical activity levels (PAL) remains poorly understood. AIM: To compare adolescents with asthma and FAO and adolescents with asthma without FAO in terms of aerobic fitness, PAL, muscle strength, and health-related quality of life (HRQoL). METHODS: This cross-sectional study included adolescents with asthma, both sexes, and aged 12-18 years. They were divided into two groups: FAO and non-FAO groups. The adolescents were diagnosed with asthma according to the Global Initiative for Asthma guidelines and underwent optimal pharmacological treatment for at least 12 months. FAO was diagnosed when the forced expiratory volume in the first second/forced vital capacity ratio was below the lower limit of the normal range after optimal treatment. Aerobic fitness, PAL, peripheral and respiratory muscle strength, and HRQoL were evaluated. RESULTS: No significant differences were observed between FAO and non-FAO groups regarding the peak oxygen uptake (34.6 ± 8.5 vs. 36.0 ± 8.4 mLO2 /min/kg), sedentary time (578 ± 126 vs. 563 ± 90 min/day), upper limb muscle strength (29.1 ± 5.9 vs. 28.1 ± 5.7 kilograms of force [kgf]), lower limb muscle strength (42.8 ± 8.6 vs. 47.6 ± 9.6 kgf), or HRQoL (5.1 ± 1.3 vs. 4.7 ± 1.4 score; p > .05). However, the FAO group exhibited a higher maximal expiratory pressure than the non-FAO group (111.5 ± 15.5 vs. 101.5 ± 15.0 cmH2 O, respectively). CONCLUSION: Our results suggest that FAO does not impair aerobic fitness, PAL, peripheral muscle strength, or HRQoL in adolescents with asthma. Furthermore, adolescents with asthma were physically deconditioned.

P-wave dispersion: an update.

P-wave dispersion (PWD, Pd or Pdis) is a noninvasive electrocardiographic (ECG) marker for atrial remodeling and predictor for atrial fibrillation (AF). PWD is defined as the difference between the widest and the narrowest P-wave duration recorded from the 12 ECG leads. Increased P-wave duration and PWD reflect prolongation of intraatrial and interatrial conduction time with lack of a well-coordinated conduction system within the atrial muscles, with inhomogeneous, asynchronic, pro-inflammatory and anti-inflammatory effect mediated by interleukin-6 (IL-6) in patients with the CG + GG genotype IL-6 -634C/G polymorphism [1] and discontinuous propagation of sinus impulses mainly between the left and right atria, interstitial/extracellular fibroblast activation and collagen deposition with fibrosis (via TGF-ß) in atrial tissue, insufficient blood supply, significant not isotropic myoelectric activity, and thin wall thickness and consequent expansion tendency all well-known electrophysiological characteristics in patients with atrial arrhythmias and especially paroxysmal atrial fibrillation (PAF) [2].

Normality that is abnormal.

Supernormal conduction is defined as better-than-expected conduction in patients with depressed conduction during a short interval in the ventricular cycle. It is mainly observed in long-duration electrocardiogram (ECG) assessments. Its occurrence during 12-lead ECG is uncommon and its interpretation demands knowledge on electrophysiological alterations that are hard to understand. By reporting this case we aim to propose a rationale sequence that should be considered when facing an ECG with these same features, which would enable a greater accuracy to make a definitive diagnosis.

Electrocardiographic changes in dermatomyositis and polymyositis.

INTRODUCTION: Cardiac involvement is frequent in inflammatory myopathies. Electrocardiogram (ECG) may show evidence of this involvement and its changes should be well-known and described. OBJECTIVES: Due to the lack of studies in the literature, we conducted an analysis of the ECG findings in patients with dermatomyositis (DM) and polymyositis (PM), comparing them with a control group. METHODS: This cross-sectional study compared the ECG of 86 individuals with no rheumatic disorders (controls) with 112 patients (78 DM and 34 PM), during 2010-2013. The ECG findings between DM and PM were also compared. RESULTS: Demographic characteristics, comorbidities and ECG abnormalities were similar between controls and patients (p>0.05), except for a higher frequency of left ventricular hypertrophy (LVH) in patients (10.7% vs. 1.2%, p=0.008). Demographic characteristics, comorbidities, clinical and laboratory manifestations, were also similar between the groups PM and DM, except for the presence of cutaneous lesions only in DM. One-third of the patients had ECG abnormalities, which were more prevalent in PM than DM (50% vs. 24.4%, p=0.008). LVH, left atrial enlargement, rhythm and conduction abnormalities were more frequent in PM than DM (p<0.05 for all), especially the left anterior fascicular block. CONCLUSIONS: We showed distinct ECG changes between DM and PM and a higher frequency of LVH in patients compared to controls. Investigation of cardiac involvement should be considered even in asymptomatic patients, especially PM. Further studies are necessary in order to determine the correlation of ECG findings with other complementary tests, clinical manifestations, disease activity and progression to other cardiac diseases.

Electrocardiographic changes in dermatomyositis and polymyositis / Alterações eletrocardiográficas em dermatomiosite e polimiosite

ABSTRACT Introduction: Cardiac involvement is frequent in inflammatory myopathies. Electrocardiogram (ECG) may show evidence of this involvement and its changes should be well-known and described. Objectives: Due to the lack of studies in the literature, we conducted an analysis of the ECG findings in patients with dermatomyositis (DM) and polymyositis (PM), comparing them with a control group. Methods: This cross-sectional study compared the ECG of 86 individuals with no rheumatic disorders (controls) with 112 patients (78 DM and 34 PM), during 2010 to 2013. The ECG findings between DM and PM were also compared. Results: Demographic characteristics, comorbidities and ECG abnormalities were similar between controls and patients (p > 0.05), except for a higher frequency of left ventricular hypertrophy (LVH) in patients (10.7% vs. 1.2%, p = 0.008). Demographic characteristics, comorbidities, clinical and laboratory manifestations, were also similar between the groups PM and DM, except for the presence of cutaneous lesions only in DM. One third of the patients had ECG abnormalities, which were more prevalent in PM than DM (50% vs. 24.4%, p = 0.008). LVH, left atrial enlargement, rhythm and conduction abnormalities were more frequent in PM than DM (p < 0.05 for all), especially the left anterior fascicular block. Conclusions: We showed distinct ECG changes between DM and PM and a higher frequency of LVH in patients compared to controls. Investigation of cardiac involvement should be considered even in asymptomatic patients, especially PM. Further studies are necessary in order to determine the correlation of ECG findings with other complementary tests, clinical manifestations, disease activity and progression to other cardiac diseases.

RESUMO Introdução: Acometimento cardíaco nas miopatias inflamatórias é frequente. Eletrocardiograma (ECG) pode mostrar indícios desse acometimento e suas alterações devem ser bem conhecidas e descritas. Objetivos: Devido à escassez de trabalhos na literatura, analisamos as alterações de ECG em pacientes com dermatomiosite (DM) e polimiosite (PM) e as comparamos com um grupo controle. Métodos: Este estudo transversal comparou ECGs de 86 indivíduos sem doenças reumatológicas (controles) com 112 pacientes (78 DM e 34 PM), de 2010 a 2013. Também comparamos os ECGs entre DM e PM. Resultados: Características demográficas, comorbidades e alterações de ECG foram semelhantes entre controles e pacientes (p > 0,05), exceto pela maior frequência de sobrecarga de ventrículo esquerdo (SVE) nos pacientes (10,7% vs. 1,2%; p = 0,008). Características demográficas, comorbidades, manifestações clínicas e laboratoriais também foram semelhantes entre os grupos PM e DM, exceto por lesões cutâneas apenas em pacientes com DM. Um terço dos pacientes apresentou alterações de ECG, que foram mais prevalentes em PM do que em DM (50% vs. 24,4%, p = 0,008). Sobrecarga de câmaras esquerdas (SCE), distúrbios do ritmo e da condução foram mais encontrados em PM do que em DM (p < 0,05 para todos), sobretudo o bloqueio divisional do ramo anterossuperior. Conclusões: Encontramos alterações distintas de ECG entre PM e DM e frequência aumentada de SVE em pacientes quando comparados com controles. Investigação do acometimento cardíaco nessas doenças deve ser considerada mesmo em pacientes assintomáticos, especialmente em se tratando de PM. Mais estudos são necessários para correlacionar os achados de ECG com outros exames complementares, manifestações clínicas, atividade das miopatias e evolução para outras doenças cardíacas.