Survival of Patients with Acute Heart Failure and Mid-range Ejection Fraction in a Developing Country - A Cohort Study in South Brazil. / Sobrevida de Pacientes com Insuficiência Cardíaca Aguda e Fração de Ejeção Intermediária em um País em Desenvolvimento ­ Estudo de Coorte no Sul do Brasil.

BACKGROUND: Heart Failure with mid-range Ejection Fraction (HFmEF) was recently described by European and Brazilian guidelines on Heart Failure (HF). The ejection fraction (EF) is an important parameter to guide therapy and prognosis. Studies have shown conflicting results without representative data from developing countries. OBJECTIVE: To analyze and compare survival rate in patients with HFmEF, HF patients with reduced EF (HFrEF), and HF patients with preserved EF (HFpEF), and to evaluate the clinical characteristics of these patients. METHODS: A cohort study that included adult patients with acute HF admitted through the emergency department to a tertiary hospital, reference in cardiology, in south Brazil from 2009 to 2011. The sample was divided into three groups according to EF: reduced, mid-range and preserved. A Kaplan-Meier curve was analyzed according to the EF, and a logistic regression analysis was done. Statistical significance was established as p < 0.05. RESULTS: A total of 380 patients were analyzed. Most patients had HFpEF (51%), followed by patients with HFrEF (32%) and HFmEF (17%). Patients with HFmEF showed intermediate characteristics related to age, blood pressure and ventricular diameters, and most patients were of ischemic etiology. Median follow-up time was 4.0 years. There was no statistical difference in overall survival or cardiovascular mortality (p=.0031) between the EF groups (reduced EF: 40.5% mortality; mid-range EF 39.7% and preserved EF 26%). Hospital mortality was 7.6%. CONCLUSION: There was no difference in overall survival rate between the EF groups. Patients with HFmEF showed higher mortality from cardiovascular diseases in comparison with HFpEF patients. (Arq Bras Cardiol. 2021; 116(1):14-23).

FUNDAMENTO: A insuficiência cardíaca (IC) com fração de ejeção na faixa média ou intermediária (ICFEI) (em inglês, "mid-range ejection fraction) foi recentemente descrita em diretrizes europeia e brasileira recentes sobre o manejo da insuficiência cardíaca (IC). A fração de ejeção (FE) é um parâmetro importante para direcionar terapia e prognóstico. Estudos têm mostrado resultados conflitantes sem dados representativos de países em desenvolvimento. OBJETIVO: Analisar e comparar a taxa de sobrevida em pacientes com ICFEI com pacientes com IC e FE reduzida (ICFEr), e pacientes com IC e FE preservada, e avaliar as características clínicas desses pacientes. MÉTODOS: Estudo coorte que incluiu pacientes com IC aguda admitidos no departamento de emergência de um hospital terciário, referência em cardiologia, localizado no sul do Brasil, entre 2009 e 2011. A amostra foi dividida em três grupos de acordo com a FE: reduzida, intermediária e preservada. Curva de Kaplan-Meier foi analisada de acordo com a FE, e uma análise de regressão logística foi realizada. A significância estatística foi estabelecida em p<0,05. RESULTADOS: Um total de 380 pacientes foram analisados. A maioria dos pacientes apresentaram ICFEp (515), seguido de ICFEr (32%) e ICFEI (17%). Os pacientes com ICFEI apresentaram características intermediárias em relação à idade, pressão arterial, e diâmetros ventriculares, e a maioria era de etiologia isquêmica. O período mediano de acompanhamento foi de 4 anos. Não se observou diferença na sobrevida geral ou na mortalidade cardiovascular (p=0,03) entre os grupos de FE (FE reduzida: mortalidade de 40,5%; FE intermediária: 39,7%, e FE preservada 26%). A mortalidade hospitalar foi 7,6%. CONCLUSÃO: Não houve diferença na taxa de sobrevida entre os grupos de FE diferentes. Os pacientes com ICFEI apresentaram maior mortalidade por doenças cardiovasculares em comparação a pacientes com ICFEp. (Arq Bras Cardiol. 2021; 116(1):14-23).

Prevalence of peripheral arterial disease in patients with heart failure with preserved ejection fraction.

OBJECTIVES: To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF). METHODS: A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups. RESULTS: The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD. CONCLUSION: Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

Update in Heart Rhythm Abnormalities and Indications for Pacemaker After Transcatheter Aortic Valve Implantation.

OBJECTIVE: Rhythm abnormalities following transcatheter aortic valve implantation (TAVI) and indications for permanent pacemaker implantation (PPI) were reviewed, which aren't well established in the current guidelines. New left bundle branch block and atrioventricular block are the most common electrocardiographic changes after TAVI. PPI incidence ranges from 9-42% for self-expandable and 2.5-11.5% for balloon expandable devices. Not only anatomical variations in conduction system have an important role in conduction disorders, but different valve characteristics and their relationship with cardiac structures as well. Previous right bundle branch block has been confirmed as one of the most significant predictors for PPI.

Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study.

BACKGROUND: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. OBJECTIVE: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. METHODS: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. RESULTS: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. CONCLUSION: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.

Sobrevida de Pacientes com Insuficiência Cardíaca Aguda e Fração de Ejeção Intermediária em um País em Desenvolvimento - Estudo de Coorte no Sul do Brasil / Survival of Patients with Acute Heart Failure and Mid-range Ejection Fraction in a Developing Country - A Cohort Study in South Brazil

Resumo Fundamento A insuficiência cardíaca (IC) com fração de ejeção na faixa média ou intermediária (ICFEI) (em inglês, "mid-range ejection fraction) foi recentemente descrita em diretrizes europeia e brasileira recentes sobre o manejo da insuficiência cardíaca (IC). A fração de ejeção (FE) é um parâmetro importante para direcionar terapia e prognóstico. Estudos têm mostrado resultados conflitantes sem dados representativos de países em desenvolvimento. Objetivo Analisar e comparar a taxa de sobrevida em pacientes com ICFEI com pacientes com IC e FE reduzida (ICFEr), e pacientes com IC e FE preservada, e avaliar as características clínicas desses pacientes. Métodos Estudo coorte que incluiu pacientes com IC aguda admitidos no departamento de emergência de um hospital terciário, referência em cardiologia, localizado no sul do Brasil, entre 2009 e 2011. A amostra foi dividida em três grupos de acordo com a FE: reduzida, intermediária e preservada. Curva de Kaplan-Meier foi analisada de acordo com a FE, e uma análise de regressão logística foi realizada. A significância estatística foi estabelecida em p<0,05. Resultados Um total de 380 pacientes foram analisados. A maioria dos pacientes apresentaram ICFEp (515), seguido de ICFEr (32%) e ICFEI (17%). Os pacientes com ICFEI apresentaram características intermediárias em relação à idade, pressão arterial, e diâmetros ventriculares, e a maioria era de etiologia isquêmica. O período mediano de acompanhamento foi de 4 anos. Não se observou diferença na sobrevida geral ou na mortalidade cardiovascular (p=0,03) entre os grupos de FE (FE reduzida: mortalidade de 40,5%; FE intermediária: 39,7%, e FE preservada 26%). A mortalidade hospitalar foi 7,6%. Conclusão Não houve diferença na taxa de sobrevida entre os grupos de FE diferentes. Os pacientes com ICFEI apresentaram maior mortalidade por doenças cardiovasculares em comparação a pacientes com ICFEp. (Arq Bras Cardiol. 2021; 116(1):14-23)

Abstract Background Heart Failure with mid-range Ejection Fraction (HFmEF) was recently described by European and Brazilian guidelines on Heart Failure (HF). The ejection fraction (EF) is an important parameter to guide therapy and prognosis. Studies have shown conflicting results without representative data from developing countries. Objective To analyze and compare survival rate in patients with HFmEF, HF patients with reduced EF (HFrEF), and HF patients with preserved EF (HFpEF), and to evaluate the clinical characteristics of these patients. Methods A cohort study that included adult patients with acute HF admitted through the emergency department to a tertiary hospital, reference in cardiology, in south Brazil from 2009 to 2011. The sample was divided into three groups according to EF: reduced, mid-range and preserved. A Kaplan-Meier curve was analyzed according to the EF, and a logistic regression analysis was done. Statistical significance was established as p < 0.05. Results A total of 380 patients were analyzed. Most patients had HFpEF (51%), followed by patients with HFrEF (32%) and HFmEF (17%). Patients with HFmEF showed intermediate characteristics related to age, blood pressure and ventricular diameters, and most patients were of ischemic etiology. Median follow-up time was 4.0 years. There was no statistical difference in overall survival or cardiovascular mortality (p=.0031) between the EF groups (reduced EF: 40.5% mortality; mid-range EF 39.7% and preserved EF 26%). Hospital mortality was 7.6%. Conclusion There was no difference in overall survival rate between the EF groups. Patients with HFmEF showed higher mortality from cardiovascular diseases in comparison with HFpEF patients. (Arq Bras Cardiol. 2021; 116(1):14-23)

Electrocardiographic recognition of the epicardial origin of ventricular tachycardias.

BACKGROUND: Some ventricular tachycardias (VTs) originating from the epicardium are not suitable for endocardial radiofrequency ablation and require an epicardial approach. The aim of this study was to define the ECG characteristics that may identify an epicardial origin of VTs. METHODS AND RESULTS: We analyzed the 12-lead ECG recordings during epicardial and endocardial left ventricular pacing in 9 patients to verify the hypothesis that the epicardial origin of the ventricular activation widens the initial part of the QRS complex. Then, we analyzed the ECG pattern in 14 VTs successfully ablated from the epicardium after a failed endocardial approach (group A), in 27 VTs successfully ablated from the endocardium (group B), and in 28 additional VTs that could not be ablated from the endocardium (group C). Four distinct intervals of ventricular activation were defined and measured: (1) the pseudodelta wave, (2) the intrinsicoid deflection time in V2, (3) the shortest RS complex, and (4) the QRS complex. VTs from groups A and C showed a significantly longer pseudodelta wave, intrinsicoid deflection time, and RS complex duration compared with VTs of group B. There was no difference between groups A and C. A pseudodelta wave of > or =34 ms has a sensitivity of 83% and a specificity of 95%, an intrinsicoid deflection time of > or =85 ms has a sensitivity of 87% and a specificity of 90%, and an RS complex duration of > or =121 ms has a sensitivity of 76% and a specificity of 85% in identifying an epicardial origin of the VTs. CONCLUSIONS: ECG suggests VTs originating from the epicardium and those with an unsuccessful radiofrequency ablation from the endocardium.

Incidence of pulmonary vein stenosis in patients submitted to atrial fibrillation ablation: a comparison of the Selective Segmental Ostial Ablation vs the Circumferential Pulmonary Veins Ablation.

INTRODUCTION: Pulmonary vein (PV) stenosis is an important complication of the AF ablation and could be underestimated if their assessment is not systematically done. Selective Segmental Ostial Ablation (SSOA) and Circunferential Pulmonary Veins Ablation (CPVA) have demonstrated efficacy in atrial fibrillation (AF) treatment. In this study the real incidence of PV stenosis in patients (pts) submitted to both SSOA and CPVA was compared. METHODS: Those pts with focal activity and normal left atrial size were submitted to SSOA, remaining pts were submitted to CPVA to treat refractory, symptomatic AF. Contrast enhanced magnetic resonance angiography (MRA) was routinely performed in all patients 4 months after the procedure. RESULTS: A series of 73 consecutive patients (mean age of 51 +/- 11 years; 75% male) were included. SSOA was performed in 32 patients, and the remaining 41 patients underwent to CPVA, obtaining similar efficacy rates (72% vs 76% arrythmia free probability at 12 months; log rank test p = NS). Six patients had a significant PV stenosis, all in SSOA group none in CPVA group (18.8% vs 0%; p = 0.005). All patients were asymptomatic and the stenosis was detected in routine MRA. No predictors of stenosis has been identified analysing patient procedure characteristics. CONCLUSION: PV stenosis is a potential complication of SSOA not seen in CPVA. The study confirms than MRA is useful for identifying patients with asymptomatic PV stenosis.

Association between the effect of spontaneous contrast in the thoracic aorta and recent ischemic stroke determined by transesophageal echocardiography.

OBJECTIVE: To assess the independent association between the presence of spontaneous echo contrast in the aorta and recent stroke events. METHODS: Two hundred and twenty-four individuals with a diagnosis of recent stroke and 85 control individuals who were examined due to various present/suspected heart diseases were studied through transesophageal echocardiography. The effects of spontaneous contrast in the aorta and the presence of other potential sources of cardiac embolism associated with them were researched and a questionnaire was completed about patients' clinical risk factors at the time of examination. RESULTS: The effects of contrast in the aorta was associated with stroke (OR=2.83; CI = 95%, 1.65-4.46; P<0.001) in the bivariate analysis. In the multivariate analysis, it remained associated with recent stroke (OR=2.05; CI = 90%, 1.10-3.85; P=0.06). Age > 60 years, a history of systemic blood hypertension and smoking, and dyslipidemia were risk factors independently associated with the effects of contrast in the aorta. The presence of a spontaneous contrast effect in the left atrium and Lambl's excrescences were echocardiographic factors independently associated with the effects of contrast in the aorta. CONCLUSION: The effect of contrast in the aorta was independently associated with recent stroke and with its clinical risk factors. These results reinforce the hypothesis that the phenomenon is a predictor of several risk factors.

Impact of cerebral cardiopulmonary resuscitation maneuvers in a general hospital: prognostic factors and outcomes.

OBJECTIVE: To assess survival of patients undergoing cerebral cardiopulmonary resuscitation maneuvers and to identify prognostic factors for short-term survival. METHODS: Prospective study with patients undergoing cardiopulmonary resuscitation maneuvers. RESULTS: The study included 150 patients. Spontaneous circulation was re-established in 88 (58%) patients, and 42 (28%) were discharged from the hospital. The necessary number of patients treated to save 1 life in 12 months was 3.4. The presence of ventricular fibrillation or tachycardia (VF/VT) as the initial rhythm, shorter times of cardiopulmonary resuscitation maneuvers and cardiopulmonary arrest, and greater values of mean blood pressure (BP) prior to cardiopulmonary arrest were independent variables for re-establishment of spontaneous circulation and hospital discharge. The odds ratios for hospital discharge were as follows: 6.1 (95% confidence interval [CI] = 2.7-13.6), when the initial rhythm was VF/VT; 9.4 (95% CI = 4.1-21.3), when the time of cerebral cardiopulmonary resuscitation was < 15 min; 9.2 (95% CI = 3.9-21.3), when the time of cardiopulmonary arrest was < 20 min; and 5.7 (95% CI = 2.4-13.7), when BP was > 70 mmHg. CONCLUSION: The presence of VF/VT as the initial rhythm, shorter times of cerebral cardiopulmonary resuscitation and of cardiopulmonary arrest, and a greater value of BP prior to cardiopulmonary arrest were independent variables of better prognosis.

Prevalence of oral anticoagulation in atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores.

Atrial fibrillation ablation by use of electroanatomical mapping: efficacy and recurrence factors.

BACKGROUND: Radiofrequency catheter ablation guided by electroanatomical mapping is currently an important therapeutic option for the treatment of atrial fibrillation. The complexity of the procedure, the several techniques used and the diversity of the patients hinder the reproduction of the results and the indication for the procedure. OBJECTIVE: To evaluate the efficacy and factors associated with recurrence of atrial fibrillation. METHODS: Prospective cohort study with consecutive patients submitted to atrial fibrillation ablation treatment guided by electroanatomical mapping. The inclusion criteria were as follows: minimum age of 18 years; presence of paroxysmal, persistent or long-standing persistent AF; AF recording on an electrocardiogram, exercise testing or Holter monitoring (duration longer than 15 minutes); presence of symptoms associated with AF episodes; AF refractoriness to, at least, two antiarrhythmic drugs, one of which being amiodarone, or impossibility to use antiarrhythmic drugs. RESULTS: The study included 95 patients (age 55 ± 12 years, 84% men, mean CHADS2 = 0.8) who underwent 102 procedures with a median follow-up of 13.4 months. The recurrence-free rate after the procedure was 75.5% after 12 months. Atrial fibrillation recurred as follows: 26.9% of patients with paroxysmal and persistent atrial fibrillation; 45.8% of patients with long-standing persistent atrial fibrillation (p = 0.04). Of the analyzed variables, the increased size of the left atrium has proven to be an independent predictor of atrial fibrillation recurrence after the procedure (HR = 2.58; 95% CI: 1.26-4.89). Complications occurred in 4.9% of the procedures. CONCLUSION: Atrial fibrillation ablation guided by electroanatomical mapping has shown good efficacy. The increase in left atrium size was associated with atrial fibrillation recurrence.

Prevalence of peripheral arterial disease in patients with heart failure with preserved ejection fraction

OBJECTIVES: To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF). METHODS: A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups. RESULTS: The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD. CONCLUSION: Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

Update in heart rhythm abnormalities and indications for pacemaker after transcatheter aortic valve implantation

Abstract Objective: Rhythm abnormalities following transcatheter aortic valve implantation (TAVI) and indications for permanent pacemaker implantation (PPI) were reviewed, which aren't well established in the current guidelines. New left bundle branch block and atrioventricular block are the most common electrocardiographic changes after TAVI. PPI incidence ranges from 9-42% for self-expandable and 2.5-11.5% for balloon expandable devices. Not only anatomical variations in conduction system have an important role in conduction disorders, but different valve characteristics and their relationship with cardiac structures as well. Previous right bundle branch block has been confirmed as one of the most significant predictors for PPI.

Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study / Preditores de Mortalidade Total e de Resposta Ecocardiográfica à Terapia de Ressincronização Cardíaca: Um Estudo de Coorte

Abstract Background: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. Objective: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. Methods: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. Results: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. Conclusion: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.

Resumo Fundamento: Estudos Clínicos demonstram que até 40% dos pacientes não respondem à terapia de ressincronização cardíaca (TRC), assim a seleção apropriada dos pacientes é fundamental para o sucesso da TRC na insuficiência cardíaca. Objetivo: Avaliação de preditores de mortalidade e resposta à TRC no cenário brasileiro. Métodos: Estudo de coorte retrospectivo incluindo os pacientes submetidos à TRC em hospital terciário no Sul do Brasil entre 2008-2014. A sobrevida foi avaliada através de banco de dados da Secretaria Estadual de Saúde (RS). Os preditores de resposta ecocardiográfica foram avaliados utilizando método de regressão de Poisson. A análise de sobrevida foi feita por regressão de Cox e curvas de Kaplan Meyer. Um valor de p bicaudal inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Foram incluídos 170 pacientes com seguimento médio de 1011 ± 632 dias. A mortalidade total foi de 30%. Os preditores independentes de mortalidade identificados foram idade (hazzard ratio [HR] de 1,05; p = 0,027), infarto agudo do miocárdio (IAM) prévio (HR de 2,17; p = 0,049) e doença pulmonar obstrutiva crônica (DPOC) (HR de 3,13; p = 0,015). O percentual de estimulação biventricular em 6 meses foi identificado com fator protetor de mortalidade ([HR] 0,97; p = 0,048). Os preditores independentes associados à reposta ecocardiográfica foram ausência de insuficiência mitral, presença de bloqueio de ramo esquerdo e percentual de estimulação biventricular. Conclusão: A mortalidade nos pacientes submetidos à TRC em hospital terciário foi independentemente associada à idade, presença de DPOC e IAM prévio. O percentual de estimulação biventricular avaliado 6 meses após o implante do ressincronizador foi independentemente associado a melhora da sobrevida e resposta ecocardiográfica.

Prevalence of oral anticoagulation in atrial fibrillation

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores. .

Ablacao de Fibrilacao Atrial por Mapeamento Eletroanatomico: Eficacia e Fatores de Recorrencia / Atrial Fibrillation Ablation by Use of Electroanatomical Mapping: Efficacy and Recurrence Factors

Fundamento: A ablação por cateter de radiofrequência guiada por mapeamento eletroanatômico é, atualmente, uma importante opção terapêutica para o tratamento da fibrilação atrial. A complexidade do procedimento, as diferentes técnicas e a diversidade de pacientes dificultam a reprodução dos resultados bem como a indicação do procedimento. Objetivo: Avaliar a eficácia e os fatores relacionados à recorrência de fibrilação atrial. Métodos: Estudo de coorte prospectivo com pacientes consecutivos submetidos ao tratamento de fibrilação atrial por ablação e mapeamento eletroanatômico. Foram incluídos os seguintes pacientes: idade acima de 18 anos; portadores de fibrilação atrial paroxística, persistente ou persistente de longa duração; com registro de fibrilação atrial em eletrocardiograma, Holter ou ergometria (duração > 15 minutos); com sintomas associados aos episódios de fibrilação atrial; e apresentando refratariedade a, pelo menos, duas drogas antiarrítmicas (entre elas amiodarona) ou impossibilidade do uso de drogas antiarrítmicas. Resultados: Foram incluídos 95 pacientes (idade 55 ± 12 anos, 84% homens, CHADS2 médio = 0,8) que realizaram 102 procedimentos com seguimento mediano de 13,4 meses. A taxa livre de recorrência após o procedimento foi de 75,5% após 12 meses. Os pacientes portadores de fibrilação atrial paroxística e fibrilação atrial persistente apresentaram recorrência de 26,9% versus 45,8% dos pacientes portadores de fibrilação atrial persistente de longa duração (p = 0,04). Das variáveis analisadas, o tamanho do átrio esquerdo demonstrou ser preditor independente de recorrência de fibrilação atrial após ...

Background: Radiofrequency catheter ablation guided by electroanatomical mapping is currently an important therapeutic option for the treatment of atrial fibrillation. The complexity of the procedure, the several techniques used and the diversity of the patients hinder the reproduction of the results and the indication for the procedure. Objective: To evaluate the efficacy and factors associated with recurrence of atrial fibrillation. Methods: Prospective cohort study with consecutive patients submitted to atrial fibrillation ablation treatment guided by electroanatomical mapping. The inclusion criteria were as follows: minimum age of 18 years; presence of paroxysmal, persistent or long-standing persistent AF; AF recording on an electrocardiogram, exercise testing or Holter monitoring (duration longer than 15 minutes); presence of symptoms associated with AF episodes; AF refractoriness to, at least, two antiarrhythmic drugs, one of which being amiodarone, or impossibility to use antiarrhythmic drugs. Results: The study included 95 patients (age 55 ± 12 years, 84% men, mean CHADS2 = 0.8) who underwent 102 procedures with a median follow-up of 13.4 months. The recurrence-free rate after the procedure was 75.5% after 12 months. Atrial fibrillation recurred as follows: 26.9% of patients with paroxysmal and persistent atrial fibrillation; 45.8% of patients with long-standing persistent atrial fibrillation (p = 0.04). Of the analyzed variables, the increased size of the left atrium has proven to be an independent predictor of atrial fibrillation recurrence after the procedure (HR = 2.58; 95% CI: 1.26-4.89). Complications occurred in 4.9% of the procedures. Conclusion: Atrial fibrillation ablation guided by electroanatomical mapping has shown good efficacy. The increase in left atrium size was associated with atrial fibrillation recurrence. .

Avaliação da função renal após a terapia de ressincronização cardíaca / Assessment of renal function after cardiac resynchronization therapy

A síncope é um problema médico comum e, se relacionada a distúrbio da condução atrioventricular (AV), pode indicar o implante de marcapasso definitivo. Por isso, a distinção entre o bloqueio AV devido a doença degenerativa e aquele induzido por aumento do tônus vagal tem importante implicação prognóstica e terapêutica. O mecanismo responsável pela síncope vasovagal é a perda abrupta e transitória da consciência decorrente de hipoperfusão cerebral global e transitória, com início rápido, curta duração e recuperação completa e espontânea. É uma causa comum de síncope e tem bom prognóstico. Em sua forma cardioinibitória, costuma ter como mecanismo a bradicardia sinusal ou a assistolia associada a queda da pressão sanguínea, porém podem ocorrer outras apresentações menos comuns, como o bloqueio AV (BAVT, BAV 2:1 BAV avançado). Descreve-se o caso de uma paciente do sexo feminino, com 54 anos, hipertensa, chagásica (megaesôfago) e vários episódios de síncope no último ano. Foi investigada com eletrocardiograma (BAV 1º grau), ecocardiograma (normal), Holter (BAV 2 grau Mobitz I durante o sono), teste ergométrico (resposta cronotrópica e condução AV normais durante o esforço) e tilt test sensibilizado positivo (BAVT) com manutenção de distúrbios da condução atrioventricular (BAVT, BAV avançado) associados a pré-síncope após retorno a zero grau, quadro que durou 25 minutos. Como parte da investigação, foi submetida a estudo eletrofisiológico com intervalo HV normal. Foi indicado marcapasso definitivo, porém a paciente recusou-se. Retornou após um ano com manutenção do quadro de síncope. Foi então submetida a implante de marcapasso definitivo de dupla-câmara e encontra-se há 15 meses sem sintomas.

Abstract: Syncope is a common medical problem and if related to disorder of atrioventricular (AV) conduction may be indicative of permanent pacemaker implantation. Therefore, the distinction between AV block due to degenerative disease and that induced by increased vagal tone has important prognostic and therapeutic implications. The mechanism responsible for vasovagal syncope is a sudden and transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration, and spontaneous complete recovery. It is a common cause of syncope and has a good prognosis. When cardioinhibitory, usually has as a mechanism of syncope sinus bradycardia or asystole associated to drop in blood pressure, but other less common presentations may occur as AV block (AVB, advanced AVB, AVB 2:1). We describe the case of a female patient, 54 years old, with hypertension, Chagas disease (megaesophagus) and several episodes of syncope in the last year. She was investigated by electrocardiogram (1st degree AVB), echocardiogram (normal), holter (Mobitz I 2nd degree AVB during sleep), exercise testing (normal chronotropic response and AV conduction during exercise) and tilt test (complete AVB) with maintenance of atrioventricular block (complete AVB and advanced AVB) associated with pre-syncope after returning to zero degree. This situation last for 25 minutes. As part of the investigation she underwent electrophysiologic study with normal HV interval. Permanent pacemaker was indicated but the patient refused. After 1 year she returned with maintenance of syncope and then underwent implantation of a permanent dual chamber pacemaker. She is without symptoms in the last 15 months.

Short head-up tilt test potentiated with oral nitroglycerine: comparison with a conventional test using isoproterenol.

Conventional tilt test protocols are time consuming and there is no consensus regarding the optimal duration of the test and the provocative drug to be used. This study evaluated the diagnostic power of a short nitroglycerine test against a conventional isoproterenol protocol. A cohort of 128 patients with unexplained syncope was studied. A group of 64 consecutive patients were tilted with a short nitroglycerine test consisting of a passive phase of 15 minutes and if this proved negative, 400 microg of sublingual nitroglycerin spray for a further 15 minutes. The control group consisted of 64 patients tilted with a conventional isoproterenol protocol with a passive phase of 30 minutes and a drug-challenge phase of 20 minutes. In the nitroglycerine protocol 39 (60.9%) patients showed a positive response versus 27(42.2%) in the isoproterenol group (P = 0.034). The duration of the protocol was 23.2 +/- 7.2 minutes in the nitroglycerine group versus 41.1 +/- 15.5 minutes with isoproterenol (P = 0.001). The time until syncope was 18.87 +/- 6.1 versus 29 +/- 18, respectively (P = 0.002). For evaluating unexplained syncope the short tilt test protocol with nitroglycerine is less time consuming, easier to perform, and has a higher rate of positive response than a conventional isoproterenol protocol.

Avaliação da estabilidade de anticoagulação entre a Varfarina e a Femprocumona / Oral anticoagulation stability assessment with Warfarin and Phenprocoumon

Fundamentos: A varfarina e a femprocumona são os anticoagulantes orais mais utilizados; no entanto, até então, não existem estudos randomizados comparando a estabilidade da anticoagulação entre estes dois fármacos. Objetivos: Comparar a varfarina e femprocumona quanto à estabilidade na manutenção de anticoagulação em nível terapêutico (razão normatizada internacional [RNI] entre 2,0 e 3,0) e avaliar a incidência de complicações hemorrágicas e tromboembólicas decorrentes de anticoagulação inadequada.Métodos: Ensaio clínico, randomizado, duplo-cego, incluindo pacientes em tratamento vigente com anticoagulante oral, porém com RNI abaixo do alvo terapêutico nas últimas três semanas, randomizados para uso de varfarina ou femprocumona. O ajuste da dose da medicação foi realizado conforme algoritmo pré-estabelecido. Resultados: Foram randomizados 62 pacientes, sendo 31 em cada grupo, durante as cinco primeiras semanas de estudo. Verificou-se que a femprocumona se mostrou mais instável comparada à varfarina. A partir da sexta aferição de RNI, o grupo femprocumona apresentou melhora na estabilidade do valor do RNI, porém não houve significância estatística. Também não houve diferença significativa em relação aos efeitos colaterais dos fármacos. Conclusão: A varfarina demonstrou maior eficácia na estabilidade do RNI em relação à femprocumona.

Background: Although warfarin and phenprocoumon are the most widely used oral anticoagulants, there a r e n o r a n d o m i z e d s t u d i e s c o m p a r i n g t h e anticoagulation stability of these two drugs.Objectives: To compare warfarin and phenprocoumon in terms of therapeutic anticoagulation maintenance stability (international normalized ratio [INR] between 2.0 and 3.0) and evaluate the incidence of thromboembolic and hemorrhagic complications arising from inadequate anticoagulation.Methods: Randomized double-blind clinical trial with patients undergoing current oral anticoagulant treatment but with INR below the therapeutic target during the past 3 weeks, randomized for warfarin or phenprocoumon. Medication dosages were adjusted in compliance with a predetermined algorithm.Results: With 62 patients randomized into two groups of 31 each during the first five weeks of the study, phenprocoumon was found to be more unstable than warfarin. From the sixth INR measurement onwards, the stability of the INR value improved in the phenprocoumon group, but with no statistical significance. There were no significant differences in the side effects of the drugs.Conclusion: Warfarin demonstrated greater effectiveness for INR stability than phenprocoumon.