Right bundle brunch block in patients with acute myocardial infarction is associated with a higher in-hospital arrhythmic risk and mortality, and a worse prognosis after discharge.

INTRODUCTION: Recently, the presence of right bundle brunch block (RBBB) in patients with persistent ischaemic symptoms has been suggested as an indication for emergent coronary angiography. OBJECTIVE: The aim of this study was to assess the prognostic impact of RBBB in patients with acute myocardial infarction (AMI) before the implementation of the recent recommendations. METHODS: We retrospectively studied consecutive patients admitted with AMI between 2011 and 2013. Patients with left bundle brunch block, pacemaker, or nonspecific intraventricular conduction delay were excluded. Patients with RBBB were compared with those without RBBB. Clinical characteristics, in-hospital evolution, and major adverse cardiovascular events (MACE) during follow-up, defined as cardiovascular death, sustained ventricular arrhythmias, acute heart failure syndromes, recurrent myocardial infarction, or acute stroke, were analysed. RESULTS: The analysis included 481 patients. Thirty two patients (6.7%) had RBBB. Patients with RBBB were older. During hospital admission, RBBB patients had a higher rate of sustained ventricular tachycardia and death. Survival curve analysis showed that patients with RBBB had a lower in-hospital survival rate (Log-rank, p = 0.004). After discharge, during a mean follow-up time of 24.3 ± 11.6 months, 53 patients (12%) died. Survival curve analysis showed a lower survival rate free of MACE for those patients with RBBB (Log-rank, p = 0.011). RBBB was independently associated with MACE occurrence (HR 2.17, 95% CI 1.07-4.43; p = 0.033), after adjusting for demographic data, coronary angiography findings, treatment performed, echocardiographic evaluation, and medical therapy. CONCLUSION: Patients with RBBB had a higher rate of in-hospital mortality and arrhythmic events, and an increased risk of MACE during follow-up.

Knowledge and Beliefs about Herb/Supplement Consumption and Herb/Supplement-Drug Interactions among the General Population, including Healthcare Professionals and Pharmacists: A Systematic Review and Guidelines for a Smart Decision System.

The increased consumption of a variety of herbs/supplements has been raising serious health concerns. Owing to an inadequate understanding of herb/supplement-drug interactions, the simultaneous consumption of these products may result in deleterious effects and, in extreme cases, even fatal outcomes. This systematic review is aimed at understanding the knowledge and beliefs about the consumption of herbs/supplements and herb/drug-supplement interactions (HDIs). The study follows the PRISMA guidelines. Four online databases (Web of Science; PubMed; Cochrane; and EBSCOhost) were searched, and a total of 44 studies were included, encompassing 16,929 participants. Herb and supplement consumption is explained mostly by the reported benefits across multiple conditions and ease of use. Regarding HDIs, most people take both herbs/supplements and prescription drugs simultaneously. Only a small percentage of participants have knowledge about their interaction effects, and many reported adverse interactions or side effects. Nevertheless, the main reason for stopping the prescribed drug intake is the perceived lack of its effect, and not due to interactions. Therefore, it is important to increase the knowledge about supplement use so that further strategies can be elaborated to better detect or be alert for whenever a potentially dangerous reaction and/or interaction may occur. This paper raises awareness regarding the need for developing a decision support system and ends with some considerations about the development of a technological solution capable of detecting HDIs and, thereby, aiding in the improvement of pharmacy services.

Acute coronary syndrome and stress: Is there a relationship?

INTRODUCTION: Acute coronary syndrome (ACS) is the result of a complex pathophysiological process with various dynamic factors. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument for estimating stress levels in clinical practice and may be useful in the assessment of ACS. METHODS: We carried out a single-center prospective study engaging patients hospitalized with ACS between March 20, 2019 and March 3, 2020. The PSS-10 was completed during the hospitalization period. The ACS group was compared to a control group (the general Portuguese population), and a subanalysis in the stress group were then performed. RESULTS: A total of 171 patients with ACS were included, of whom 36.5% presented ST-elevation myocardial infarction (STEMI), 38.1% were female and the mean PSS score was 19.5±7.1. Females in the control group scored 16.6±6.3 on the PSS-10 and control males scored 13.4±6.5. The female population with ACS scored 22.8±9.8 on the PSS-10 (p<0.001). Similarly, ACS males scored a mean of 17.4±6.4 (p<0.001). Pathological stress levels were not a predictor of major adverse cardiovascular events or severity at admission. CONCLUSIONS: ACS patients had higher perceived stress levels compared to the control group. Perceived stress level was not associated with worse prognosis in ACS patients.

Prognostic value of brain natriuretic peptide in ST-elevation myocardial infarction patients: A Portuguese registry.

INTRODUCTION: Brain natriuretic peptide (BNP) is a highly sensitive and specific biomarker for the extent of myocardial infarction that is strongly related to short- and long-term prognosis in patients with acute coronary syndromes. OBJECTIVE: To assess the prognostic value of BNP levels in a Portuguese cohort of ST-elevation myocardial infarction (STEMI) patients. METHODS: We performed a retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010 and 2019. Patients were divided into three groups according to BNP level (<100 pg/ml, 100-399 pg/ml and ≥400 pg/ml) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. For sample homogenization, propensity score matching and pairwise matching with a tolerance level of 0.005 were performed. RESULTS: A total of 1650 patients were included, of whom 21.5% presented high BNP levels (≥400 pg/ml). These were older and had more comorbidities, lower admission systolic blood pressure and hemoglobin, higher heart rate, Killip class and creatinine, worse left ventricular systolic function and severe coronary anatomy. Higher BNP was associated with more in-hospital complications, in-hospital mortality and adverse outcomes at one year. CONCLUSION: BNP levels during the index hospitalization were a powerful prognostic biomarker for all-cause mortality and major adverse cardiac events in patients admitted with STEMI to Portuguese hospitals.

Permanent cardiac pacing for patients with iatrogenic or potentially reversible bradyarrhythmia. / Bradidisrritmia puramente iatrogénica existe?

INTRODUCTION: In iatrogenic or potentially reversible bradyarrhythmia, drug discontinuation or metabolic correction is recommended before permanent cardiac pacemaker (PM) implantation. These patients often have conduction system disease and there are few data on recurrence or the need for a permanent PM. OBJECTIVE: To analyze the need for PM implantation in patients with iatrogenic bradyarrhythmia or bradyarrhythmia associated with other potentially reversible causes. METHODS: We assessed consecutive symptomatic patients admitted to the emergency department with a primary diagnosis of bradyarrhythmia (atrioventricular [AV] node disease - complete or second-degree AV block (AVB) [CAVB: 2nd-degree AVB - 2:1], sinus bradycardia [SB] and atrial fibrillation [AF] with slow ventricular response [SVR]) in the context of iatrogenic causes or metabolic abnormalities. We determined the percentage of patients who required PM implantation. RESULTS: We studied 153 patients (47% male) admitted for iatrogenic or potentially reversible bradyarrhythmia. Diagnoses were SB 16%, CAVB 63%, second-degree AVB 12%, and AF with SVR 10%. Eighty-five percent of patients were under negative chronotropic therapy, 3% had hyperkalemia and 12% had a combined etiology. After correction of the cause, 55% of patients (n=84) needed a PM. In these patients the most common type of bradyarrhythmia was CAVB, in 77% (n=65) patients. CONCLUSION: In a high percentage of patients with bradyarrhythmia associated with a potentially reversible cause, the arrhythmia recurs or does not resolve during follow-up. Patients with AV node disease constitute a subgroup with a higher risk of recurrence who require greater vigilance during follow-up and should be considered for PM implantation after the first episode.

Are defibrillators less useful in patients with non-ischemic heart disease? / Será a implantação de desfibrilhador menos útil nos doentes com cardiopatia não isquémica?

INTRODUCTION AND OBJECTIVE: The benefits of implanted defibrillators in patients with ischemic heart disease (IHD) are well known. However, the evidence is less robust in patients with non-ischemic heart disease (non-IHD). We aimed to determine whether patients with non-IHD have a similar incidence of appropriate shocks and all-cause mortality compared to those with IHD. METHODS: In a retrospective single-center study we analyzed all patients with implantable cardioverter-defibrillators or cardiac resynchronization therapy-defibrillators implanted for primary prevention between 2004 and 2014. The population was divided into two groups: patients with IHD and patients with non-IHD. The composite endpoint was appropriate shock and all-cause mortality. RESULTS: Two hundred and eighty-one patients were studied, of whom 187 (66%) had IHD. Patients with IHD were older, more frequently male and with more cardiovascular risk factors. Mean follow-up was 55±42 months. Thirty-four patients (18%) with IHD and 20 patients (21%) with non-IHD had an appropriate shock (p=0.64). Eighty-nine patients (47%) with IHD and 36 (38%) with non-IHD died during follow-up (p=0.19). The rate of shocks or death over time was similar in patients with IHD and non-IHD according to Kaplan-Meier survival curve analysis (log-rank p=0.10). CONCLUSION: In this population, there were no differences in appropriate shocks or all-cause mortality in the two groups.

Prognostic Impact of Iron Metabolism Changes in Patients with Acute Coronary Syndrome.

BACKGROUND: Iron metabolism disorders have been associated with an increased risk of cardiovascular events. However, the prognostic impact on patients (pts) with acute coronary syndrome (ACS) has yet to be clarified. OBJECTIVE: To determine the prognostic value of serum iron and ferritin levels in pts with ACS in the short and long-term. METHODS: Consecutive pts admitted to a coronary care unit with a diagnosis of ACS, for a period of 2 years, were evaluated. The population was divided into tertiles of serum iron and ferritin distribution. The primary adverse events were the occurrence of in-hospital death or heart failure (HF) and death or HF at 1 year of follow-up. RESULTS: We studied 280 pts (73% males; mean age 68 ± 13 years). The mean levels of serum iron and ferritin were 59 ± 34 mcg/dL and 205 ± 185 ng/mL, respectively. Patients included in the 1st tertile of serum iron (≤ 40 mcg/dL) had a higher rate of adverse events, in-hospital and after 1 year. Lower and higher levels of ferritin (1st and 3rd tertiles, ≤ 110; >219 ng/ml, respectively) were associated with a higher incidence of HF during hospitalization and death at 1 year. A ferritin value >316 ng /mL was an independent risk factor for death at 1 year (adjusted OR: 14; 95%CI: 2.6 to 75.9). CONCLUSION: In this population, iron metabolism alterations were associated with a higher rate of adverse events and higher ferritin levels constituted an independent mortality predictor in the long-term.

Relationship between nocturnal blood pressure profiles and the presence and severity of hypertensive retinopathy. / Relação entre o perfil tensional noturno e a prevalência e gravidade da retinopatia hipertensiva.

INTRODUCTION: Non-dipper and extreme dipper blood pressure (BP) profiles are associated with a worse cardiovascular prognosis. The relationship between nocturnal BP profile and hypertensive retinopathy (HR) is not fully established. AIM: To assess the association between the prevalence and severity of HR and nocturnal BP. METHODS: We prospectively studied hypertensive patients who underwent 24-hour ambulatory BP monitoring. The population was divided into two groups according to the presence or absence of lesions and compared according to baseline characteristics, nocturnal BP profile (dippers, non-dippers, inverted dippers/risers and extreme dippers) and mean nocturnal systolic (SBP) and diastolic (DBP) BP values. The presence and severity of HR were assessed using the Scheie classification. The relationship between nocturnal SBP and DBP values (and nocturnal BP profile) and the prevalence and severity of HR was determined. RESULTS: Forty-six patients (46% male, aged 63±12 years) were analyzed, of whom 91% (n=42) were under antihypertensive treatment. Seventy percent (n=33) had uncontrolled BP. HR was diagnosed in 83% (n=38). Patients with HR had higher mean systolic nocturnal BP (151±23 vs. 130±13 mmHg), p=0.008). Patients with greater HR severity (Scheie stage ≥2) had higher nocturnal BP (153±25 vs. 140±16 mmHg, p=0.04). There was no statistically significant association between DBP and nocturnal BP patterns and HR. CONCLUSIONS: The prevalence and severity of HR were associated with higher nocturnal SBP. No relationship was observed between nocturnal BP profile and the presence of HR.

Excessive atrial ectopic activity as an independent risk factor for ischemic stroke.

BACKGROUND: Excessive atrial ectopic activity (EAEA) has been related with an increased risk of atrial fibrillation (AF) and stroke but different cutoff values have been used. We aimed to determine the association between EAEA and stroke, AF and overall death. METHODS: Consecutive 24-hour Holter monitoring performed between 2005 and 2010 in a single center was evaluated. Patients with a previous diagnosis of stroke or AF were excluded. The number of premature atrial contractions (PACs) during 24h was analyzed in 2480 subjects and according to that 3 sub-groups were defined: >97PACs/h (above the top 5th percentile of the population) (EAEA+); intermediate value of PACs/h (below the top 5th percentile but above 30PACs/h) (EAEA+/-) and <30PACs/h (EAEA-). RESULTS: After adjusting for risk factors, laboratory findings and medication, EAEA+ was associated with ischemic stroke (hazard ratio [HR] 2.83; 95% confidence interval [CI], 1.65-4.84, p<0.001). Both EAEA+ and EAEA+/- were independently associated with AF (HR 2.05; 95% CI 1.31-3.23, p=0.010 for EAEA+ and HR 1.90; 95% CI 1.10-2.78, p=0.020 for EAEA+/-) and overall death (HR 2.17; 95% CI 1.48-3.28, p=0.031 for EAEA+; HR 2.01; 95% CI 1.06-2.52, p=0.029 for EAEA+/-). CONCLUSION: In this population, having >30PACs/h was independently associated with a higher risk of AF and overall death but only subjects with >97PACs/h had a higher risk of ischemic stroke. In the majority of subjects with stroke and EAEA+, AF has not been detected before stroke event.

In-hospital acute myocardial infarction: A case of type II Kounis syndrome. / Enfarte agudo do miocárdio intra­hospitalar: um caso de síndrome de Kounis tipo II.

Kounis syndrome (KS) is the coincidental occurrence of acute coronary syndrome (ACS) and anaphylactic or allergic insult. It results from mast cell degranulation with subsequent release of numerous inflammatory mediators, leading to coronary vasospasm or atheromatous plaque rupture. Diagnosis is clinical and based on the temporal relationship between the two events. Despite the growing number of reported cases, especially in southern Europe, the lack of awareness of this association may lead to under-reporting in Portugal. Recognition of KS, even if retrospective, has clinical implications since individual atopy must be investigated and desensitization measures should be employed, if possible, to prevent future events. We report the case of a 70-year-old man who was admitted to hospital because of generalized exanthema and itching and onset of chest pain while under observation. Coronary angiography confirmed coronary artery disease and ACS and he was diagnosed as having type II KS.

Hypersensitivity to aspirin and urgent percutaneous coronary intervention: A therapeutic challenge. / Hipersensibilidade à aspirina e coronariografia urgente: desafio terapêutico.

Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs are common and five types of reactions have been defined. The prevalence of such reactions in patients with myocardial infarction is unclear, and so antiplatelet therapy in this population is a challenge. Various desensitization protocols have been developed but there are no specific guidelines for their use. The authors present the case of a patient with acute coronary syndrome and aspirin hypersensitivity referred for urgent coronary angiography. Aspirin desensitization therapy is safe and successful in many patients, but more randomized trials are needed to confirm its benefits in coronary artery disease patients.

Prognostic Impact of Iron Metabolism Changes in Patients with Acute Coronary Syndrome / Impacto Prognóstico das Alterações do Metabolismo do Ferro em doentes com Síndrome Coronária Aguda

Abstract Background: Iron metabolism disorders have been associated with an increased risk of cardiovascular events. However, the prognostic impact on patients (pts) with acute coronary syndrome (ACS) has yet to be clarified. Objective: To determine the prognostic value of serum iron and ferritin levels in pts with ACS in the short and long-term. Methods: Consecutive pts admitted to a coronary care unit with a diagnosis of ACS, for a period of 2 years, were evaluated. The population was divided into tertiles of serum iron and ferritin distribution. The primary adverse events were the occurrence of in-hospital death or heart failure (HF) and death or HF at 1 year of follow-up. Results: We studied 280 pts (73% males; mean age 68 ± 13 years). The mean levels of serum iron and ferritin were 59 ± 34 mcg/dL and 205 ± 185 ng/mL, respectively. Patients included in the 1st tertile of serum iron (≤ 40 mcg/dL) had a higher rate of adverse events, in-hospital and after 1 year. Lower and higher levels of ferritin (1st and 3rd tertiles, ≤ 110; >219 ng/ml, respectively) were associated with a higher incidence of HF during hospitalization and death at 1 year. A ferritin value >316 ng /mL was an independent risk factor for death at 1 year (adjusted OR: 14; 95%CI: 2.6 to 75.9). Conclusion: In this population, iron metabolism alterations were associated with a higher rate of adverse events and higher ferritin levels constituted an independent mortality predictor in the long-term.

Resumo Fundamento: Alterações do metabolismo do ferro têm sido associadas a um aumento do risco de eventos cardiovasculares. No entanto, o impacto prognóstico em doentes (dts) com síndrome coronária aguda (SCA) encontra-se ainda pouco esclarecido. Objetivo: Determinar o valor prognóstico a curto e longo prazo dos níveis séricos do ferro e ferritina em dts com SCA. Métodos: Foram avaliados doentes consecutivos admitidos numa Unidade Coronária com o diagnóstico de SCA no período de 2 anos. A população foi agrupada segundo os tercis de distribuição de ferro e ferritina. Os eventos adversos primários foram a ocorrência de morte intrahospitalar e a 1 ano, bem como, insuficiência cardíaca (IC) intrahospitalar e a 1 ano de follow-up. Resultados: Estudaram-se 280 dts (73% sexo masculino; idade média de 68 ± 13 anos). O nível médio de ferro sérico e de ferritina foi 59 ± 34 mcg/dl e 205 ± 185 ng/ml, respetivamente. Os doentes incluídos no 1º tercil (≤ 40 mcg/dl) de ferro sérico apresentaram maior percentagem de eventos adversos intrahospitalares e a 1 ano. Níveis mais baixos e mais elevados de ferritina (1º e 3º tercil, respetivamente, ≤ 110; > 219 ng/ml) estiveram associados a uma maior ocorrência de IC em internamento e de morte a 1 ano. Um valor de ferritina > 316 ng/mL constituiu fator de risco independente de morte a 1 ano (OR ajustado 14 IC 95% 2,6-75,9). Conclusão: Nesta população alterações do metabolismo do ferro estiveram associadas a uma maior ocorrência de eventos adversos e níveis elevados de ferritina constituíram preditor independente de mortalidade a longo prazo.

Pressão de pulso como marcador prognóstico na síndrome coronariana aguda / Pulse pressure as a marker of prognosis in acute coronary syndrome

Fundamentos: Pressão de pulso (PP) corresponde à diferença entre pressão arterial sistólica e diastólica. Na síndrome coronariana aguda (SCA), a PP à admissão relaciona-se potencialmente com o prognóstico. Objetivo: Avaliar o impacto prognóstico da PP na admissão hospitalar por SCA. Métodos: Estudaram-se 8 152 pacientes, incluídos no Registro Nacional Português de SCA, calculando-se a PP àadmissão hospitalar. Criaram-se dois grupos de acordo com um valor cut-off de PP a partir do qual é mais significativa a presença de eventos adversos intra-hospitalares [morte, reinfarto, hemorragia, insuficiência cardíaca(IC)]. Foi então avaliada a ocorrência dos eventos adversos e a gravidade da doença coronariana. Resultados: O valor cut-off foi 50 mmHg. O Grupo 1 (PP ≥50 mmHg) incluiu 5 459 (67,0%) pacientes, sendo significativamente mais velhos (67,0±13,0 anos vs. 63,0±14,0 anos; p<0,001) com mais hipertensão arterial (75,0%vs. 59,4%; p<0,001), diabetes (33,0% vs. 23,1%; p<0,001) e doença multiarterial (56,1% vs. 51,9%. Valores de PP<50 mmHg (Grupo 2) estão associados à maior taxa de eventos adversos – combinado de morte, reinfarto,hemorragia e IC (56,2% vs. 47,0%; p<0,001). PP <50mmHg foi preditor independente de IC (OR 1,3 IC95% 1,1-1,4)e do combinado de eventos (OR 1,2 IC95% 1,1-1,4). Conclusão: Apesar de os valores de PP mais elevados se relacionarem significativamente com pior perfil de risco cardiovascular, valores de PP mais baixos estiveram mais associados a eventos adversos intra-hospitalares.

Background: Pulse pressure (PP) is the difference between the systolic and the diastolic blood pressure. In the acute coronary syndrome (ACS), PP at the admission is potentially related to the prognosis.Objective: Evaluating the PP prognosis impact at the hospital admission due to ACS. Methods: The study featured 8152 patients, included in the Portuguese National Record of ACS, calculating the PP at the hospital admission. Two groups were created under a cut-off PP value from which the presence of intra-hospital adverse events [death,reinfarction, bleeding, heart failure (HF)] is more significant. Then, the occurrence of adverse events and the coronary disease seriousness were evaluated. Results: The cut-off value was 50 mmHg. Group 1 (PP ≥50 mmHg) featured 5459 (67.0%) patients, being significantly older(67.0±13.0 years vs. 63.0±14.0 years; p<0.001) with more hypertension (75.0% vs. 59.4%; p<0.001), diabetes (33.0% vs. 23.1%;p<0.001), and multiarterial disease (56.1% vs. 51.9%). PP values <50 mmHg (Group 2) are related to a higher rate of adverseevents – a combination of death, reinfarction, bleeding and HF (56.2% vs. 47.0%; p<0.001). PP <50 mmHg was independente predictor of HF (OR 1.3 CI95% 1.1-1.4) and of the combination of events (OR 1.2 CI95% 1.1-1.4). Conclusion: Despite higher PP values being significantly related to worst cardiovascular risk profile, lower PP values were more associated to intra-hospital adverse events.