RESUMEN
Ventricular tachycardia (VT) is a rare but potentially fatal complication in pregnancy. We present a case of a pregnant woman with cardiomyopathy due to frequent premature ventricular complexes (PVCs) and VT originating from the left ventricular outflow tract. After presenting late in the third trimester, the decision was made to deliver the fetus after 4 days of medication titration due to continued sustained episodes of VT. After delivery, the patient continued to have frequent PVCs and VT several months after discharge, and she ultimately underwent a PVC ablation with dramatic reduction in PVC burden and improvement in cardiomyopathy. Multidisciplinary planning with a pregnancy heart team led to appropriate contingency planning and a successful delivery. This case highlights how multidisciplinary management is best practice in pregnancy complicated by VT and the need for better diagnostic guidelines for PVC-induced cardiomyopathy in the setting of pregnancy.
Asunto(s)
Cardiomiopatías , Complicaciones Cardiovasculares del Embarazo , Taquicardia Ventricular , Complejos Prematuros Ventriculares , Humanos , Femenino , Embarazo , Taquicardia Ventricular/terapia , Taquicardia Ventricular/etiología , Cardiomiopatías/terapia , Cardiomiopatías/complicaciones , Complicaciones Cardiovasculares del Embarazo/terapia , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Adulto , Complejos Prematuros Ventriculares/terapia , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/etiología , Periodo Periparto , Ablación por Catéter , Electrocardiografía , Antiarrítmicos/uso terapéutico , Antiarrítmicos/administración & dosificaciónRESUMEN
The spiked-helmet sign (SHS) is an electrocardiographic finding characterised by a distinctive pattern associated with critical illness, resolving once the clinical condition improves. While the underlying mechanism remains uncertain, different mechanisms have been proposed to account for these findings including changes in intrathoracic or intra-abdominal pressures, transient compression of the coronary arteries, repolarisation abnormalities and electromechanical artefacts. We describe the development of the SHS in a patient with underlying left bundle branch pacing following the development of respiratory failure due to haemoptysis and review proposed mechanisms for its pathophysiology.
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Enfermedad Crítica , Dispositivos de Protección de la Cabeza , Humanos , Electrocardiografía , Sistema de Conducción CardíacoRESUMEN
The widespread use of cardiac computed tomography and cardiac magnetic resonance imaging in patients undergoing echocardiography presents an opportunity to correlate the images side by side. Accordingly, the aim of this report is to review aspects of the standard echocardiographic examination alongside similarly oriented images from the two tomographic imaging modalities. It is hoped that this exercise will enhance understanding of the structures depicted by echocardiography as they relate to other structures in the thorax. In addition to reviewing basic cardiac anatomy, the authors take advantage of these correlations with computed tomography and cardiac magnetic resonance imaging to better understand the issue of foreshortening, a common pitfall in transthoracic echocardiography. The authors also highlight an important role that three-dimensional echocardiography can potentially play in the future, especially as advances in image processing permit higher fidelity multiplanar reconstruction images.
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Ecocardiografía Tridimensional , Ecocardiografía , Humanos , Ecocardiografía/métodos , Atrios Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Ecocardiografía Tridimensional/métodos , Pericardio/diagnóstico por imagenRESUMEN
OBJECTIVES: The purpose of this study was to determine the relationship between body composition, N-terminal B-type natriuretic peptide (NT-proBNP) levels, and heart failure (HF) phenotypes and outcomes. BACKGROUND: Abnormalities in body composition can influence metabolic dysfunction and HF severity; however, data assessing fat distribution and skeletal muscle (SM) size in HF with reduced (HFrEF) and preserved EF (HFpEF) are limited. Further, whether NPs relate more closely to axial muscle mass than measures of adiposity is not well studied. METHODS: We studied 572 adults without HF (n = 367), with HFrEF (n = 113), or with HFpEF (n = 92). Cardiac magnetic resonance was used to assess subcutaneous and visceral abdominal fat, paracardial fat, and axial SM size. We measured NT-proBNP in 334 participants. We used Cox regression to analyze the relationship between body composition and mortality. RESULTS: Compared with controls, pericardial and subcutaneous fat thickness were significantly increased in HFpEF, whereas patients with HFrEF had reduced axial SM size after adjusting for age, sex, race, and body height (p < 0.05 for comparisons). Lower axial SM size, but not fat, was significantly predictive of death in unadjusted (standardized hazard ratio: 0.63; p < 0.0001) and multivariable-adjusted analyses (standardized hazard ratio = 0.72; p = 0.0007). NT-proBNP levels more closely related to lower axial SM rather than fat distribution or body mass index (BMI) in network analysis, and when simultaneously assessed, only SM (p = 0.0002) but not BMI (p = 0.18) was associated with NT-proBNP. However, both NT-proBNP and axial SM mass were independently predictive of death (p < 0.05). CONCLUSIONS: HFpEF and HFrEF have distinct abnormalities in body composition. Reduced axial SM, but not fat, independently predicts mortality. Greater axial SM more closely associates with lower NT-proBNP rather than adiposity. Lower NT-proBNP levels in HFpEF compared with HFrEF relate more closely to muscle mass rather than obesity.
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Insuficiencia Cardíaca , Anciano , Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina , Biomarcadores , Composición Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico , Fragmentos de Péptidos , Valor Predictivo de las Pruebas , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
Systemic arterial hypertension constitutes the leading cause of mortality worldwide, and affects people living at different altitudes above sea level (AASL). AASL has a major impact on cardiovascular function and various biologic pathways that regulate blood pressure-related phenotypes, but whether it affects the clinical response to antihypertensive therapy is unknown. The hemodynamic adaptations observed among lowlanders acutely exposed to high altitude (HA) is distinct from those observed among HA dwellers. However, the phenotypic patterns of hypertension and the response to standard antihypertensive agents among adults chronically exposed to different AASL are poorly understood. The authors describe the protocol for the INTERVENCION trial, a randomized clinical trial designed to assess the effects of three first-line antihypertensive monotherapies (a thiazide diuretic, an angiotensin receptor blocker, and a calcium channel blocker) on peripheral and central blood pressure, in-office blood pressure, and ambulatory blood pressure hemodynamics of hypertensive patients living at different AASL (low altitude, intermediate altitude, and high altitude). The primary end point is the reduction in 24-hour brachial systolic blood pressure. The INTERVENCION trial will provide the first clinical trial data regarding the influence of AASL on the response to antihypertensive monotherapy, as well as the hemodynamic characteristics of arterial hypertension at different AASL.
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Altitud , Antihipertensivos/uso terapéutico , Hipertensión , Adulto , Antagonistas de Receptores de Angiotensina/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Monitoreo Ambulatorio de la Presión Arterial , Bloqueadores de los Canales de Calcio/uso terapéutico , Diuréticos/uso terapéutico , Humanos , Hipertensión/tratamiento farmacológico , Fenotipo , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Background: Kidney health needs to be studied in low- and middle-income countries with populations living at high altitude and undergoing urbanization. We studied whether greater level of urbanization was associated with worse kidney function and higher hemoglobin was associated with worse kidney function at high altitude. Methods: Cross-sectional analysis of population-based studies in Peru including five sites at different altitude above the sea level and urbanization level (in decreasing order of urbanization): Lima (sea level), Arequipa (2335 m), urban Puno (3825 m), Tumbes (sea level), and rural Puno (3825 m). The exposures were urbanization and altitude as per study site, and hemoglobin (g/dL). The outcome was the estimated glomerular filtration rate (eGFR). Results: Four thousand two hundred eight people were studied: mean age was 57.4 years (standard deviation: 12.4) and 51.9% were women. In comparison to rural Puno, eGFR was similar in Lima; in comparison to rural Puno, Arequipa, urban Puno, and Tumbes had worse eGFR, for example, in Arequipa, ß = -8.07 (95% confidence interval [CI]: -10.90 to -5.24). Intermediate (ß = -8.60; 95% CI: -10.55 to -6.66) and high (ß = -11.21; 95% CI: -14.19 to -8.24) altitude were negatively correlated with eGFR when only urban places were analyzed. At high altitude, there was a trend for a negative association between hemoglobin and eGFR: ß = -1.09 (95% CI: -2.22 to 0.04). Conclusions: Apparently, higher altitude and level of urbanization, except for one highly urbanized site, were associated with worse kidney function. Our findings suggest that some of the adverse impact of high altitude on kidney function has been balanced by the lower risk conferred by rural environments.
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Altitud , Tasa de Filtración Glomerular , Hemoglobinas/análisis , Urbanización , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Perú , Población RuralAsunto(s)
Altitud , Hipertensión , Humanos , Obesidad , Variación Biológica Poblacional , PrevalenciaRESUMEN
Background Blood pressure is determined by the interactions between the heart and arterial properties, and subjects with identical blood pressure may have substantially different hemodynamic determinants. Whether arterial hemodynamic indices quantified by impedance cardiography ( ICG ), a simple operator-independent office procedure, independently predict all-cause mortality in adults from the general population, and specifically among those who do not meet criteria for American College of Cardiology/American Heart Association stage 2 hypertension, is currently unknown. Methods and Results We studied 1639 adults aged 18 to 80 years from the general population. We used ICG to measure hemodynamic parameters and metrics of cardiac function. We assessed the relationship between hemodynamic parameters measured at baseline and all-cause mortality over a mean follow-up of 10.9 years. Several ICG parameters predicted death. The strongest predictors were total arterial compliance index (standardized hazard ratio=0.38; 95% confidence interval=0.31-0.46; P<0.0001) and indices of cardiac contractility: velocity index (standardized hazard ratio=0.45; 95% confidence interval=0.37-0.55; P<0.0001) and acceleration index (standardized hazard ratio=0.44; 95% confidence interval=0.35-0.55; P<0.0001). These remained independently predictive of death after adjustment for multiple confounders, as well as systolic and diastolic blood pressure. Among subjects without stage 2 hypertension (n=1563), indices of cardiac contractility were independently predictive of death and identified a subpopulation (25% of non-stage-2 hypertensives) that demonstrated a high 10-year mortality risk, equivalent to that of stage 2 hypertensives. Conclusions Hemodynamic patterns identified by ICG independently predict mortality in the general population. The predictive value of ICG applies even in the absence of American College of Cardiology/American Heart Association stage 2 hypertension and identifies higher-risk individuals who are in earlier stages of the hypertension continuum.
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Cardiografía de Impedancia/métodos , Hemodinámica/fisiología , Hipertensión/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea/fisiología , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Incidencia , Masculino , Persona de Mediana Edad , Perú/epidemiología , Valor Predictivo de las Pruebas , Pronóstico , Tasa de Supervivencia/tendencias , Factores de Tiempo , Adulto JovenRESUMEN
AIMS: There is no consensus as to which Metabolic Syndrome (MetS) definition to use for South-American populations. The aim of this study is to compare the prevalence of MetS and abdominal obesity using different criteria in Andean adults aged 40 and older living permanently at high altitude. METHODS: We conducted a cross-sectional study in Chivay (Andean highlands). 237 participants were included. Anthropometric measurements, glucose and lipid assessments were done in all subjects. Adult Treatment Panel III (ATPIII) and International Diabetes Federation (IDF) criteria for MetS were used. Abdominal obesity prevalence was determined using the American Diabetes Association (ADA), IDF, and PREVENCION Study criteria. Cohen's Kappa coefficient (κ) was analyzed to assess agreement level between different criteria. Multiple regression analyses were performed to find predictors for waist circumference. RESULTS: MetS was identified in 28.7% (95%CI=23.8-33.5) using ATPIII criteria, and 37.9% (95%CI=32.7-43.0) using IDF criteria, with higher prevalence in women. The κ statistics for agreement between both criteria was 0.775 (95%CI=0.690-0.859). Abdominal obesity prevalence according to ADA, IDF, and PREVENCION criteria was 35.9% (95%CI=29.7-42.0), 75.9% (95%CI=70.5-81.4), and 42.6% (95%CI=36.3-49.0), respectively. Agreement between ADA and PREVENCION criteria was highest (κ=0.859, 95%CI=0.792-0.925). The strongest predictors for higher waist circumference values were triglycerides and BMI in women, and systolic blood pressure, triglycerides, fasting plasma glucose, and HDL-cholesterol in men. CONCLUSIONS: MetS according to ATP III and IDF criteria was highly prevalent. IDF criteria identified a larger number of subjects with MetS. Different abdominal obesity criteria tended to show variation when applied to our sample population.