Long-term follow-up of patients with chronic chagas disease and implantable cardioverter-defibrillator.

BACKGROUND/OBJECTIVES: Chronic Chagas heart disease (ChHD) is associated with ventricular tachyarrhythmias and an increased risk of sudden cardiac death. Little is known about the effectiveness of implantable cardioverter-defibrillator (ICD) therapy in this population. The objective of this study was to evaluate the efficacy of ICD in patients with ChHD and to identify predictors of mortality and appropriate ICD shocks. METHODS: The cohort study included 65 patients with ChHD and ICD for primary and secondary prevention of sudden death. The Cox model was applied to evaluate the predictors of mortality, and survival was assessed by Kaplan-Meier analysis. RESULTS: The median age was 56 ± 11.9 years. The median follow-up was 40 ± 26.8 months. Among the patients 23 (36.5%) had appropriate shocks. A total of 13 (20%) patients died (6.1% of annual mortality rate), and there was no sudden death. In univariate Cox model, functional class IV (hazard ratio [HR] = 1.99; 95% confidence interval [CI], 1.05-3.76; P = 0.034), primary prevention (HR = 0.29; 95% CI, 0.09-0.99; P = 0.048), lower education (HR = 2.51; 95% CI, 1.05-5.99; P = 0.038), and ejection fraction <30% (HR = 2.80; 95% CI, 1.09-7.18; P = 0.032) were predictors of worse prognosis (death). In the multivariate Cox model, an ejection fraction <30% and the low education remained predictors of poor prognosis. Predictors of appropriate shocks were not found. CONCLUSIONS: The ICD was effective for the prevention of sudden cardiac death in patients with chronic ChHD. An ejection fraction <30% and low education were predictors of poor prognosis.

Predictors of Appropriate Therapies and Death in Patients with Implantable Cardioverter-Defibrillator and Chronic Chagas Heart Disease. / Preditores de Terapias Apropriadas e Óbito em Pacientes com Cardiodesfibrilador Implantável e Cardiopatia Chagásica Crônica.

BACKGROUND: There are few retrospective and prospective studies on implantable cardioverter-defibrillators (ICD) in primary and secondary prevention of sudden death in chronic Chagas heart disease (CCHD). OBJECTIVES: To describe the long-term evolution of patients with CCHD and ICD and to identify and analyze predictors of mortality and appropriate device therapy in this population. METHODS: This was a historical prospective study with 117 patients with ICD and CCHD. Devices were implanted from January 2003 to December 2021. Predictors of appropriate therapies and long-term mortality were identified and analyzed. The level of statistical significance was p < 0.05. RESULTS: Patients (n = 117) had a median follow-up of 61 months (25 to 121 months); they were predominantly male (74%), with a median age of 55 years (48 to 64 years). There were 43.6% appropriate shocks, 26.5% antitachycardia pacing (ATP), and 51% appropriate therapies. During follow-up, 46 patients (39.7%) died. Mortality was 6.2% person-years (95% confidence interval [CI]: 4.6 to 8.3), with 2 sudden deaths during follow-up. Secondary prevention (hazard ratio [HR] 2.1; 95% CI: 1.1 to 4.3; p = 0.029) and ejection fraction less than 30% (HR 1.8; 95% CI: 1.1 to 3.1; p < 0.05) were predictors of appropriate therapies. Intermediate Rassi score showed a strong association with the occurrence of ATP alone (p = 0.015). Functional class IV (p = 0.007), left ventricular ejection fraction < 30 (p = 0.010), and age above 75 years (p = 0.042) were predictors of total mortality. CONCLUSION: ICDs in CCHD showed a high incidence of appropriate activation, especially in patients with secondary prevention, low left ventricular ejection fraction, and intermediate Rassi score. Patients with congestive heart failure, elevated functional class, and age over 75 years showed elevated mortality. Survival function of patients with implantable cardioverter-defibrillators and chronic Chagas heart disease. A - According to New York Heart Association functional class; B - According to left ventricular ejection fraction; C - According to Rassi score. D - According to age. CCHD: chronic Chagas heart disease; HR: hazard ratio; ICD: implantable cardioverter-defibrillator.

Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection. / Reprocessamento de Marca-Passos em Países de Língua Portuguesa: Uma Reflexão Clínica.

There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.

Há uma enorme disparidade entre os países de alta renda e outros em termos de acesso a dispositivos médicos cardíacos, como marca-passos e desfibriladores implantáveis. Os custos são uma das principais barreiras ao uso de dispositivos cardíacos nesses países. Existem iniciativas internacionais que visam reduzir essa disparidade, e o reuso de marca-passos tem sido discutido como uma possível alternativa. O conceito de reutilização de marca-passos não é novo; entretanto, estudos recentes têm se mostrado seguros, éticos e eficazes para aqueles que precisam de dispositivos eletrônicos cardíacos implantáveis e não tem como adquiri-los. Parte dos países de língua portuguesa, especialmente na África, precisam de uma resposta imediata que beneficie seus inúmeros pacientes que sofrem de arritmias tratáveis.

Association between endothelial biomarkers and lipid and glycemic levels: a cross-sectional study with diabetic patients.

Background: Biomarkers can help understand the impact of achieving therapeutic goals in developing vascular diseases in diabetics. Aim: To assess the association between lipid and glycemic profiles and endothelial biomarkers in diabetics. Methods: Cross-sectional study that evaluated lipid and glycemic levels and biomarkers (VCAM-1, Sdc-1, FGF-23 and KIM-1 in diabetics. Results: Higher VCAM-1 levels were associated with higher low-density lipoprotein cholesterol and non-high-density lipoprotein (HDL) cholesterol levels (in the group with inadequate glycohemoglobin A1c [HbA1c] levels), with higher glycemic levels (in the group with inadequate HDL cholesterol levels) and with lower HDL cholesterol levels (both groups). VCAM-1 was independently associated with not achieving adequate HbA1c levels. Conclusion: In uncontrolled diabetics, VCAM-1 was independently associated with having inadequate HbA1c levels, suggesting they may already have endothelial damage.

Remote monitoring of pacemakers and defibrillators: Effective and safe in Brazil?

Background: The remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has become a common method of in-home monitoring and follow-up in high-income countries given its effectiveness, safety, convenience, and the possibility of early intervention. However, in Brazil, RM is still underutilized. Objectives: This observational study aims to demonstrate our experience of using RM in Brazil and the predictive factors of RM of CIED follow-up in Brazil. Methods: This was a prospective cohort study of patients with a CIED. Event rates are reported and clinical responses to those findings and outcomes based on the detection of RM. A logistic regression model was performed to identify predictors of more events, with P < .05 for statistical significance. Results: This study evaluated consecutive 119 patients: 30.2% with pacemakers, 42.8% with implantable cardioverter-defibrillator, 22.7% with cardiac resynchronization therapy (CRT) with defibrillator, and 3.3% with CRT with pacemaker. Events were detected in 63.9% of the cases in 29.5 ± 23 months of follow-up. The outcomes found were that 44.5% needed elective evaluation in medical treatment and 23.5% needed immediate evaluation in therapy. Logistic regression analysis showed that the groups with CRT or CRT with defibrillator (75.0%), reduced ejection fraction (76.5%), and New York Heart Association functional class ≥II (75.0%) had the highest RM event rates. Conclusions: RM proved to be effective and safe in the follow-up of patients with CIEDs in Brazil, allowing early interventions and facilitating therapeutic management.

Dysautonomia: A Forgotten Condition - Part 1. / Disautonomia: Uma Condição Esquecida ­ Parte 1.

Dysautonomia covers a range of clinical conditions with different characteristics and prognoses. They are classified as Reflex Syndromes, Postural Orthostatic Tachycardia Syndrome (POTS), Chronic Fatigue Syndrome, Neurogenic Orthostatic Hypotension (nOH) and Carotid Sinus Hypersensitivity Syndrome. Reflex (vasovagal) syndromes will not be discussed in this article. Reflex (vasovagal) syndromes are mostly benign and usually occur in patients without an intrinsic autonomic nervous system (ANS) or heart disease. Therefore, they are usually studied separately. Cardiovascular Autonomic Neuropathy (CAN) is the term most currently used to define dysautonomia with impairment of the sympathetic and/or parasympathetic cardiovascular autonomic nervous system. It can be idiopathic, such as multisystemic atrophy or pure autonomic failure, or secondary to systemic pathologies such as diabetes mellitus, neurodegenerative diseases, Parkinson's disease, dementia syndromes, chronic renal failure, amyloidosis and it may also occur in the elderly. The presence of Cardiovascular Autonomic Neuropathy (CAN) implies greater severity and worse prognosis in various clinical situations. Detection of Orthostatic Hypotension (OH) is a late sign and means greater severity in the context of dysautonomia, defined as Neurogenic Orthostatic Hypotension (nOH). It must be differentiated from hypotension due to hypovolemia or medications, called non-neurogenic orthostatic hypotension (nnOH). OH can result from benign causes, such as acute, chronic hypovolemia or use of various drugs. However, these drugs may only reveal subclinical pictures of Dysautonomia. All drugs of patients with dysautonomic conditions should be reevaluated. Precise diagnosis of CAN and the investigation of the involvement of other organs or systems is extremely important in the clinical suspicion of pandysautonomia. In diabetics, in addition to age and time of disease, other factors are associated with a higher incidence of CAN, such poor glycemic control, hypertension, dyslipidemia and obesity. Among diabetic patients, 38-44% can develop Dysautonomia, with prognostic implications and higher cardiovascular mortality. In the initial stages of DM, autonomic dysfunction involves the parasympathetic system, then the sympathetic system and, later on, it presents as orthostatic hypotension. Valsalva, Respiratory and Orthostatic tests (30:15) are the gold standard methods for the diagnosis of CAN. They can be associated with RR Variability tests in the time domain, and mainly in the frequency domain, to increase the sensitivity (protocol of the 7 tests). These tests can detect initial or subclinical abnormalities and assess severity and prognosis. The Tilt Test should not be the test of choice for investigating CAN at an early stage, as it detects cases at more advanced stages. Tilt response with a dysautonomic pattern (gradual drop in blood pressure without increasing heart rate) may suggest CAN. Treatment of patients at moderate to advanced stages of dysautonomia is quite complex and often refractory, requiring specialized and multidisciplinary evaluation. There is no cure for most types of Dysautonomia at a late stage. NOH patients can progress with supine hypertension in more than 50% of the cases, representing a major therapeutic challenge. The immediate risk and consequences of OH should take precedence over the later risks of supine hypertension and values greater than 160/90 mmHg are tolerable. Sleeping with the head elevated (20-30 cm), not getting up at night, taking short-acting antihypertensive drugs for more severe cases, such as losartan, captopril, clonidine or nitrate patches, may be necessary and effective in some cases. Preventive measures such as postural care; good hydration; higher salt intake; use of compression stockings and abdominal straps; portioned meals; supervised physical activity, mainly sitting, lying down or exercising in the water are important treatment steps. Various drugs can be used for symptomatic nOH, especially fludrocortisone, midodrine and droxidopa, the latter not available in Brazil. The risk of exacerbation or triggering supine hypertension should be considered. Chronic Fatigue Syndrome represents a form of Dysautonomia and has been renamed as a systemic disease of exercise intolerance, with new diagnostic criteria: 1 - Unexplained fatigue, leading to occupational disability for more than 6 months; 2 - Feeling ill after exercising; 3 - Non-restorative sleep; 4 - One of the following findings: cognitive impairment or orthostatic intolerance. Several pathologies today have evolved with chronic fatigue, being called chronic diseases associated with chronic fatigue. Postural orthostatic tachycardia syndrome (POTS), another form of presentation of dysautonomic syndromes, is characterized by sustained elevation of heart rate (HR) ≥30 bpm (≥40 bpm if <20 years) or HR ≥120 bpm, in the first 10 minutes in an orthostatic position or during the tilt test, without classical orthostatic hypotension associated. A slight decrease in blood pressure may occur. Symptoms appear or get worse in an orthostatic position, with dizziness, weakness, pre-syncope, palpitations, and other systemic symptoms being common.

O termo disautonomia abrange um conjunto de condições clínicas com características e prognósticos distintos. Classificam-se em síndromes reflexas, síndrome postural ortostática taquicardizante (SPOT), síndrome da fadiga crônica, Hipotensão Ortostática Neurogênica (HON) e a Síndrome da hipersensibilidade do seio carotídeo. As síndromes reflexas (vasovagal) não serão discutidas neste artigo. As síndromes reflexas (vasovagal) são, na maioria das vezes, benignas, e ocorrem usualmente em pacientes sem doença intrínseca do sistema nervoso autônomo (SNA) ou do coração. Por isso, geralmente são estudadas separadamente. O termo neuropatia autonômica cardiovascular (NAC) é o mais utilizado na atualidade para definir as disautonomias com comprometimento do sistema nervoso autônomo cardiovascular simpático e/ou parassimpático. Pode ser idiopática, como a atrofia multissistêmica ou a falência autonômica pura, ou secundária a patologias sistêmicas como diabetes mellitus, doenças neurodegenerativas, doença de Parkinson, síndromes demenciais, insuficiência renal crônica, amiloidose, podendo também acometer idosos. A presença de neuropatia autonômica cardiovascular (NAC) implica em maior gravidade e pior prognóstico em diversas situações clínicas. A detecção de hipotensão ortostática (HO) é um sinal tardio e significa maior gravidade no contexto das disautonomias, definida como hipotensão ortostática neurogênica (HON). Deve ser diferenciada das hipotensões por hipovolemia ou medicamentosas, chamadas de hipotensão ortostática não neurogênica (HONN). A HO pode decorrer de causas benignas, como a hipovolemia aguda, crônica, ou ao uso de diversos fármacos. Esses fármacos podem, entretanto, apenas desmascarar quadros subclínicos de disautonomia. Deve-se reavaliar todos os fármacos de pacientes com quadros disautonômicos. O diagnóstico preciso de NAC e a investigação do envolvimento de outros órgãos ou sistemas é de extrema importância na suspeita clínica de uma pandisautonomia. No diabético, além da idade e do tempo de doença, outros fatores estão associados a maior ocorrência de NAC, como descontrole glicêmico, hipertensão, dislipidemia e obesidade. Entre os pacientes diabéticos, 38­44% podem evoluir com disautonomia, com implicações prognósticas e maior mortalidade cardiovascular. Nas etapas iniciais da DM, a disfunção autonômica envolve o sistema parassimpático, posteriormente o simpático e mais tardiamente manifesta-se com hipotensão ortostática. Os testes de Valsalva, respiratório e ortostático (30:15) são os métodos de padrão ouro para o diagnóstico de NAC. Eles podem ser associados aos testes de variabilidade RR no domínio do tempo, e principalmente da frequência, para aumento da sensibilidade (protocolo dos 7 testes). Esses testes podem detectar alterações iniciais ou subclínicas e avaliar a gravidade e o prognóstico. O teste de inclinação (tilt test) não deve ser o exame de escolha para investigação de NAC em fase inicial, pois detecta casos em fases mais avançadas. A resposta no tilt com padrão disautonômico (queda gradativa da pressão arterial sem aumento da frequência cardíaca) pode sugerir NAC. O tratamento dos pacientes em fases moderadas a avançadas das disautonomias é bastante complexo e muitas vezes refratário, necessitando de avaliação especializada e multidisciplinar. Não há cura para a maioria das disautonomias em fase tardia. Os pacientes com HON podem evoluir com hipertensão supina em mais de 50% dos casos, representando um grande desafio terapêutico. O risco imediato e as consequências da HO devem ter preferência sobre os riscos mais tardios da hipertensão supina e valores maiores que 160/90 mmHg são toleráveis. Medidas como dormir com a cabeceira elevada (20­30 cm), não levantar à noite, uso de anti-hipertensivo de ação curta noturna para casos mais severos, como a losartana, captopril, clonidina ou adesivos de nitratos, podem ser necessários e efetivos em alguns casos. As medidas preventivas como cuidados posturais, boa hidratação, maior ingesta de sal, uso de meias e cintas abdominais compressoras, refeições fracionadas, atividade física supervisionada principalmente sentada, deitada ou exercícios na água são etapas importantes no tratamento. Diversos fármacos podem ser usados para HON sintomática, principalmente a fludrocortisona, a midodrina e a droxidopa. Esses últimas não estão disponíveis no Brasil. O risco de exacerbação ou desencadeamento de hipertensão supina deve ser considerado. A síndrome da fadiga crônica representa uma forma de disautonomia e tem sido renomeada como doença sistêmica de intolerância ao exercício, com novos critérios diagnósticos: 1 - Fadiga inexplicada, levando a incapacidade para o trabalho por mais que 6 meses; 2 - Mal-estar após exercício; 3 - Sono não reparador; 4 - Mais um dos seguintes achados: comprometimento cognitivo ou intolerância ortostática. Várias patologias na atualidade têm evoluído com fadiga crônica, sendo denominadas de doenças crônicas associadas a fadiga crônica. A síndrome postural ortostática taquicardizante (SPOT), outra forma de apresentação das síndromes disautonômicas, é caracterizada por elevação sustentada da frequência cardíaca (FC) ≥30 bpm (≥40 bpm se <20 anos) ou FC ≥120 bpm, nos primeiros 10 minutos em posição ortostática ou durante o tilt test, sem hipotensão ortostática clássica associada. Pode ocorrer leve redução na pressão arterial. Os sintomas manifestam-se ou pioram em posição ortostática, sendo comuns a tontura, fraqueza, pré-síncope, palpitações, além de outros sintomas sistêmicos.

Syncope in Patients with Cardiac Pacemakers.

INTRODUCTION: It is challenging to diagnose syncope in patients with pacemakers. Because these patients have increased morbidity and mortality risks, they require immediate attention to determine the causes in order to provide appropriate treatment. This study aimed to investigate the causes and predictive factors of syncope as well as the methods used to diagnose syncope in cardiac pacemaker patients. METHODS: Patients with pacemakers implanted owing to sinus node disease or atrioventricular block were evaluated with standardized questionnaires, endocavitary electrograms, and other tests based on the suspected causes of syncope. Mann- Whitney U tests were used to analyze continuous variables and Chi-squared or Fisher's exact tests were used for categorical variables. Logistic regression was used for multivariate analyses. Statistical significance was P<0.05. RESULTS: The study included 95 patients with pacemakers: 47 experienced syncope in the last 12 months and 48 did not. Of the 100 documented episodes of syncope, 48.9% were vasovagal syncopes, 17% had cardiac-related causes, 10.6% had unknown causes, and 8.5% had pacemaker failure. The multivariate analysis showed that a New York Heart Association (NYHA) Functional Class II was a significant factor for developing syncope (P<0.01). CONCLUSION: While the most common type of syncope in pacemaker patients was neurally mediated, it is important to perform detailed evaluations in this population as the causes of syncope can be life-threatening. The best diagnostic methods were stored electrogram analysis and the tilt table test. NYHA Functional Class II patients were found to have a higher risk for syncope.

Prevalence of Trypanosoma Cruzi Infection in Blood Donors. / Prevalência da Infecção pelo Trypanosoma cruzi em Doadores de Sangue.

BACKGROUND: Chagas disease (CD) is considered a public health problem in Latin America. The northeastern region, especially the state of Ceará, still represents a major concern in terms of the risk of transmission of CD. OBJECTIVE: To estimate the prevalence of T. cruzi in blood donors from the state of Ceará. METHODS: This is a retrospective descriptive study that was performed in the period from 2010 to 2015 from data recorded in the computerized system of the Hematology and Hemotherapy Center of Ceará (HEMOCE in Portuguese). RESULTS: Of the 763,731 potential blood donors, 14,159 were serologically ineligible; 1,982 (0.33%) were serologically ineligible due to positive / inconclusive diagnosis for CD. A total of 425 individuals came to the HEMOCE to repeat the test, with 28.2% (120/425) declared ineligible for donations due to CD. CONCLUSION: No significant reduction of positive / inconclusive serology was observed in the period between 2010 and 2015, but a reduction was observed when compared to 1996/1997 in the state. The determination of the prevalence of CD in blood banks may be relevant as an indicator of the risk of CD transmission through blood transfusions in a given region. New serological tests for triage with better accuracy in screening are needed, in an attempt to reduce the unnecessary disposal of blood bags, reduce costs for the Brazilian Unified Health System, and diminish insecurity for the patient and family members. (Arq Bras Cardiol. 2020; 115(6):1082-1091).

FUNDAMENTO: A doença de Chagas (DC) é considerada um problema de saúde pública na América Latina. A região nordeste, principalmente o estado do Ceará, ainda representa grande preocupação em termos de risco de transmissão da doença. OBJETIVO: Estimar a prevalência de T. cruzi em doadores de sangue do estado do Ceará. MÉTODOS: Trata-se um de estudo retrospectivo descritivo realizado no período de 2010 a 2015, a partir de dados registrados no sistema informatizado do Centro de Hematologia e Hemoterapia do Ceará (HEMOCE). RESULTADOS: Dos 763.731 potenciais doadores de sangue, 14.159 foram considerados impedidos de fazer a doação devido à sorologia, sendo que 1.982 (0,33%) o foram devido à positividade/inconclusão para doença de Chagas. Compareceram à Hemorrede para a repetição 425 indivíduos, sendo confirmados 28,2% (120/425) como impedidos de doar devido a DC. CONCLUSÃO: Não houve redução significativa das sorologias positivas/inconclusivas no período entre 2010-2015, porém foi observada redução em relação a 1996/1997 no estado. A determinação da prevalência da doença de Chagas em bancos de sangue pode ser relevante como indicador do risco de transmissão transfusional em determinada região. Novos testes sorológicos para triagem com melhor acurácia são necessários, reduzindo o descarte desnecessário de bolsas de sangue, os custos para o Sistema Único de Saúde e a insegurança para os pacientes e familiares. (Arq Bras Cardiol. 2020; 115(6):1082-1091).

Exercise Stress Test in The Assessment of Brugada Syndrome Patients

Abstract Brugada syndrome (BS) is a genetic channelopathy, clinically characterized by an increased risk of sudden cardiac death. The diagnosis requires a typical electrocardiographic pattern, and data on risk stratification are limited in the literature. The aim of this study was to conduct a review on the importance of exercise stress test (EST) in risk stratification in BS. Articles were searched in the PubMed, Scielo and Google Scholar databases. From the 200 articles retrieved, eight were included, with a total of 712 patients (95% men) aged between 35 and 60 years. Severe symptoms and ventricular arrhythmias were reported by 256 patients before the EST, with syncope being reported in 70% of cases. The reviewed articles suggest that the EST is a safe method that can help in the diagnosis and risk stratification for malignant arrhythmias in patients with BS. Potential predictors of poor prognosis were: augmentation in ST-segment elevation > 0.5 mV in V1, V2 or V3 in early recovery; J-point elevation in lead > 2mm in aVR in late recovery; heart rate reduction < 40% from maximum heart rate in late recovery and occurrence of ventricular extrasystoles in early recovery.

Reprocessamento de Marca-Passos em Países de Língua Portuguesa: Uma Reflexão Clínica / Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection

Resumo Há uma enorme disparidade entre os países de alta renda e outros em termos de acesso a dispositivos médicos cardíacos, como marca-passos e desfibriladores implantáveis. Os custos são uma das principais barreiras ao uso de dispositivos cardíacos nesses países. Existem iniciativas internacionais que visam reduzir essa disparidade, e o reuso de marca-passos tem sido discutido como uma possível alternativa. O conceito de reutilização de marca-passos não é novo; entretanto, estudos recentes têm se mostrado seguros, éticos e eficazes para aqueles que precisam de dispositivos eletrônicos cardíacos implantáveis e não tem como adquiri-los. Parte dos países de língua portuguesa, especialmente na África, precisam de uma resposta imediata que beneficie seus inúmeros pacientes que sofrem de arritmias tratáveis.

Abstract There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.

Trypanosoma cruzi seroprevalence among solid organ donors in Ceará State, Brazil.

INTRODUCTION: The transmission of Chagas disease (CD) through blood transfusion, organ transplantation, and oral transmission has gained greater visibility as a result of intensified vector control activities in endemic regions and to control CD in non-endemic regions. In Brazil, Ceará is one of the states that perform the most organ transplants. Therefore, the objective of this study was to assess the prevalence of Trypanosoma cruzi infection in organ donor candidates. METHODS: A retrospective analysis was performed on data from potential organ donors at the Center of Transplantation of the State of Ceará from 2010 - 2015. RESULTS: Data from a total of 2,822 potential donors were obtained, of which 1,038 were effective donors and 1,784 were excluded, likely due to lack of family authorization or medical contraindication. The prevalence of T. cruzi infection among these potential donors was 1.3% (n = 29). The majority of infected donors were males aged 41 - 60 years, residing in the interior of the state. Interestingly, 72.4% (n = 21) had positive or inconclusive serology for additional infections, such as cytomegalovirus, hepatitis B and C, and toxoplasmosis. Probability analysis revealed that stroke was the most common cause of death among potential donors with CD. CONCLUSIONS: There was a high prevalence of CD and other coinfections among potential solid organ donors in Ceará, and statistical tests have shown that these individuals are at increased risk of stroke when compared to potential non-reactive donors. This work highlights the importance of screening DC infection in potential donors.

Pharmacotherapeutic follow-up of patients with Chagas disease using benznidazole: drug-related problems and pharmaceutical interventions.

INTRODUCTION: Benznidazole (BNZ) is a drug available for the etiological treatment of Chagas disease. However, this drug is toxic and has a limited effectiveness on the chronic phase of this disease, often leading to poor treatment adherence. METHODS:: This is a descriptive and exploratory study conducted at the Pharmaceutical Care Service for Chagas disease patients of the Federal University of Ceará. Drug-related problems (DRPs) and pharmaceutical interventions (PIs) were classified according to the Second Consensus of Granada. RESULTS:: The average age of patients with Chagas disease was 62 years, with the majority residing in the Ceará countryside (86.7%), and having low education levels (63.3% with elementary school education). Regarding family income, most patients belonged to a household that earned ≤1-2 times the minimum wage per month. Approximately 73% of these patients complied with the BNZ treatment, and nearly 7% underwent therapy interruption after medical evaluation. A total of 189 DRPs were identified, of which 51.9% (n=98) were classified as potential, and 48.1% (n=91) as actual. The most frequent DRPs were related to safety (qualitative safety; n=70; 37%), necessity (non-adherence; n=52; 27.5%), and effectiveness (qualitative effectiveness/non-optimal drug selection; n=45; 23.8%). Among the 216 PIs conducted, the majority were related to patient education (n=168; 77.8%) and pharmacological strategy (n=42; 19.4%). CONCLUSIONS:: This study indicates the need for pharmacotherapeutic monitoring in patients with Chagas because of the high number of therapeutic interventions, DRPs (approximately 3 DRPs/patient), BNZ adherence, and polypharmacy.

Prognostic Value of Coronary Flow Reserve Obtained on Dobutamine Stress Echocardiography and its Correlation with Target Heart Rate.

BACKGROUND:: Normal coronary flow velocity reserve (CFVR) (≥ 2) obtained in the left anterior descending coronary artery (LAD) from transthoracic echocardiography is associated with a good prognosis, but there is no study correlating CFVR with submaximal target heart rate (HR). OBJECTIVE:: To evaluate the prognostic value of CFVR obtained in the LAD of patients with preserved (>50%) left ventricular ejection fraction (LVEF) who completed a dobutamine stress echocardiography (DSE), considering target HR. METHODS:: Prospective study of patients with preserved LVEF and CFVR obtained in the LAD who completed DSE. In Group I (GI = 31), normal CFVR was obtained before achieving target HR, and, in Group II (GII = 28), after that. Group III (G III=24) reached target HR, but CFVR was abnormal. Death, acute coronary insufficiency, coronary intervention, coronary angiography without further intervention, and hospitalization were considered events. RESULTS:: In 28 ± 4 months, there were 18 (21.6%) events: 6% (2/31) in GI, 18% (5/28) in GII, and 46% (11/24) in GIII. There were 4 (4.8%) deaths, 6 (7.2%) coronary interventions and 8 (9.6%) coronary angiographies without further intervention. In event-free survival by regression analysis, GIII had more events than GI (p < 0.001) and GII (p < 0.045), with no difference between GI and GII (p = 0.160). After adjustment, the only difference was between GIII and GI (p = 0.012). CONCLUSION:: In patients with preserved LVEF and who completed their DSE, normal CFVR obtained before achieving target HR was associated with better prognosis. FUNDAMENTO:: A reserva de velocidade de fluxo coronariano (RVFC) adequada (≥ 2) obtida na artéria descendente anterior (ADA) através do ecocardiograma transtorácico associa-se a bom prognóstico, mas não há estudo correlacionando-a com a frequência cardíaca (FC) alvo (submáxima). OBJETIVO:: Avaliar o valor prognóstico da RVFC obtida na ADA de pacientes com fração de ejeção do ventrículo esquerdo (FEVE) preservada (>50%) e ecocardiograma sob estresse com dobutamina (EED) concluído, considerando a FC alvo submáxima. MÉTODOS:: studo prospectivo de pacientes com FEVE preservada e RVFC obtida na ADA durante EED concluído. No Grupo I (GI=31), a RVFC adequada foi obtida antes de se atingir a FC alvo, e no Grupo II (G II=28), após. O Grupo III (G III=24) atingiu a FC alvo, mas a RVFC foi inadequada. Foram considerados eventos: óbito, insuficiência coronariana aguda, intervenção coronariana, coronariografia sem intervenção subsequente e internamento hospitalar. RESULTADOS:: Em 28 ± 4 meses, ocorreram 18 (21,6%) eventos, sendo 6% (2/31) no GI, 18% (5/28) no GII e 46% (11/24) no GIII. Foram 4 (4,8%) óbitos, 6 (7,2%) intervenções coronarianas e 8 (9,6%) coronariografias sem intervenção subsequente. Na sobrevida livre de eventos pela análise de regressão, GIII apresentou mais eventos do que GI (p < 0,001) ou GII (p < 0,045), não havendo diferença entre GI e GII (p = 0,160). Após o ajustamento, foi mantida a diferença apenas entre GIII e GI (p = 0,012). CONCLUSÃO:: Em pacientes com FEVE preservada e EED concluído, a RVFC adequada obtida antes da FC alvo associou-se ao melhor prognóstico.

Clinical Course After Cardioverter-Defibrillator Implantation: Chagasic Versus Ischemic Patients.

BACKGROUND: The outcome of Chagas disease patients after receiving implantable cardioverter defibrillator (ICD) is still controversial. OBJECTIVE: To compare clinical outcomes after ICD implantation in patients with chronic Chagas cardiomyopathy (CCC) and ischemic heart disease (IHD). METHODS: Prospective study of a population of 153 patients receiving ICD (65 with CCC and 88 with IHD). The devices were implanted between 2003 and 2011. Survival rates and event-free survival were compared. RESULTS: The groups were similar regarding sex, functional class and ejection fraction. Ischemic patients were, on average, 10 years older than CCC patients (p < 0.05). Patients with CCC had lower schooling and monthly income than IHD patients (p < 0.05). The number of appropriate therapies was 2.07 higher in CCC patients, who had a greater incidence of appropriate shock (p < 0.05). Annual mortality rate and electrical storm incidence were similar in both groups. There was no sudden death in CCC patients, and only one in IHD patients. Neither survival time (p = 0.720) nor event-free survival (p = 0.143) significantly differed between the groups. CONCLUSION: CCC doubles the risk of receiving appropriate therapies as compared to IHD, showing the greater complexity of arrhythmias in Chagas patients.

Syncope in patients with cardiac pacemakers

Abstract Introduction: It is challenging to diagnose syncope in patients with pacemakers. Because these patients have increased morbidity and mortality risks, they require immediate attention to determine the causes in order to provide appropriate treatment. This study aimed to investigate the causes and predictive factors of syncope as well as the methods used to diagnose syncope in cardiac pacemaker patients. Methods: Patients with pacemakers implanted owing to sinus node disease or atrioventricular block were evaluated with standardized questionnaires, endocavitary electrograms, and other tests based on the suspected causes of syncope. Mann-Whitney U tests were used to analyze continuous variables and Chi-squared or Fisher's exact tests were used for categorical variables. Logistic regression was used for multivariate analyses. Statistical significance was P<0.05. Results: The study included 95 patients with pacemakers: 47 experienced syncope in the last 12 months and 48 did not. Of the 100 documented episodes of syncope, 48.9% were vasovagal syncopes, 17% had cardiac-related causes, 10.6% had unknown causes, and 8.5% had pacemaker failure. The multivariate analysis showed that a New York Heart Association (NYHA) Functional Class II was a significant factor for developing syncope (P<0.01). Conclusion: While the most common type of syncope in pacemaker patients was neurally mediated, it is important to perform detailed evaluations in this population as the causes of syncope can be life-threatening. The best diagnostic methods were stored electrogram analysis and the tilt table test. NYHA Functional Class II patients were found to have a higher risk for syncope.