Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

BACKGROUND: Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. METHODS: This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. RESULTS: Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. CONCLUSION: In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

Congenital short QT syndrome: A review focused on electrocardiographic features

Congenital short QT syndrome is a very low prevalence inherited primary arrhythmia syndrome first reported in 2000 by Gussak et al., who described two families with a short QT interval, syncope, and sudden cardiac death. In 2004, Ramon Brugada et al. identified the first genetic type of this entity. To date, a total of nine genotypes have been described. The diagnosis is easy from the electrocardiogram (ECG), not only due to the short QT duration, but also based on other aspects covered in this review. During 24-h Holter monitoring, paroxysmal atrial fibrillation spontaneously converting to sinus rhythm may be found. Even though the T wave may appear symmetric on the ECG, the T loop of the vectorcardiogram confirms that the T wave is constantly asymmetric due to the presence of dashes closer to each other in the efferent branch. In this review, we also describe the minus-plus T wave sign that we have described in a previously published article. In addition to congenital causes, we briefly highlight the existence of numerous acquired causes of short QT interval.

Violence and aggression against nurses during the COVID-19 pandemic in Latin America. From the emerging leaders program of the Interamerican Society of Cardiology (SIAC).

INTRODUCTION: During the Coronavirus (COVID-19) pandemic, healthcare providers have overcome difficult experiences such as workplace violence. Nurses are particularly vulnerable to workplace violence. The objective of this study was to characterize violence and aggression against nurses during the COVID-19 pandemic in Latin America. METHODS: An electronic cross-sectional survey was conducted in 19 Latin American countries to characterize the frequency and type of violent actions against front-line healthcare providers. RESULTS: Of the original 3544 respondents, 16% were nurses (n = 567). The mean age was 39.7 ± 9.0 years and 79.6% (n = 2821) were women. In total, 69.8% (n = 2474) worked in public hospitals and 81.1% (n = 2874) reported working regularly with COVID-19 patients. Overall, about 68.6% (n = 2431) of nurses experienced at least one episode of workplace aggression during the pandemic. Nurses experienced weekly aggressions more frequently than other healthcare providers (45.5% versus 38.1%, p < .007). Nurses showed a trend of lower reporting rates against the acts of aggression suffered (p = .076). In addition, nurses were more likely to experience negative cognitive symptoms after aggressive acts (33.4% versus 27.8%, p = .028). However, nurses reported considering changing their work tasks less frequently compared to other healthcare providers after an assault event (p = .005). CONCLUSION: Workplace violence has been a frequent problem for all healthcare providers during COVID-19 pandemic in Latin America. Nurses were a particularly vulnerable subgroup, with higher rates of aggressions and cognitive symptoms and lower rate of complaints than other healthcare providers who suffered from workplace violence. It is imperative to develop strategies to protect this vulnerable group from aggressions during their tasks.

Differential Effects of Remdesivir and Lumacaftor on Homomeric and Heteromeric hERG Channels.

The human ether-a-go-go-related gene (hERG) encodes for the pore-forming subunit of the channel that conducts the rapidly activating delayed K+ current (IKr) in the heart. The hERG channel is important for cardiac repolarization, and reduction of its expression in the plasma membrane due to mutations causes long QT syndrome type 2 (LQT2). As such, promoting hERG membrane expression is a strategy to rescue mutant channel function. In the present study, we applied patch clamp, western blots, immunocytochemistry, and quantitative reverse transcription polymerase chain reaction techniques to investigate the rescue effects of two drugs, remdesivir and lumacaftor, on trafficking-defective mutant hERG channels. As our group has recently reported that the antiviral drug remdesivir increases wild-type (WT) hERG current and surface expression, we studied the effects of remdesivir on trafficking-defective LQT2-causing hERG mutants G601S and R582C expressed in HEK293 cells. We also investigated the effects of lumacaftor, a drug used to treat cystic fibrosis, that promotes CFTR protein trafficking and has been shown to rescue membrane expression of some hERG mutations. Our results show that neither remdesivir nor lumacaftor rescued the current or cell-surface expression of homomeric mutants G601S and R582C. However, remdesivir decreased while lumacaftor increased the current and cell-surface expression of heteromeric channels formed by WT hERG and mutant G601S or R582C hERG. We concluded that drugs can differentially affect homomeric WT and heteromeric WT+G601S (or WT+R582C) hERG channels. These findings extend our understanding of drug-channel interaction and may have clinical implications for patients with hERG mutations. SIGNIFICANCE STATEMENT: Various naturally occurring mutations in a cardiac potassium channel called hERG can impair channel function by decreasing cell-surface channel expression, resulting in cardiac electrical disturbances and even sudden cardiac death. Promotion of cell-surface expression of mutant hERG channels represents a strategy to rescue channel function. This work demonstrates that drugs such as remdesivir and lumacaftor can differently affect homomeric and heteromeric mutant hERG channels, which have biological and clinical implications.

Right atrial collision time (RACT): A novel marker of propensity for typical atrial flutter.

INTRODUCTION: The risk of typical atrial flutter (AFL) is increased proportionately to right atrial (RA) size or right atrial scarring that results in reduced conduction velocity. These characteristics result in propagation of a flutter wave by ensuring the macro re-entrant wave front does not meet its refractory tail. The time taken to traverse the circuit would take account of both of these characteristics and may provide a novel marker of propensity to develop AFL. Our goal was to investigate right atrial collision time (RACT) as a marker of existing typical AFL. METHODS: This single-centre, prospective study recruited consecutive typical AFL ablation patients that were in sinus rhythm. Controls were consecutive electrophysiology study patients >18 years of age. While pacing the coronary sinus (CS) ostium at 600 ms, a local activation time map was created to locate the latest collision point on the anterolateral right atrial wall. This RACT is a measure of conduction velocity and distance from CS to a collision point on the lateral right atrial wall. RESULTS: Ninety-eight patients were included in the analysis, 41 with atrial flutter and 57 controls. Patients with atrial flutter were older, 64.7 ± 9.7 versus 52.4 ± 16.8 years (<.001), and more often male (34/41 vs. 31/57 [.003]). The AFL group mean RACT (132.6 ± 17.3 ms) was significantly longer than that of controls (99.1 ± 11.6 ms) (p < .001). A RACT cut-off of 115.5 ms had a sensitivity and specificity of 92.7% and 93.0%, respectively for diagnosis of atrial flutter. A ROC curve indicated an AUC of 0.96 (95% CI: 0.93-1.0, p < .01). CONCLUSION: RACT is a novel and promising marker of propensity for typical AFL. This data will inform larger prospective studies.

Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study.

AIMS: Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). METHODS AND RESULTS: This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. CONCLUSION: Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.

Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis.

AIMS: Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. METHODS AND RESULTS: We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07). CONCLUSIONS: Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.

Academic cardiac electrophysiologists' perspectives on sleep apnea care.

PURPOSE: Obstructive sleep apnea syndrome (OSAS) is an important, modifiable risk factor in the pathophysiology of arrhythmias including atrial fibrillation (AF). The purpose of the study was to evaluate cardiac electrophysiologists' (EPs) perception of OSAS. METHODS: We designed a 27-item online Likert scale-based survey instrument entailing several domains: (1) relevance of OSAS in EP practice, (2) OSAS screening and diagnosis, (3) perception on treatments for OSAS, (4) opinion on the OSAS care model. The survey was distributed to 89 academic EP programs in the USA and Canada. While the survey instrument questions refer to the term sleep apnea (SA), our discussion of the diagnosis, management, and research on the sleep disorder is more accurately described with the term OSAS. RESULTS: A total of 105 cardiac electrophysiologists from 49 institutions responded over a 9-month period. The majority of respondents agreed that sleep apnea (SA) is a major concern in their practice (94%). However, 42% reported insufficient education on SA during training. Many (58%) agreed that they would be comfortable managing SA themselves with proper training and education and 66% agreed cardiac electrophysiologists should become more involved in management. Half of EPs (53%) were not satisfied with the sleep specialist referral process. Additionally, a majority (86%) agreed that trained advanced practice providers should be able to assess and manage SA. Time constraints, lack of knowledge, and the referral process are identified as major barriers to EPs becoming more involved in SA care. CONCLUSIONS: We found that OSAS is widely recognized as a major concern for EP. However, incorporation of OSAS care in training and routine practice lags. Barriers to increased involvement include time constraints and education. This study can serve as an impetus for innovation in the cardiology OSAS care model.

The "Bayés Spirit" as a guide for new generations: How to combine one's personal life and friendships with science and profession.

Recent studies suggest that up to a quarter of physicians in training suffer from burnout and psychological disorders. Scientist-physicians, cardiologists, cardiology residents, and first-year medical residents seem to be more prone to developing varying degrees of emotional distress. Concerned about the new generations of clinicians and researchers, the authors aim to provide guidelines for reconciling professional success with a fulfilling and satisfying personal life. The figure of Antonio Bayés de Luna (cardiology and electrocardiology guru) is used as the ideal example to learn how to combine one's personal life, family, and friendships with science and their professional career. This can be done in a healthy and balanced way, prioritizing the former while continuing to have an intense dedication to the latter.

Left bundle branch pacing in alternating bundle branch block.

We present a case of symptomatic intermittent AV block showing during monitorization alternating bundle branch block. Presuming a high need of pacing, conduction system pacing was considered a more physiological alternative in this patient. Left bundle branch pacing restored a stable atrioventricular synchrony with a paced QRS complex similar to the native one and might be a good alternative in these cases.

New pattern of atypical advanced interatrial block.

INTRODUCTION: Interatrial block (IAB) is defined as prolonged P-wave duration (≥ 120 ms) due to delayed conduction in the Bachmann bundle. This is readily identifiable using surface electrocardiogram (ECG). Advanced IAB can be classified as typical and atypical. Atypical IAB can be further categorized by (i) duration or (ii) morphology. In this report, we have identified a new pattern of atypical IAB with triphasic morphology of the P-wave in the inferior leads. METHODS: Two clinical cases were evaluated including surface ECGs. P-wave durations and amplitudes were measured with digital calipers using ECG analysis software (MUSE, GE HealthCare). Comparisons were made using prior data to evaluate IAB and P-wave duration and morphology. RESULTS: A new pattern of atypical advanced IAB shows prolonged P-wave duration (P wave >160 ms) and triphasic morphology in all inferior leads with P +/+/- and P +/-/+, respectively. We speculate that triphasic P-waves in the inferior leads represent three moments of atrial depolarization; from right to left. CONCLUSION: This study describes a novel pattern of atypical advanced IAB. Further investigation regarding the increased risk of atrial fibrillation and stroke associated with this new pattern is warranted in the future.

Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial.

BACKGROUND: Electrocardiogram (ECG) interpretation training is a fundamental component of medical education across disciplines. However, the skill of interpreting ECGs is not universal among medical graduates, and numerous barriers and challenges exist in medical training and clinical practice. An evidence-based and widely accessible learning solution is needed. DESIGN: The EDUcation Curriculum Assessment for Teaching Electrocardiography (EDUCATE) Trial is a prospective, international, investigator-initiated, open-label, randomized controlled trial designed to determine the efficacy of self-directed and active-learning approaches of a web-based educational platform for improving ECG interpretation proficiency. Target enrollment is 1000 medical professionals from a variety of medical disciplines and training levels. Participants will complete a pre-intervention baseline survey and an ECG interpretation proficiency test. After completion, participants will be randomized into one of four groups in a 1:1:1:1 fashion: (i) an online, question-based learning resource, (ii) an online, lecture-based learning resource, (iii) an online, hybrid question- and lecture-based learning resource, or (iv) a control group with no ECG learning resources. The primary endpoint will be the change in overall ECG interpretation performance according to pre- and post-intervention tests, and it will be measured within and compared between medical professional groups. Secondary endpoints will include changes in ECG interpretation time, self-reported confidence, and interpretation accuracy for specific ECG findings. CONCLUSIONS: The EDUCATE Trial is a pioneering initiative aiming to establish a practical, widely available, evidence-based solution to enhance ECG interpretation proficiency among medical professionals. Through its innovative study design, it tackles the currently unaddressed challenges of ECG interpretation education in the modern era. The trial seeks to pinpoint performance gaps across medical professions, compare the effectiveness of different web-based ECG content delivery methods, and create initial evidence for competency-based standards. If successful, the EDUCATE Trial will represent a significant stride towards data-driven solutions for improving ECG interpretation skills in the medical community.

Predictors of fatal arrhythmic events in patients with non-compaction cardiomyopathy: a systematic review.

Left ventricular non-compaction cardiomyopathy (LVNC) is a congenital heart disease with autosomal dominant inheritance. This review aims to summarize the existing data about the predictors of fatal arrhythmias in patients with LVNC. Medline and Cochrane library databases were searched from inception to November 2021 for articles on LVNC. The reference lists of the relevant research studies as well as the relevant review studies and meta-analyses were also searched. Clinical symptoms and electrocardiogram findings such as left bundle branch block are significantly associated with ventricular arrhythmias. Other non-invasive tools such as Holter monitoring, echocardiography, and cardiac magnetic resonance (CMR) can provide additional value for risk stratification. CMR-derived left and right ventricular ejection fraction, left ventricular end-diastolic diameter, late gadolinium enhancement, and non-compacted to compacted myocardium ratio are predictive of ventricular arrhythmias. An electrophysiological study can provide additional prognostic data in patients with LVNC who are at moderate risk of ventricular arrhythmias. Risk stratification of LVNC patients with no prior history of a fatal arrhythmic event remains challenging. Symptoms assessment, electrocardiogram, Holter monitoring, and cardiac imaging should be performed on every patient, while an electrophysiological study should be performed for moderate-risk patients. Large cohort studies are needed for the construction of score models for arrhythmic risk stratification purposes.

Right ventricular outflow tract endocardial unipolar substrate mapping: implications in risk stratification of Brugada syndrome.

Brugada syndrome (BrS) is a complex arrhythmogenic disease displaying electrical and micro-structural abnormalities mainly located at the epicardium of the right ventricular outflow tract (RVOT). It is well-known that fibrosis, fatty infiltration, inflammation and reduced gap junction expression have been demonstrated at the epicardial anterior aspect of the RVOT providing the arrhythmogenic substrate for ventricular arrhythmic events in BrS. A number of models have been proposed for the risk stratification of patients with BrS. Endocardial unipolar electroanatomical mapping is an emerging tool that has been reintroduced to identify and quantify epicardial electrical abnormalities. Interestingly, current findings correlate the presence of large-sized endocardial unipolar electroanatomical abnormalities with either ventricular fibrillation inducibility during programmed ventricular stimulation or symptom status. This review aims to present existing data about the role of endocardial unipolar electroanatomical mapping for the identification of RVOT epicardial abnormalities as well as its potential clinical implications in risk stratification of BrS.

Paced P-wave duration as a significant predictor for atrial high-rate episodes in patients with cardiac implantable electronic devices.

BACKGROUND: Atrial pacing (AP) can unmask or aggravate a preexisting interatrial block (IAB). The aim of our study was to determine whether AP is associated with the development of atrial high-rate episodes (AHRE) during follow-up. METHODS: Patients with dual-chamber cardiac implantable electronic devices (CIEDs), no previous documented atrial fibrillation, and with a 6-month minimum follow-up were included. In all patients, sinus and paced P-wave duration were measured. AHRE was defined as an episode of atrial rate ≥225 bpm with a minimum duration of 5 min, excluding those documented during the first 3 months after implantation. RESULTS: A total of 220 patients were included (75 ± 10 years, 61% male). After a mean follow-up of 59 ± 25 months, 46% of patients presented AHRE. Mean paced P-wave duration was significantly longer than the sinus P-wave duration (154 ± 27 vs. 115 ± 18 ms; p < .001). Sinus and paced P-waves were significantly longer in those who developed AHRE (sinus: 119 ± 20 vs. 112 ± 16; p = .006; paced: 161 ± 29 vs. 148 ± 23; p < .001). A paced P-wave ≥160 ms was the best predictor of AHRE, especially those lasting >24 h (odds ratio [OR] 4.2 [95% confidence interval (CI)] [1.6-11.4]; p = .004). CONCLUSIONS: AP significantly prolongs P-wave duration and is associated with further development of AHRE. A paced P-wave ≥160 ms is a strong predictor of AHRE and should be taken into consideration as a new definition of IAB in the presence of AP.

Electrocardiographic predictors of atrial fibrillation in patients with cryptogenic stroke.

BACKGROUND: Empiric anticoagulation is not routinely indicated in patients with cryptogenic stroke without documentation of atrial fibrillation (AF). Therefore, identification of patients at increased risk of AF from this vulnerable group is vital. OBJECTIVES: To identify electrocardiographic (ECG) predictors of AF in patients with cryptogenic stroke or transient ischemic attack (TIA) undergoing insertion of an implantable cardiac monitor (ICM). METHODS: In this single-center study, 48 patients with cryptogenic stroke or TIA had an ICM implanted for detection of AF between January 2013 and September 2019. Patients with and without AF were compared in terms of p-wave duration and a novel index (MVP score). RESULTS: During a mean follow-up of 16 ± 14 months, AF was detected in seven patients (15%). Diagnosis of AF was made after a mean of 10 ± 14 months, with time to first AF detection ranging between 1 and 40 months. Patients with AF had a longer p-wave duration (136 ± 9 ms vs. 116 ± 10 ms; p = .0001) and a higher MVP score (4.5 ± 1.2 vs. 2.0 ± 0.9, p = .0001) than those without AF. Advanced interatrial block (IAB) was observed in 43% of patients with ICM evidence of AF and 0% of those without AF (p = .002). Age, LA size or LVEF were not predictors of AF. CONCLUSION: An increased p-wave duration, advanced IAB and high MVP score are associated with AF occurrence in patients with cryptogenic stroke. Identifying patients with these markers may be helpful as they may benefit from more exhaustive and prolonged monitoring.

Effectiveness of intra-operative topical amiodarone for prevention of postcardiac surgery new-onset atrial fibrillation: A review of current evidence.

BACKGROUND: Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery and is associated with increased morbidity. Intraoperative topical amiodarone application on epicardial tissue has been shown to reduce systemic concentrations while maintaining therapeutic myocardial concentrations, thereby, lowering the risk of extracardiac adverse effects associated with oral and intravenous amiodarone therapy. However, the efficacy and safety of topical amiodarone in preventing POAF is unclear. OBJECTIVES: This study summarizes the clinical studies to-date that have investigated the efficacy and safety of topical amiodarone administration in preventing POAF following cardiac surgery. METHODS: A database search was conducted using Medline, Embase, and Cochrane Library to identify relevant studies. Abstracts were screened and data were extracted from relevant full-text articles that met the inclusion and exclusion criteria. RESULTS: The search returned four studies with variable findings on the effect of topical amiodarone therapy on the incidence of POAF, cardiac effects, extracardiac effects, and hospital length of stay. CONCLUSION: Prophylactic topical application of amiodarone may be effective and safe for preventing post-operative new-onset atrial fibrillation. Further investigation is required to evaluate the efficacy and safety of topical amiodadrone therapy before it can be widely integrated into current practice.

[Control of arterial hypertension: a pending issueControle da hipertensão arterial: um assunto inacabado]. / El control de la hipertensión arterial, una asignatura pendiente.

Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular.Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT.It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative.Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT.Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas.Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS.Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas.Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS.Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

Brugada phenocopy in a patient with unstable angina and three-vessel coronary artery disease.

A 52-year-old male was admitted with unstable angina and three-vessel coronary artery disease. Electrocardiography (ECG) changes consistent with type-1 Brugada ECG pattern were noted during admission. The patient was asymptomatic for syncope and had no family history of sudden cardiac death, ICD implantation, and Brugada syndrome. After coronary by-pass graft the Brugada ECG pattern resolved, and ajmaline test did not elicit type-1 ECG pattern, confirming the suspicion of Brugada phenocopy.

Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials.

AIMS: Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. METHODS: We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. RESULTS: From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. CONCLUSION: Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.