The First Brazilian Cardiovascular Registry of Atrial Fibrillation: Primary Results of the RECALL Study.

BACKGROUND: It is estimated that atrial fibrillation (AF) affects approximately 1.5 million people in Brazil; however, epidemiological data are limited. We sought to evaluate the characteristics, treatment patterns, and clinical outcomes in patients with AF in Brazil by creating the first nationwide prospective registry. METHODS: RECALL was a multicenter, prospective registry that included and followed for 1 year 4,585 patients with AF at 89 sites across Brazil from April 2012 to August 2019. Patient characteristics, concomitant medication use, and clinical outcomes were analyzed using descriptive statistics and multivariable models. RESULTS: Of 4,585 patients enrolled, the median age was 70 (61, 78) years, 46% were women, and 53.8% had permanent AF. Only 4.4% of patients had a history of previous AF ablation and 25.2% had a previous cardioversion. The mean (SD) CHA2DS2-VASc score was 3.2 (1.6); median HAS-BLED score was 2 (2, 3). At baseline, 22% were not on anticoagulants. Of those taking anticoagulants, 62.6% were taking vitamin K antagonists and 37.4% were taking direct oral anticoagulants. The primary reasons for not using an oral anticoagulant were physician judgment (24.6%) and difficulty in controlling (14.7%) or performing (9.9%) INR. Mean (SD) TTR for the study period was 49.5% (27.5). During follow-up, the use of anticoagulants and INR in the therapeutic range increased to 87.1% and 59.1%, respectively. The rates/100 patient-years of death, hospitalization due to AF, AF ablation, cardioversion, stroke, systemic embolism, and major bleeding were 5.76 (5.12-6.47), 15.8 (14.6-17.0), 5.0 (4.4-5.7), 1.8 (1.4-2.2), 2.77 (2.32-3.32), 1.01 (0.75-1.36), and 2.21 (1.81-2.70). Older age, permanent AF, New York Heart Association class III/IV, chronic kidney disease, peripheral arterial disease, stroke, chronic obstructive pulmonary disease, and dementia were independently associated with increased mortality while the use of anticoagulant was associated with lower risk of death. CONCLUSIONS: RECALL represents the largest prospective registry of patients with AF in Latin America. Our findings highlight important gaps in treatment, which can inform clinical practice and guide future interventions to improve the care of these patients.

A cohort study of cardiac resynchronization therapy in patients with chronic Chagas cardiomyopathy.

Aims: Cardiac resynchronization therapy (CRT) is an established procedure for patients with heart failure. However, trials evaluating its efficacy did not include patients with chronic Chagas cardiomyopathy (CCC). We aimed to assess the role of CRT in a cohort of patients with CCC. Methods and results: This retrospective study compared the outcomes of CCC patients who underwent CRT with those of dilated (DCM) and ischaemic cardiomyopathies (ICM). The primary endpoint was all-cause mortality and the secondary endpoints were the rate of non-advanced New York Heart Association (NYHA) class 12 months after CRT and echocardiographic changes evaluated at least 6 months after CRT. There were 115 patients in the CCC group, 177 with DCM, and 134 with ICM. The annual mortality rates were 25.4%, 10.4%, and 11.3%, respectively (P < 0.001). Multivariate analysis adjusted for potential confounders showed that the CCC group had a two-fold [hazard ratio 2.34 (1.47-3.71), P < 0.001] higher risk of death compared to the DCM group. The rate of non-advanced NYHA class 12 months after CRT was significantly higher in non-CCC groups than in the CCC group (DCM 74.0% vs. ICM 73.9% vs. 56.5%, P < 0.001). Chronic Chagas cardiomyopathy and ICM patients had no improvement in the echocardiographic evaluation, but patients in the DCM group had an increase in left ventricular ejection fraction and a decrease in left ventricular end-diastolic diameter. Conclusion: This study showed that CCC patients submitted to CRT have worse prognosis compared to patients with DCM and ICM who undergo CRT. Studies comparing CCC patients with and without CRT are warranted.

Evidence for cardiac safety and antiarrhythmic potential of chloroquine in systemic lupus erythematosus.

AIMS: To perform a comprehensive evaluation of heart rhythm disorders and the influence of disease/therapy factors in a large systemic lupus erythematosus (SLE) cohort. METHODS AND RESULTS: Three hundred and seventeen consecutive patients of an ongoing electronic database protocol were evaluated by resting electrocardiogram and 142 were randomly selected for 24 h Holter monitoring for arrhythmia and conduction disturbances. The mean age was 40.2 ± 12.1 years and disease duration was 11.4 ± 8.1 years. Chloroquine (CQ) therapy was identified in 69.7% with a mean use of 8.5 ± 6.7 years. Electrocardiogram abnormalities were detected in 66 patients (20.8%): prolonged QTc/QTd (14.2%); bundle-branch block (2.5%); and atrioventricular block (AVB) (1.6%). Age was associated with AVB (P = 0.029) and prolonged QTc/QTd (P = 0.039) whereas anti-Ro/SS-A and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores were not (P > 0.05). Chloroquine was negatively associated with AVB (P = 0.01) as was its longer use (6.1 ± 6.9 vs. 1.0 ± 2.5 years, P = 0.018). Time of CQ use was related with the absence of AVB [odds ratio (OR) = 0.103; 95% confidence interval (CI) = 0.011-0.934, P = 0.043] in multiple logistic regression. Holter monitoring revealed abnormalities in 121 patients (85.2%): supraventricular ectopies (63.4%) and tachyarrhythmia (18.3%); ventricular ectopies (45.8%). Atrial tachycardia/fibrillation (AT/AF) were associated with shorter CQ duration (7.05 ± 7.99 vs. 3.63 ± 5.02 years, P = 0.043) with a trend to less CQ use (P = 0.054), and older age (P < 0.001). Predictors of AT/AF in multiple logistic regression were age (OR = 1.115; 95% CI = 1.059-1.174, P < 0.001) and anti-Ro/SS-A (OR = 0.172; 95% CI = 0.047-0.629, P = 0.008). CONCLUSIONS: Chloroquine seems to play a protective role in the unexpected high rate of cardiac arrhythmias and conduction disturbances observed in SLE. Further studies are necessary to determine if this antiarrhythmic effect is due to the disease control or a direct effect of the drug.

Mortality risk score for patients with Chagas cardiomyopathy and pacemaker.

BACKGROUND: Prognosis of Chronic Chagasic Cardiomyopathy (CCC) patients depends on functional and clinical factors. Bradyarrhythmia requiring pacemaker is a common complication. Prognosis of these patients is poorly studied, and mortality risk factors are unknown. We aimed to identify predictors of death and to define a risk score for mortality in a large cohort of CCC patients with pacemaker. METHODS: It was an observational, unicentric and prospective study. The endpoint was all-cause mortality. Cox regression was used to identify predictors of death and to define a risk score. Bootstrapping method was used to internal score validation. RESULTS: We included 555 patients and after a mean follow-up of 3.7±1.5 years, 100 (18%) deaths occurred. Predictors of death were: right ventricular dysfunction (HR [hazard ratio] 2.24; 95%CI 1.41-3.53; P = 0.001); heart failure class III or IV (HR 2.16; 95% confidence interval [95%CI] 1.16-4.00; P = 0.014); renal disease (HR 2.14; 95%CI 1.24-3.68; P = 0.006); left ventricular end-systolic diameter > 44mm (HR 1.97; 95%CI 1.26-3.05; P = 0.003); atrial fibrillation (HR 1.94; 95%CI 1.25-2.99; P = 0.003) and cardiomegaly on X-ray (HR 1.87; 95%CI 1.10-3.17; P = 0.020). The score identified patients with: low (0-20 points), intermediate (21-30 points) and high risk (>31points). The optimism-corrected C-statistic of the predictive model was 0.751 (95% CI 0.696-0.806). Internal validation with bootstrapping revealed a calibration slope of 0.946 (95% CI 0.920-0.961), reflecting a small degree of over-optimism and C-statistic of 0.746 (95% CI 0.692-0.785). CONCLUSIONS: This study identified predictors of mortality in CCC patients with pacemaker defining a simple, validated and specific risk score.

2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders.

This international multidisciplinary document is intended to guide electrophysiologists, cardiologists, other clinicians, and health care professionals in caring for patients with arrhythmic complications of neuromuscular disorders (NMDs). The document presents an overview of arrhythmias in NMDs followed by detailed sections on specific disorders: Duchenne muscular dystrophy, Becker muscular dystrophy, and limb-girdle muscular dystrophy type 2; myotonic dystrophy type 1 and type 2; Emery-Dreifuss muscular dystrophy and limb-girdle muscular dystrophy type 1B; facioscapulohumeral muscular dystrophy; and mitochondrial myopathies, including Friedreich ataxia and Kearns-Sayre syndrome, with an emphasis on managing arrhythmic cardiac manifestations. End-of-life management of arrhythmias in patients with NMDs is also covered. The document sections were drafted by the writing committee members according to their area of expertise. The recommendations represent the consensus opinion of the expert writing group, graded by class of recommendation and level of evidence utilizing defined criteria. The recommendations were made available for public comment; the document underwent review by the Heart Rhythm Society Scientific and Clinical Documents Committee and external review and endorsement by the partner and collaborating societies. Changes were incorporated based on these reviews. By using a breadth of accumulated available evidence, the document is designed to provide practical and actionable clinical information and recommendations for the diagnosis and management of arrhythmias and thus improve the care of patients with NMDs.

Predictors of death in chronic Chagas cardiomyopathy patients with pacemaker.

BACKGROUND: Chronic Chagas cardiomyopathy (CCC) is the most serious and frequent manifestation of Chagas disease. Conduction abnormalities and bradycardia requiring pacemaker are common. The aim of this study was to determine the rate and predictors of death in CCC patients with pacemaker. METHODS: In this single-center prospective cohort study we assessed the outcome of 396 CCC patients with pacemaker, followed-up for at least 24months. All patients underwent a clinical and device assessment, 12-lead electrocardiography and echocardiography. RESULTS: During the median follow-up of 1.9years (Interquartile range 1.6-2.4), there were 65 (16.4%) deaths, yielding an annual mortality rate of 8.6%. The major cause was sudden death (33.8%), followed by heart failure (HF), 32.3%. All the investigated variables were examined as potential predictors of death. The final multivariate logistic regression model included five independent variables: advanced HF functional class (OR [odds ratio] 6.71; 95% confidence interval [95% CI] 1.95-23.2; P=0.003), renal disease (OR 5.71; 95% CI 1.80-18.0; P=0.003), QRS ≥150ms (OR 2.80; 95% CI 1.08-7.27; P=0.034), left atrial enlargement (OR 2.75; 95% CI 1.09-6.95; P=0.032) and left ventricular ejection fraction ≤43% (OR 2.31; 95% CI 1.07-4.97; P=0.032). The model had good discrimination, confirmed by bootstrap validation (optimism-adjusted c-statistic of 0.78) and the calibration curve showed a proper calibration (slope=0.972). CONCLUSIONS: CCC patients with pacemaker have a high annual mortality rate despite that the pacemaker related variables were not predictors of death. The independent predictors of death can help us to identify the poor prognosis patients.

Registro brasileiro de estimulação fisiológica da sociedade brasileira de arritmias cardíacas - SOBRAC / Brazilian registry of physiological stimulation of the brazilian society of cardiac arrhythmias - SOBRAC

INTRODUÇÃO: Resultados favoráveis foram relatados com estimulação direta do sistema de excito-condutor cardíaco, o que tem motivado a inclusão desta técnica em recomendações e diretrizes atuais. Entretanto, não há dados disponíveis dessa prática no Brasil. OBJETIVOS: Descrever as características demográficas, eletrocardiográficas e ecocardiográficas assim como os achados intra e peri-operatórios dos pacientes submetidos a estimulação fisiológica no Brasil. MÉTODOS: Trata-se de um registro multicêntrico realizado em 15 centros no Brasil. A técnica cirúrgica utilizada seguiu a rotina dos centros participantes. RESULTADOS: 180 pacientes (64,9% homens, 74,8±12,5 anos) foram incluídos na análise entre maio e setembro de 2021. Características clínicas: 82,7% eram hipertensos, 33,5% diabéticos, 51,9% tinham antecedente de sincope, 23,2% DAC e 0,7% doença de Chagas; 76,7% apresentavam-se em CF-NYHA I ou II. A cardiopatia subjacente e o motivo do implante estão ilustrados na figura 1. Em 13,5% dos pacientes, o CDI foi concomitantemente indicado. Quanto aos achados eletrocardiográficos, 89,2% dos pacientes apresentavam-se em ritmo sinusal e 10,8% em FA/flutter atrial. O QRS basal médio era de 131±32ms; 28,1% dos pacientes apresentavam BRE e 31,4% BRD. A FEVE média foi de 54,14±16,66%. Todos os centros reportaram sucesso do implante. O tempo médio de fluoroscopia foi de 17,6±14,5min e a duração média do procedimento 81,8±43,8. Dispositivo bicameral foi predominante na maior parte dos casos (figura 2). Em 75,1% dos casos, o eletrodo ventricular foi posicionado no RE/septo profundo (LVAT médio 77,7±10,7ms, potencial de RE reportado em 25,7%) enquanto o feixe de His foi a posição escolhida em 24,9% dos casos. Em 6,6% dos pacientes procedeu-se HOT/LOT-CRT. A onda R média foi 9,8mV e o limiar de captura 1,17V x 1,0ms. A duração média do QRS final foi 107,46 ± 18,6ms. As taxas de complicações foram baixas (figura 3). CONCLUSÕES: O implante de marcapasso fisiológico é factível e seguro. As características dos pacientes incluídos nesse registro brasileiro, a preferência quanto ao tipo de estimulação (RE) e os resultados intra e pós operatórios precoces estão alinhados com as publicações internacionais mais recentes.

Cardiac arrhythmias and Covid-19

ABSTRACT: Cardiovascular manifestations of COVID-19 include cardiac rhythm disturbances, whose mechanisms, incidence, and most common types are not well established in this population. Intense inflammatory response and metabolic activity contribute to recurrence of pre-existing arrhythmias, and other arrhythmias can occur due to myocardial injury, acute coronary insufficiency, and electrolyte disturbances. Brady- and tachyarrhythmias, as well as conduction disorders have been described. QT interval prolongation and fatal ventricular arrhythmias (Torsades de Pointes) may result from the pathological process or adverse effect of drugs (antiarrhythmics, chloroquine / hydroxychloroquine, azithromycin and antivirals). Patients with congenital heart disease and hemodynamic repercussions, patients with signs of heart failure, pulmonary hypertension, cyanosis, hypoxemia, and those who underwent heart transplantation and immunosuppression are at greater risk. In patients with implantable cardioverter defibrillators (ICDs), the risk depends on the presence of structural heart disease. In the course of COVID-19, in-person assessment of these patients should be limited to high-risk situations, including syncope, worsening of heart failure and shock delivery by ICDs. Likewise, cardiac implantable electronic device implantation or replacement surgery should be limited to emergency and urgent cases, including symptomatic high-degree atrioventricular block, ICD for secondary prevention and pulse generator replacement due to battery drain.

Cardiac damage from chronic use of chloroquine: a case report and review of the literature.

Chloroquine has been widely used in rheumatological treatment, but potential severe side effects require careful follow-up. Cardiac damage is not a common consequence, but its clinical relevance has not yet been described. We report the case of a 58-year-old woman with rheumatoid arthritis, in whom chronic chloroquine use resulted in major irreversible cardiac damage. She presented with syncopal episodes due to complete atrioventricular block confirmed by electrophysiological study whose changes were concluded to be irreversible and a permanent pacemaker was indicated. Endomyocardial biopsy was also performed to search for histopathological and ultrastructural cardiac damage. We also reviewed the 22 cases of chloroquine-induced cardiopathy described to date as well as its pathophysiology.

Acute cholestatic hepatitis caused by amoxicillin/clavulanate.

Amoxicillin/clavulanate is a synthetic penicillin that is currently commonly used, especially for the treatment of respiratory and cutaneous infections. In general, it is a well-tolerated oral antibiotic. However, amoxicillin/clavulanate can cause adverse effects, mainly cutaneous, gastrointestinal, hepatic and hematologic, in some cases. Presented here is a case report of a 63-year-old male patient who developed cholestatic hepatitis after recent use of amoxicillin/clavulanate. After 6 wk of prolonged use of the drug, he began to show signs of cholestatic icterus and developed severe hyperbilirubinemia (total bilirubin > 300 mg/L). Diagnostic investigation was conducted by ultrasonography of the upper abdomen, serum tests for infection history, laboratory screening of autoimmune diseases, nuclear magnetic resonance (NMR) of the abdomen with bile duct-NMR and transcutaneous liver biopsy guided by ultrasound. The duration of disease was approximately 4 mo, with complete resolution of symptoms and laboratory changes at the end of that time period. Specific treatment was not instituted, only a combination of anti-emetic (metoclopramide) and cholestyramine for pruritus.

Arrhythmias in systemic lupus erythematosus.

Cardiac involvement is present in more than half of the patients with Systemic Lupus Erythematosus (SLE). However, studies on the prevalence of arrhythmias in this disease and laboratory correlations predictive of their development do not exist. It seems possible that the classic second mortality peak is related to arrhythmias, mainly due to the sudden nature of those deaths. Autoimmune process, atherosclerotic complications, and even adverse effects secondary to the treatment of this disorder (chloroquine cardiotoxicity) seem to be the main pathophysiological mechanisms of those disturbances. The direct participation of autoantibodies, such as anti-Ro/SSA and anti-RNP, is still controversial. All types of AV blocks (AVB), intraventricular conduction disturbances, and sick sinus syndrome have already been described in this disease. Tachycardias identified more often include sinus tachycardia, atrial fibrillation, and atrial ectopies. Long QT syndrome and the presence of late potentials in signal-averaged ECG have also been described in SLE patients and they can be associated with increased mortality rates. Cardiac toxicity secondary to chloroquine could be responsible for several types of arrhythmias. However, few cases of fascicular block evolving to complete AV block have been described. Since these adverse effects are rarely reported, the beneficial anti-inflammatory and immune properties support the use of antimalarials in this disease. A complete cardiologic evaluation should include the conduction system and must be carried out in all SLE patients to identify arrhythmias, therefore preventing symptoms and also sudden cardiac death.

Eventos arrítmicos no lúpus eritematoso sistêmico: [revisão] / Arrhythmias in systemic lupus erythematosus: [review]

Mais da metade dos pacientes com lúpus eritematoso sistêmico (LES) apresentam envolvimento cardíaco. Porém, não existem estudos de prevalência de eventos arrítmicos (EA) nesta doença, nem de correlações laboratoriais preditoras de sua ocorrência. É possível que o clássico segundo pico de mortalidade da doença esteja relacionado com a ocorrência da EA, sobretudo pela natureza súbita dos óbitos relatados. Processo autoimune, complicações ateroscleróticas e, até mesmo, efeito adverso do tratamento (cardiotoxicidade pela cloroquina) parecem ser os mecanismos fisiopatológicos mais prováveis para estes distúrbios. A participação direta de autoanticorpos, como o anti-Ro/SSA e o anti-RNP ainda é controversa.Todos os tipos de bloqueios atrioventriculares (BAV), distúrbios da condução intraventricular e a doença do nó sinusal já foram descritos na doença. As taquicardias mais identificadas são a taquicardia sinusal, a fibrilação atrial e as extrassístoles atriais. O prolongamento do intervalo QT e a presença de potenciais tardios ao eletrocardiograma de alta resolução também já foram documentados em pacientes com LES e podem estar associados a maiores taxas de mortalidade. A toxicidade cardíaca secundária ao uso de cloroquina poderia determinar diversos tipos de EA. Entretanto, existem poucos relatos de bloqueio fascicular que poderiam evoluir para BAVT com o uso desta droga. Uma vez que estes efeitos adversos são raramente descritos, os benefícios das propriedades anti-inflamatórias e imunes reforçam o uso dos antimaláricos nesta doença. Uma avaliação cardiológica completa deve incluir exames do sistema excito-condutor e deve ser realizada em todos os pacientes com LES no sentido de identificar EA, prevenindo sintomas e até mesmo a morte súbita.

Cardiac involvement is present in more than half of the patients with Systemic Lupus Erythematosus (SLE). However, studies on the prevalence of arrhythmias in this disease and laboratorial correlations predictive of their development do not exist. It seems possible that the classic second mortality peak is related to arrhythmias, mainly due to the sudden nature of those deaths. Autoimmune process, atherosclerotic complications, and even adverse effects secondary to the treatment of this disorder (chloroquine cardiotoxicity) seem to be the main pathophysiological mechanisms of those disturbances. The direct participation of autoantibodies, such as anti-Ro/SSA and anti-RNP, is still controversial. All types of AV blocks (AVB), intraventricular conduction disturbances, and sick sinus syndrome have already been described in this disease. Tachycardias identified more often include sinus tachycardia, atrial fibrillation, and atrial ectopies. Long QT syndrome and the presence of late potentials in signal-averaged ECG have also been described in SLE patients and they can be associated with increased mortality rates. Cardiac toxicity secondary to chloroquine could be responsible for several types of arrhythmias. However, few cases of fascicular block evolving to complete AV block have been described. Since these adverse effects are rarely reported, the beneficial anti-inflammatory and immune properties support the use of antimalarials in this disease. A complete cardiologic evaluation should include the conduction system and must be carried out in all SLE patients to identify arrhythmias, therefore preventing symptoms and also sudden cardiac death.