Modelo predictivo del fracaso de la terapia eléctrica en la fibrilación auricular paroxística / Predictive model of electrical therapy failure in paroxysmal atrial fibrillation

Introducción: La fibrilación auricular es la arritmia recurrente más habitual en la práctica clínica. Su prevalencia se multiplica en la población actual y tiene diferentes causas fisiopatológicas que la convierten en una pandemia mundial. Objetivos: Diseñar un modelo predictivo de fracaso de la terapia eléctrica en pacientes con fibrilación auricular paroxística. Métodos: Se realizó un estudio de casos y controles, con 33 casos y 66 controles. Variables predictoras: edad, fracción de eyección ≤ 40 por ciento, volumen de aurícula izquierda ≥ 34 mL/m2. A partir de la regresión logística se obtuvo un modelo en el que fueron incluidos el valor predictivo positivo, valor predictivo negativo, la sensibilidad y especificidad. Resultados: Los factores de riesgo predictores fueron: edad ≥ 55 años (p= 0,013; odds ratio (OR)= 3,58; intervalo de confianza -IC- 95 por ciento: 1,33-9,67); la fracción de eyección del ventrículo izquierdo (FEVI) ≤ 40 por ciento se observó en 20 pacientes (22,7 por ciento) (p= 0,004; OR= 4,45; IC95 por ciento: 1,54-12,8); presión de aurícula izquierda elevada, volumen de aurícula izquierda elevado (p= 0,004; OR= 3,11; IC95 por ciento: 1,24-8,77), según el modelo de regresión logística. Se realizó la validación interna por división de datos; se confirmó que el modelo pronostica bien los que van a tener éxito en el resultado terapéutico. Conclusiones: El modelo predictivo elaborado está compuesto por los predictores edad > 55 años, FEVI; volumen de aurícula izquierda; presenta un buen ajuste y poder discriminante, sobre todo valor predictivo positivo(AU)

Introduction: Atrial fibrillation is the most common recurrent arrhythmia in clinical practice. Its prevalence is multiplying in the current population and has different pathophysiological causes that make it a global pandemic. Objectives: To design a predictive model for failure of electrical therapy in patients with paroxysmal atrial fibrillation. Methods: A case-control study was carried out with 33 cases, and 66 controls. Predictor variables: age, ejection fraction ≤ 40 percent, left atrial volume ≥ 34 mL/m2. From logistic regression, a model was obtained in which the positive predictive value, negative predictive value, sensitivity and specificity were included. Results: The predictive risk factors were: age ≥ 55 years (p= 0.013; odds ratio (OR)= 3.58; 95 percent confidence interval -CI-: 1.33-9.67); left ventricular ejection fraction (LVEF) ≤ 40 percent was observed in 20 patients (22.7 percent) (p= 0.004; OR= 4.45; 95 percent CI: 1.54-12.8); elevated left atrial pressure, elevated left atrial volume (p= 0.004; OR= 3.11; 95 percent CI: 1.24-8.77), according to the logistic regression model. Internal validation was carried out by data division; It was confirmed that the model predicts very well those who will be successful in the therapeutic result. Conclusions: The predictive model developed is composed of the predictors age > 55 years, LVEF; left atrial volume; It presents a good fit and discriminating power, especially positive predictive value(AU)

Improving Time to Defibrillation Following Ventricular Tachycardia (VTach) and Ventricular Fibrillation (VFib) Cardiac Arrest: A Multicenter Retrospective and Prospective Quality Improvement Study.

The goal of this study was to identify how often 2 independent centers defibrillated patients within the American Heart Association recommended 2-minute time interval following ventricular fibrillation/ventricular tachycardia arrest. A retrospective chart review revealed significant delays in defibrillation. Simulation sessions and modules were implemented to train nursing staff in a single nursing unit at a Philadelphia teaching hospital. Recruited nurses completed a code blue simulation session to establish a baseline time to defibrillation. They were then given 2 weeks to complete an online educational module. Upon completion, they participated in a second set of simulation sessions to assess improvement. First round simulations resulted in 33% with delayed defibrillation and 27% no defibrillation. Following the module, 77% of the second round of simulations ended in timely defibrillation, a statistically significant improvement ( P < 0.00001). Next steps involve prospective collection of the code blue data to analyze improvement in real code blue events.

Cardiopulmonary Resuscitation in Prone Position

Abstract Mechanical ventilation in prone position is an alternative strategy for patients with acute respiratory discomfort syndrome (ARDS) to improve oxygenation in situations when traditional ventilation modalities have failed. However, due to the significant increase in ARDS cases during the SARS-CoV-2 pandemic and the experimental therapeutic use of potentially arrhythmogenic drugs, cardiopulmonary resuscitation in this unusual position could be needed. Therefore, we will review the available scientific evidence of cardiopulmonary resuscitation in prone position.

Cardiomiopatia arritmogênica do ventrículo direito em maratonista: relato de caso / Arrhythmogenic right ventricular cardiomyopathy in marathon runners: case report

A cardiomiopatia arritmogênica do ventrículo direito é uma desordem hereditária caracterizada pela substituição fibrogordurosa do músculo cardíaco. O manejo clínico busca reduzir os riscos de morte súbita e melhorar a qualidade de vida, aliviando os sintomas arrítmicos e de insuficiência cardíaca. O ecocardiograma é o exame inicial para a investigação da cardiomiopatia arritmogênica do ventrículo direito, podendo apresentar dilatação das câmaras direitas e disfunção sistólica do ventrículo direito. Este relato chama atenção por envolver o diagnóstico de cardiomiopatia arritmogênica do ventrículo direito em paciente atleta. Mulher, 47 anos, maratonista, sem história familiar de morte súbita cardíaca, deu entrada na emergência com palpitação associada à pré-síncope. O eletrocardiograma da admissão mostrava taquicardia ventricular. O ecocardiograma revelou aumento de câmaras cardíacas direitas e disfunção sistólica do ventrículo direito. O cateterismo cardíaco não evidenciou doença coronária obstrutiva. A paciente foi orientada acerca da necessidade de suspensão de atividades físicas, porém, 3 meses depois, foi readmitida com instabilidade hemodinâmica por nova taquicardia ventricular, tendo sido cardiovertida. Realizou ressonância cardíaca, que evidenciou áreas de discinesia e formação de microaneurismas em ventrículo direito. Foi diagnosticada com cardiomiopatia arritmogênica do ventrículo direito, tendo sido com cardioversor desfibrilador implantável, amiodarona e betabloqueador. A diferenciação entre a cardiomiopatia arritmogênica do ventrículo direito e o coração do atleta representa um desafio, devido à sobreposição de alterações estruturais que coexistem nessas entidades, daí a importância da análise integrada de fatores clínicos, eletrocardiográficos e morfofuncionais.(AU)

Joint Mexican position document on the treatment of atrial fibrillation / Posicionamiento conjunto acerca del tratamiento para fibrilación auricular

Abstract Atrial fibrillation (AF) is a frequent arrhythmia; its prevalence is near 2% in the general population; in Mexico, more than one-half million people are affected. AF needs to be considered as a public health problem. Because AF is an independent risk factor associated with mortality, due to embolic events, heart failure, or sudden death; early diagnosis is of utmost importance. In unstable patients with a recent onset of AF, electrical cardioversion should be practiced. In stable patients, once thromboembolic measures have been taken, it is necessary to assess whether it is reasonable to administer an antiarrhythmic drug to restore sinus rhythm or performed electrical cardioversion. For recidivating cases of paroxysmal and persistent presentation, the most effective strategy is performed pulmonary vein isolation with either radiofrequency or cryoballoon energy. Permanent AF is that in which recovery of sinus rhythm is not possible, the distinguishing feature of this phase is the uncontrollable variability of the ventricular frequency and could be treated pharmacologically with atrioventricular (AV) nodal blockers or with a VVIR pacemaker plus AV nodal ablation. The presence of AF has long been associated with the development of cerebral and systemic (pulmonary, limb, coronary, renal, and visceral) embolism. The prevention of embolisms in “valvular” AF should perform with Vitamin K antagonists (VKA). For patients with AF not associated with mitral stenosis or a mechanical valve prosthesis, a choice can be made between anticoagulant drugs, VKA, or direct oral anticoagulants. Antiplatelet agents have the weakest effect in preventing embolism.

Resumen La fibrilación auricular (FA) es una arritmia frecuente; su prevalencia es cercana al 2% en la población general, en México se ven afectados más de medio millón de personas por eso debe considerarse como un problema de salud pública. Debido a que la FA es un factor de riesgo independiente asociado a mortalidad, por eventos embólicos, insuficiencia cardíaca o muerte súbita, la identificación y diagnóstico temprano es de suma importancia. En el inicio reciente de FA en pacientes inestables, se debe practicar la cardioversión eléctrica. En pacientes estables, una vez que se han tomado medidas tromboembólicas, es necesario evaluar si es razonable administrar un medicamento antiarrítmico para restaurar el ritmo sinusal o realizar una cardioversión eléctrica. Para los casos que recidivan, ya sea paroxística o persistente, la estrategia más efectiva es realizar el aislamiento de la venas pulmonares con radiofrecuencia o crioablación con balón. La FA permanente es aquella en la que no es posible la recuperación del ritmo sinusal, la característica distintiva de esta fase de la FA es la variabilidad incontrolable de la frecuencia ventricular. Puede tratarse farmacológicamente con bloqueadores nodales AV o con un marcapasos VVIR mas ablación del nodo AV. La presencia de FA se ha asociado durante mucho tiempo con el desarrollo de embolia cerebral y sistémica (pulmonar, de extremidades, coronaria, renal y visceral). La prevención de embolias en la FA “valvular” debe realizarse con antagonistas de la vitamina K (AVK). Para los pacientes con FA no asociados con estenosis mitral o una prótesis valvular mecánica, se puede elegir entre medicamentos anticoagulantes, AVK o anticoagulantes orales directos (DOAC). Los agentes antiplaquetarios tienen el efecto más débil para prevenir la embolia.

Joint Mexican position document on the treatment of atrial fibrillation.

Atrial fibrillation (AF) is a frequent arrhythmia; its prevalence is near 2% in the general population; in Mexico, more than one-half million people are affected. AF needs to be considered as a public health problem. Because AF is an independent risk factor associated with mortality, due to embolic events, heart failure, or sudden death; early diagnosis is of utmost importance. In unstable patients with a recent onset of AF, electrical cardioversion should be practiced. In stable patients, once thromboembolic measures have been taken, it is necessary to assess whether it is reasonable to administer an antiarrhythmic drug to restore sinus rhythm or performed electrical cardioversion. For recidivating cases of paroxysmal and persistent presentation, the most effective strategy is performed pulmonary vein isolation with either radiofrequency or cryoballoon energy. Permanent AF is that in which recovery of sinus rhythm is not possible, the distinguishing feature of this phase is the uncontrollable variability of the ventricular frequency and could be treated pharmacologically with atrioventricular (AV) nodal blockers or with a VVIR pacemaker plus AV nodal ablation. The presence of AF has long been associated with the development of cerebral and systemic (pulmonary, limb, coronary, renal, and visceral) embolism. The prevention of embolisms in "valvular" AF should perform with Vitamin K antagonists (VKA). For patients with AF not associated with mitral stenosis or a mechanical valve prosthesis, a choice can be made between anticoagulant drugs, VKA, or direct oral anticoagulants. Antiplatelet agents have the weakest effect in preventing embolism.

La fibrilación auricular (FA) es una arritmia frecuente; su prevalencia es cercana al 2% en la población general, en México se ven afectados más de medio millón de personas por eso debe considerarse como un problema de salud pública. Debido a que la FA es un factor de riesgo independiente asociado a mortalidad, por eventos embólicos, insuficiencia cardíaca o muerte súbita, la identificación y diagnóstico temprano es de suma importancia. En el inicio reciente de FA en pacientes inestables, se debe practicar la cardioversión eléctrica. En pacientes estables, una vez que se han tomado medidas tromboembólicas, es necesario evaluar si es razonable administrar un medicamento antiarrítmico para restaurar el ritmo sinusal o realizar una cardioversión eléctrica. Para los casos que recidivan, ya sea paroxística o persistente, la estrategia más efectiva es realizar el aislamiento de la venas pulmonares con radiofrecuencia o crioablación con balón. La FA permanente es aquella en la que no es posible la recuperación del ritmo sinusal, la característica distintiva de esta fase de la FA es la variabilidad incontrolable de la frecuencia ventricular. Puede tratarse farmacológicamente con bloqueadores nodales AV o con un marcapasos VVIR mas ablación del nodo AV. La presencia de FA se ha asociado durante mucho tiempo con el desarrollo de embolia cerebral y sistémica (pulmonar, de extremidades, coronaria, renal y visceral). La prevención de embolias en la FA "valvular" debe realizarse con antagonistas de la vitamina K (AVK). Para los pacientes con FA no asociados con estenosis mitral o una prótesis valvular mecánica, se puede elegir entre medicamentos anticoagulantes, AVK o anticoagulantes orales directos (DOAC). Los agentes antiplaquetarios tienen el efecto más débil para prevenir la embolia.

Atrial fibrillation in cardiac surgery.

Atrial fibrillation is the most frequent arrhythmia in the postoperative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism and increase in days of in-hospital and mortality. Atrial fibrillation in the postoperative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle < 40% and the withdrawal of beta-blocker drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with beta-blockers and amiodarone, is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.

La fibrilación auricular es la arritmia más frecuente en el periodo posquirúrgico de la cirugía cardíaca. Se relaciona con insuficiencia cardíaca, insuficiencia renal, embolismo sistémico y más días de estancia y mortalidad. La fibrilación auricular en el periodo posquirúrgico de la cirugía cardíaca (FAPCC) suele aparecer en las primeras 48 horas. Los principales mecanismos que producen la aparición y el mantenimiento de la FAPCC son el aumento del tono simpático y la respuesta inflamatoria. Los factores de riesgo adjuntos son la edad avanzada, enfermedad pulmonar obstructiva crónica, enfermedad renal crónica, cirugía valvular, fracción de expulsión del ventrículo izquierdo menor de 40% e interrupción de fármacos bloqueadores ß. Existen instrumentos que han demostrado predecir la aparición de FAPCC. El tratamiento profiláctico con bloqueadores ß y amiodarona se relaciona con disminución de la aparición de FAPCC. Dada su naturaleza transitoria, se sugiere que el tratamiento inicial de FAPCC sea el control de la frecuencia cardíaca y sólo en caso de que el tratamiento no consiga el retorno al ritmo sinusal está indicada la cardioversión eléctrica. Se desconoce cuál debe ser el seguimiento a largo plazo y sólo se conocen en escasa medida las complicaciones más allá de este periodo. La FAPCC no es una arritmia benigna ni aislada en los pacientes sometidos a operación cardíaca, por lo que la identificación de los factores de riesgo, su prevención y el seguimiento en el ámbito ambulatorio deben formar parte de las unidades dedicadas a la atención y los cuidados de estos pacientes.

Fibrilación auricular en cirugía cardíaca / Atrial fibrillation in cardiac surgery

Resumen La fibrilación auricular es la arritmia más frecuente en el periodo posquirúrgico de la cirugía cardíaca. Se relaciona con insuficiencia cardíaca, insuficiencia renal, embolismo sistémico y más días de estancia y mortalidad. La fibrilación auricular en el periodo posquirúrgico de la cirugía cardíaca (FAPCC) suele aparecer en las primeras 48 horas. Los principales mecanismos que producen la aparición y el mantenimiento de la FAPCC son el aumento del tono simpático y la respuesta inflamatoria. Los factores de riesgo adjuntos son la edad avanzada, enfermedad pulmonar obstructiva crónica, enfermedad renal crónica, cirugía valvular, fracción de expulsión del ventrículo izquierdo menor de 40% e interrupción de fármacos bloqueadores β. Existen instrumentos que han demostrado predecir la aparición de FAPCC. El tratamiento profiláctico con bloqueadores β y amiodarona se relaciona con disminución de la aparición de FAPCC. Dada su naturaleza transitoria, se sugiere que el tratamiento inicial de FAPCC sea el control de la frecuencia cardíaca y sólo en caso de que el tratamiento no consiga el retorno al ritmo sinusal está indicada la cardioversión eléctrica. Se desconoce cuál debe ser el seguimiento a largo plazo y sólo se conocen en escasa medida las complicaciones más allá de este periodo. La FAPCC no es una arritmia benigna ni aislada en los pacientes sometidos a operación cardíaca, por lo que la identificación de los factores de riesgo, su prevención y el seguimiento en el ámbito ambulatorio deben formar parte de las unidades dedicadas a la atención y los cuidados de estos pacientes.

Abstract Atrial fibrillation is the most frequent arrhythmia in the postoperative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism and increase in days of in-hospital and mortality. Atrial fibrillation in the postoperative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle less 40% and the withdrawal of beta-blocker drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with beta-blockers and amiodarone, is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.

Heart defibrillation: relationship between pacing threshold and defibrillation probability.

BACKGROUND: Considering the clinical importance of the ventricular fibrillation and that the most used therapy to reverse it has a critical side effect on the cardiac tissue, it is desirable to optimize defibrillation parameters to increase its efficiency. In this study, we investigated the influence of stimuli duration on the relationship between pacing threshold and defibrillation probability. RESULTS: We found out that 0.5-ms-long pulses had a lower ratio of defibrillation probability to the pacing threshold, although the higher the pulse duration the lower is the electric field intensity required to defibrillate the hearts. CONCLUSION: The appropriate choice of defibrillatory shock parameters is able to increase the efficiency of the defibrillation improving the survival chances after the occurrence of a severe arrhythmia. The relationship between pulse duration and the probability of reversal of fibrillation shows that this parameter cannot be underestimated in defibrillator design since different pulse durations have different levels of safety.

Propofol for sedation for direct current cardioversion.

Direct current cardioversion is a low-risk and standard procedure to restore normal sinus rhythm in patients with tachyarrhythmias. It requires sedation to facilitate the procedure, as it is painful and distressful. The preferred anesthetic drug must be short acting, producing conscious sedation, to enable rapid recovery after the procedure. In this sense, this narrative review focuses on the critical analysis of recent randomized studies and presents about the safety and effectiveness of propofol, comparing it with other established sedatives, mainly etomidate and midazolam. The research was performed on MEDLINE database with Propofol and Cardioversion keywords. In most cases, propofol comes to be the best option, with a quick recovery time and low rates of side effects. Different studies have demonstrated no inferiority when comparing to other drugs and, when these adverse events happened, they were easily and quickly handled. Exceptions in this scenario are those patients, particularly the elderly, with baseline important structural heart disease, in which etomidate with fentanyl has been pointed to lead to better hemodynamic stability.

Video-assisted thoracoscopic cardiac denervation of refractory ventricular arrhythmias and electrical storms: a single-center series.

BACKGROUND: The combined treatment of beta-blockers with ablation and Implanted cardioverter defibrillation therapy, continues to be the mainstay treatment for ventricular arrhythmias (VAs). Despite treatment, some patients remain refractory.  Recent studies have shown success rates using video-assisted thoracoscopic (VATS) cardiac denervation as an effective therapeutic option for these patients. CASE SERIES PRESENTATION: During a period of three years, from 2015 through 2017, twenty patients (N = 20) failed traditional medical and interventional treatment for the management of ventricular arrhythmias and electrical storms. After remaining refractory, the patients were referred to our thoracic surgery department for a VATS based treatment. The patients all had ventricular arrhythmias and electrical storms secondary to different cardiomyopathies. The patients were refractory to combined medical (beta-blockers), Implanted Cardioverter defibrillation (ICD) and ablation therapy. All twenty patients agreed to surgery and were taken to cardiac denervation using a bilateral VATS approach by two thoracic surgeons at a single Cardiothoracic center. During the month prior to bilateral VATS denervation a combined total of twenty-nine (N = 29) ICD shocks were registered in addition to six (N = 6) cases of electrical storms averaging three (N = 3) shocks per day. Mean shocks per patient was 2.3. During the first three months following VATS, the patients had a 90% (N = 18/20) total resolution of ICD registered shocks, a 100% (N = 6/6) resolution of electrical storms, and a 92% (N = 11/12) resolution of shocks in patients having previous ablation therapy. No complications were documented following surgery except for one case of pneumothorax as a result of the procedure, and there were no peri-operative mortalities. CONCLUSIONS: Bilateral thoracoscopic cardiac denervation can be a safe and seemingly effective therapeutic option for patients presenting with life-threatening refractory ventricular arrhythmias and electrical storms in a variety of cardiomyopathies including Chagas disease.

Guía de práctica clínica para el manejo de pacientes con fibrilación auricular / Clinical practice guideline for the management of patients with atrial fibrillation

La fibrilación auricular (FA) es la arritmia cardiaca más frecuente en la práctica clínica, se caracteriza por presentar una frecuencia auricular desorganizada mayor a 200 latidos por minuto, asociado a una respuesta ventricular variable. La FA se puede clasificar en tres tipos distintos de acuerdo a su presentación: FA paroxística, FA persistente y FA permanente. La FA paroxística es aquella que se presenta como episodios súbitos que se autolimitan y tienen como máximo una duración de una semana. La FA persistente es aquella en la que la alteración del ritmo persiste por más de una semana, luego de ese tiempo se puede autolimitar o puede responder a tratamiento. Por otro lado, la FA permanente es aquella condición donde por consenso del médico y paciente debido a las características clínicas del paciente y la propia arritmia se decide seguir solo las estrategias de control de frecuencia para el control de síntomas, no siendo de interés restaurar el ritmo sinusal del paciente. Tanto la FA paroxística como la persistente pueden convertirse en FA permanente (1). Otro concepto importante es el de FA valvular, definido como FA en portadores de prótesis valvular mecánica o padecen de estenosis mitral moderada o severa, los cuales tendrían mayor riesgo de eventos tromboembólicos (2). Existen diversas técnicas que pueden ser útiles para el diagnóstico de FA, entre ellos se encuentra la palpación del pulso que posee una sensibilidad de 0.92 (IC 95%: 0.85 a 0.96) y una especificidad de 0.82 (IC 95%: 0.76 a 0.88) (3). La baja especificidad de la palpación del pulso significa un aumento de falsos positivos por lo que esta técnica debería ser utilizada solo en pacientes con sospecha de FA como aquellos que presentan: falta de aire/disnea, palpitaciones, síncope/mareos, dolor o disconfort de pecho y desorden cerebrovascular (DCV) isquémico. Por este motivo se considera que la palpación del pulso puede ser útil para identificar pulso irregular en pacientes con síntomas sugestivos de FA. El uso de electrocardiograma (ECG) tiene una sensibilidad de 0.91 (IC 95%: 0.86 a 0.94) y una especificidad de 0.95 (IC 95%: 0.92 a 0.97) para detectar R-R irregulares cuando es interpretado por enfermeras, médicos generales o cardiólogos (3). Por este motivo este método es útil para diagnosticar FA en todos los pacientes, sintomáticos o no, en los que se sospeche fibrilación auricular debido a la detección de pulso irregular.

Arritmias na sala de emergência e UTI. Taquicardias de QRS estreito: fundamentos para a abordagem / Arrythmias in the emergency room and ICU Narrow QRS rachycardias: bases for clinical approach

As taquicardias de QRS estreito apresentam origem supraventricular. O histórico clínico, exame físico e eletrocardiograma na sala de emergência constituem-se nas principais ferramentas para o tratamento do quadro. As taquicardias que apresentam instabilidade hemodinâmica devem ser, imediatamente, revertidas através de cardioversão elétrica sincronizada. Aquelas que se apresentam como estáveis hemodinamicamente podem, se regulares, ser tratadas através de manobras vagais ou através do uso de fármacos endovenosos. Se irregulares, podem caracterizar fibrilação e flutter atrial, sendo, então, avaliados a duração do episódio e o risco de tromboembolismo para determinar não apenas a necessidade de anticoagulação, mas também a estratégia para tratamento do quadro, seja através do controle da frequência cardíaca ou do controle do ritmo, este último podendo ser alcançado através do uso de fármacos (propafenona oral ou amiodarona endovenosa) ou da cardioversão elétrica sincronizada. Dessa forma, o papel do clínico na sala de emergência é fundamental para garantir a condução adequada dos episódios de taquicardia supraventricular, especialmente, na prevenção ou pronta intervenção em caso de deterioração hemodinâmica relacionada ao quadro

Narrow QRS tachycardias are supraventricular in origin. The clinical history, physical exam, and electrocardiogram in the emergency room are the main tools used to manage this condition. Tachycardias that present haemodynamic instability must be promptly reverted through synchronized electrical cardioversion. Those that present haemodynamic stability may be treated with vagal maneuvers or intravenous drugs. If irregular, they may take the form of atrial fibrillation or atrial flutter, and in this case, the duration of the episode and the thromboembolic risk are evaluated to determine not only the need for anticoagulation, but also the treatment strategy, whether through heart rate or rhythm control. The latter may be achieved through the use of drugs (oral propafenone or intravenous amiodarone) or synchronized electrical cardioversion. The role of the clinician in the emergency room is therefore fundamental in ensuring adequate conduct of episodes of supraventricular tachycardia, especially in prevention or prompt intervention in case of haemodynamic deterioration related to the condition

Ressuscitação cardíaca pré-hospitalar. Do pré-hospitalar à sala de emergência: minutos que salvam uma vida - suporte básico / Prehospital cardiac ressuscitation. From prehospital to the emergency room: minutes that save a life - basic support

A incidência exata de parada cardiorrespiratória (PCR) mesmo em países com registros clínicos bem estruturados ainda é desconhecida, mas as estimativas variam de 180.000 a mais de 450.000 mortes anuais. A etiologia mais comum da PCR é a doença cardiovascular isquêmica que ocasiona no desenvolvimento de arritmias letais. A sobrevivência decorrente da PCR apresenta desfechos divergentes. No cenário extra-hospitalar, os estudos relataram taxas de sobrevida de 1% a 6%. Três revisões sistemáticas de alta hospitalar sobre a PCR extra-hospitalar mostraram 5% a 10% de sobrevida entre aqueles tratados através de serviços médicos de emergência e 15% quando o distúrbio do ritmo era a fibrilação ventricular (FV). O suporte básico de vida consiste em ressuscitação cardiopulmonar (RCP) e, quando disponível, desfibrilação com desfibrilador externo automático (DEA). As chaves para a sobrevivência após a PCR são reconhecimento e tratamento precoces, especificamente, início imediato de excelente RCP e desfibrilação precoce. O presente artigo discutirá os princípios do suporte básico de vida em adultos do pré-hospitalar à sala de emergência, conforme descritos nas Diretrizes de Ressuscitação Cardiopulmonar e Atendimento Cardiovascular de Emergência do ILCOR e AHA, atualizadas em novembro de 2017

The exact incidence of cardiorespiratory arrest (CRA) even in countries with well-structured clinical records is still unknown, but estimates range from 180,000 to over 450,000 annual deaths. The most common etiology of CRA is ischemic cardiovascular disease, resulting in the development of lethal arrhythmias. Survival of CRA shows divergent outcomes. In the out-of-hospital setting, studies have reported survival rates of 1% to 6%. Three systematic reviews of hospital discharge on extra-hospital CRA showed 5% to 10% survival between those treated by emergency medical services and 15% when the rhythm disorder was ventricular fibrillation (VF). Basic life support consists of cardiopulmonary resuscitation (CPR) and, when available, defibrillation with an automatic external defibrillator (AED). The keys to survival of CRA are early recognition and treatment, specifically, immediate onset of excellent CPR and early defibrillation. This article will discuss the basics of adult life support from prehospital to emergency room, as outlined in the ILCOR and AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, updated in November 2017

Reversão de taquicardiomiopatia de coração nativo em paciente com transplante cardíaco heterotópico / Reversion of native heart tachycardiomyopathy in a patient with heterotopic cardiac transplantation

Relatamos o caso de paciente portadora de anomalia de Ebstein, submetida a transplante cardíaco heterotópico após insucesso na correção cirúrgica. Apesar da melhora clínica inicial, a paciente permanecia dispneica em decorrência de dissincronia sistólica entre os corações gerada por flutter atrial do coração nativo. Após a cardioversão desse flutter, o eletrocardiograma já apresentava espontaneamente o sincronismo sistólico entre ambos os corações. Houve significativa melhora tanto clínica como ecocardiográfica do coração nativo. A redução da frequência cardíaca do coração nativo após reversão do flutter colaborou para a melhora de seu desempenho hemodinâmico, caracterizando ser essa disfunção secundária à taquicardia.

We report the case of a patient with Ebstein Anomaly, submitted to heterotopic cardiac transplantation after a failed surgical correction. Despite the initial clinical improvement, the patient remained dyspneic due to systolic dyssynchronism between the hearts, generated by atrial flutter of the native heart. After flutter cardioversion, the electrocardiogram already presented systolic synchronism between both hearts. There was a significant clinical and echocardiographic improvement of the native heart. The heart rate reduction of the native heart after flutter reversal led to hemodynamic improvements, characterizing it as being secondary to tachycardia

Análise da variação do limiar de captura após a realização de cardioversão elétrica em portadores de dispositivos cardíacos eletrônicos implantáveis / Captured threshold variance analysis after electric cardioversion in patients using cardiaca implantable electronic devices

Introdução: Com o aumento da expectativa de vida da população e a consequente maior incidência de arritmias, que podem necessitar de cardioversão elétrica e crescente desenvolvimento e indicação de dispositivos cardíacos eletrônicos implantáveis, torna-se necessária a reavaliação do comportamento desses dispositivos após a aplicação de terapia elétrica, especialmente naqueles pacientes dependentes de estimulação. Este trabalho teve como objetivo avaliar a variação do limiar de captura ventricular após choque terapêutico para tratamento de taquiarritmias supraventriculares, em condições de prá- tica clínica diária. Método: Entre julho de 2009 e maio de 2015, foram avaliados pacientes portadores de dispositivos cardíacos eletrônicos implantáveis, na cidade de Araras (SP, Brasil), que necessitaram de cardioversão elétrica, sendo determinados os limiares de captura ventricular antes e imediatamente após a terapia. A avaliação teve como objetivo analisar a variação desse parâmetro, que reflete item de segurança do dispositivo. Resultados: Foram incluídos 12 pacientes tratados em 13 episódios de taquiarritmias supraventriculares (fibrilação e taquicardia atriais), com média de idade de 71,6 anos, predominantemente do sexo masculino, com tempo variável de implante do dispositivo, não sendo encontrada variação significativa do limiar de captura ventricular antes e após a cardioversão elétrica. Conclusão: Não há variação significativa do limiar de captura ventricular após cardioversão elétrica em pacientes com taquiarritmias supraventriculares

Background: With the increase in the population's life expectancy, a greater incidence of cardiac arrhythmias is observed. These arrhythmias may require treatment with electric cardioversion. Furthermore, with the increase in the development and indications for cardiac implantable electronic devices, the behavior of these devices after electric therapy must be reevaluated, especially in patients who depended on cardiac stimulation. This study aimed to evaluate the ventricular captured threshold variance after therapeutic countershock for the treatment of supraventricular tachyarrhythmias in daily practice conditions. Method: From July 2009 to May 2015, patients with cardiac implantable electronic devices requiring electric cardioversion were evaluated, in Araras (SP, Brazil). Captured threshold variance before and immediately after therapy was determined. The evaluation aimed at analyzing the variance of this parameter, which reflects a safety feature of the device. Results: 12 patients were included, presenting with 13 episodes of supraventricular tachyarrhythmias (atrial tachycardia and fibrillation). Mean age was 71.6 years, with a prevalence of males and variable device implant times. No significant ventricular captured threshold variation was found before and after electric cardioversion. Conclusion: There is no significant variation of ventricular captured threshold variance after electric cardioversion in patients with supraventricular tachyarrhythmias

Terapia anticoagulante na ablação e cardioversão elétrica da fibrilação atrial / Anticoagulant therapy in ablation and electric cardioversion of atrial ibrillation

tratamento da FA, os pacientes podem ser submetidos a atendimentos eletivos ou de emergência para a reversão do ritmo, incluindo a cardioversão química ou elétrica, bem como o tratamento intervencionista de ablação por cateter, visando a melhora dos sintomas e da qualidade de vida. Em todas as modalidades do tratamento, a terapia anticoagulante oral (ACO) é um dos pilares do tratamento da FA, indispensável para a prevenção de eventos tromboembólicos. A incorporação dos chamados "anticoagulantes de ação direta" (DOAC) no arsenal do tratamento representou um novo paradigma, com estudos randomizados controlados e as evidências de mundo real demonstrando resultados de eficácia e segurança comparáveis com relação à varfarina, com a vantagem de menor interação medicamentosa e alimentar e menor risco de hemorragias catastróficas. O uso de DOAC para o manejo de pacientes que serão submetidos ao procedimento de ablação por cateter para o tratamento intervencionista da FA ou cardioversão elétrica/química é hoje uma realidade cada vez mais presente e tem respaldo dos estudos randomizados controlados e das experiências em vários centros hospitalares mundiais, com esquema e programação mais simples e melhor comodidade no manejo da anticoagulação

Atrial fibrillation (AF) is the most frequent sustained arrhythmia in clinical practice. During the course of AF, patients may be submitted to elective or emergency approaches for rhythm reversal, including pharmacological or electrical cardioversion, as well interventional treatment with catheter ablation, to improve the symptoms and quality of life. In all treatment modalities, it is important to emphasize that oral anticoagulant therapy (OAC) is one of the pillars of AF treatment, and is indispensable for preventing thromboembolic events. The incorporation of so-called "direct oral anticoagulants" (DOACs) into the arsenal of treatment represented a new paradigm, with randomized controlled trials and real-world clinical evidence demonstrating comparable efficacy and safety to warfarin, with the advantage of less drug and food interaction and less risk of catastrophic bleeding. The use of DOACs for the management of patients undergoing catheter ablation for interventional AF treatment or electrical/pharmacological cardioversion is increasingly used and supported by randomized controlled trials and experiences in several worldwide hospital centers, with a simpler regimen and programming and easier management of anticoagulation