Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients.

BACKGROUND: The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. OBJECTIVE: To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. METHODS: Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. RESULTS: There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). CONCLUSION: In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients / Uso Ininterrupto de Anticoagulantes Orais na Ablação de Flutter Atrial Istmo-Cavotricuspídeo Dependente: Coorte Unicêntrica de 154 Pacientes

Abstract Background: The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. Objective: To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. Methods: Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. Results: There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). Conclusion: In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Resumo Fundamento: O uso ininterrupto de anticoagulação oral (ACO) com antagonistas da vitamina K (AVKs) para procedimentos de eletrofisiologia está sendo cada vez mais recomendado. A prática clínica em nosso serviço é de uso continuado dessas drogas para ablação de flutter atrial. Existem poucas evidências quanto ao uso ininterrupto dos anticoagulantes orais não antagonistas da vitamina K (NOACs) nesse cenário. Objetivos: Comparar as taxas de complicações relacionadas ao uso ininterrupto de diferentes tipos de anticoagulantes orais em pacientes referidos para ablação por flutter atrial (FLA). Métodos: Coorte histórica e unicêntrica dos procedimentos de ablação por FLA realizados no período de novembro de 2012 a abril de 2016. O desfecho primário foi o de ocorrência de complicação hemorrágica ou embólica durante o procedimento. O desfecho secundário foi o de ocorrência de acidente vascular cerebral (AVC) ou acidente isquêmico transitório (AIT) no acompanhamento. O nível de significância estatística adotado foi de 5%. Resultados: Foram incluídas 288 ablações por FLA; 154 foram feitas com uso ininterrupto de ACO (57,8% com AVK e 42,2% com NOAC). A idade média foi de 57 ± 13 anos. A taxa de complicação hemorrágica durante o procedimento foi de 3% em cada grupo (p = NS). A taxa de AVC/AIT foi, respectivamente, de 56/1.000-pessoas-ano no grupo AVK contra zero/1.000-pessoas-ano no grupo NOAC (p = 0,02). Conclusão: Em nossa população não ocorreram complicações hemorrágicas relacionadas ao procedimento com uso de ACO de forma ininterrupta, incluindo NOACs. Houve maior ocorrência de AVC/AIT no seguimento no grupo de pacientes em uso de AVK, contudo essa diferença pode não ser decorrente apenas do tipo de ACO em uso.

Cardiotoxicidade induzida por quimioterapia / Chemotherapy-induced cardiotoxicity

Introdução: A cardiotoxicidade resulta de efeitos diretos do tratamento do câncer na estrutura e função cardíaca, bem como na aceleração do desenvolvimento de doenças cardiovasculares em pacientes com fatores predisponentes. Isso tem levado a uma preocupação crescente no que concerne à morbidade prematura e óbito de pacientes sobreviventes ao câncer, uma vez que esse impacto negativo no prognóstico ocorre também em pacientes assintomáticos. Trata-se de um estudo de revisão da literatura com objetivo de explorar brevemente o tema sobre cardiotoxicidade. Métodos: Dados foram obtidos a partir de artigos e diretrizes atuais. Resultados: A sobrevida do câncer tem aumentado significativamente nas últimas décadas devido ao desenvolvimento de um maior número de agentes quimioterápicos. Entretanto, a área da Cardio-Oncologia carece ainda de protocolos bem estabelecidos que definam o manejo ideal no que tange à cardiotoxicidade induzida por terapia do câncer. Conclusões: A cardiotoxicidade permanece uma preocupação com impacto no prognóstico deste universo crescente de pacientes.

Introduction: Cardiotoxicity results from direct effects on cardiac structure and function in patients undergoing cancer treatment, as well as on accelerating the development of cardiovascular disease in patients with predisposing factors. This subject has led to a growing concern regarding the early morbidity and death of cancer survivors since there is negative impact on prognosis even in asymptomatic patients. This is a review of the literature which explores briefly the subject of cardiotoxicity. Methods: Our data were taken from current articles and guidelines. Results: Cancer survival has increased over time due to the development of a greater number of chemotherapeutic agents. However, Cardio-Oncology field still lacks of well-defined protocols to define the best management for cardiotoxicity. Conclusions: Cardiotoxicity remains a concern with an impact on the prognosis of this growing universe of patients.

Late Outcome and Predictors of Adverse Events Related to the Implantation of a Permanent Pacemaker in Patients with Isolated Congenital Atrioventricular Block.

Isolated congenital atrioventricular block (ICAVB) is a rare, and pacemaker implantation is the only effective treatment. We sought to identify the predictive factors of adverse events related to pacemaker implantation in ICAVB. This is a cohort study of patients diagnosed with ICAVB who underwent pacemaker implantation from 1980 to 2014 in a single center. During the studied period, a total of 647 patients underwent implantation of their first permanent cardiac pacemaker before 30 years of age. Of these, only 62 (9.5 %) were diagnosed with ICAVB. This condition was diagnosed in utero in 15 (24.2 %) cases, 5 (8.1 %) in the neonatal period, 32 (51.6 %) during childhood, and 10 (16.1 %) during adolescence and young adulthood. The presence of autoantibodies (anti-Ro/SSA) was observed in 41 % of mothers who underwent serological evaluation. Age at the time of the initial pacemaker implant was 9.8 ± 9 years. During a mean follow-up time of 15 years, 1 (1.7 %) death occurred due to infectious endocarditis. Complications related to pacemaker implant were reported in 24 patients (38.7 %). The number of complications was significantly higher in the group with an epimyocardial implantation site (HR 6; CI 2.45-14.95). Ventricular dysfunction occurred in 6 (11.7 %) patients; however, we were not able to identify any predictors of it. Our results showed a low mortality rate after permanent therapy. However, these patients exhibited high morbidity related to the pacemaker system, and the epimyocardial implant site was an independent predictor of complications. Predictors of left ventricular dysfunction were not found in the present study.

Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients / Diferenças Clínicas entre Subtipos de Fibrilação Atrial e Flutter: Registro Transversal de 407 Pacientes

Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce.

Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients.

INTRODUCTION: Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce. OBJECTIVE: To investigate the arrhythmia subtype of atrial fibrillation and flutter patients in the emergency setting and compare the clinical profile, thromboembolic risk and anticoagulants use. METHODS: Cross-sectional retrospective study, with data collection from medical records of every patient treated for atrial fibrillation and flutter in the emergency department of Instituto de Cardiologia do Rio Grande do Sul during the first trimester of 2012. RESULTS: We included 407 patients (356 had atrial fibrillation and 51 had flutter). Patients with paroxysmal atrial fibrillation were in average 5 years younger than those with persistent atrial fibrillation. Compared to paroxysmal atrial fibrillation patients, those with persistent atrial fibrillation and flutter had larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p < 0.01). The prevalence of stroke and heart failure was higher in persistent atrial fibrillation and flutter patients. Those with paroxysmal atrial fibrillation and flutter had higher prevalence of CHADS2 score of zero when compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p < 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2 was 40%. CONCLUSIONS: The population in our registry was similar in its comorbidities and demographic profile to those of North American and European registries. Despite the high thromboembolic risk, the use of anticoagulants was low, revealing difficulties for incorporating guideline recommendations. Public health strategies should be adopted in order to improve these rates.