Multiple Sclerosis and the Cardiovascular System: an overview from cardiovascular risk and clinical characteristics to treatment / Esclerose múltipla e o sistema cardiovascular: uma visão geral do risco cardiovascular e das características clínicas até o tratamento

Objective: Review the relationship between Multiple Sclerosis (MS) and the cardiovascular (CV) system, as well as the CV manifestations of the disease and the CV complications of treatment. Methods: We performed a non-systematic review of the main databases, with no time limit. Results: People with MS tend to have a different CV risk than the general population, with a higher prevalence of hypertension, hyperlipidemia, overweight, ischemic heart disease, and peripheral and cerebral artery disease. In addition, cardiac alterations can be present in any part of MS patient care. Furthermore, MS treatments are not innocuous for the CV system and require attention, especially considering fingolimod and mitoxantrone. Discussion: The findings could partially explain the higher mortality rates found in this population. Furthermore, at the onset, dysautonomia symptoms, like postural orthostatic tachycardia syndrome, can be used as a clinical marker of patients at higher risk to evolve from clinically isolated syndrome to MS. Finally, MS not only progress badly when associated with CV risk factors but are also at increased risk of CV morbidity and mortality. Conclusion: Physicians addressing MS patients should be aware of their increased cardiovascular risk and the impact that adequate control of these factors can have on disease progression, patient lifespan, and global care.

Objetivo: Analisar a relação entre a esclerose múltipla (EM) e o sistema cardiovascular (CV), bem como as manifestações CV da doença e as complicações CV do tratamento. Métodos: Foi realizada uma revisão não sistemática das principais bases de dados, sem limite de tempo. Resultados: Pessoas com EM tendem a ter um risco CV diferente da população em geral, com maior prevalência de hipertensão, hiperlipidemia, sobrepeso, cardiopatia isquêmica e doença arterial periférica e cerebral. Além disso, as alterações cardíacas podem estar presentes em qualquer parte do tratamento do paciente com EM. Além disso, os tratamentos da EM não são inócuos para o sistema CV e requerem atenção, especialmente considerando o fingolimod e a mitoxantrona. Discussão: Os achados podem explicar parcialmente as taxas de mortalidade mais altas encontradas nessa população. Além disso, no início, os sintomas de disautonomia, como a síndrome de taquicardia postural ortostática, podem ser usados como um marcador clínico de pacientes com maior risco de evoluir da síndrome clinicamente isolada para a EM. Por fim, a EM não só progride mal quando associada a fatores de risco CV, mas também apresenta um risco maior de morbidade e mortalidade CV. Conclusão: Os médicos que lidam com pacientes com EM devem estar cientes de seu risco cardiovascular aumentado e do impacto que um controle adequado desses fatores pode ter na progressão da doença, no tempo de vida do paciente e nos cuidados globais.

Impact of the left common ostium following pulmonary vein isolation in AF: Systematic review and meta-analysis.

Purpose: Pulmonary vein isolation (PVI) through catheter ablation is the basis for the treatment of atrial fibrillation (AF). The left common ostium (LCO) is a high prevalence anatomical variation and has conflicting results in the effects on the prognosis following ablation. We undertook a systematic review and meta-analysis of studies that compared the arrhythmia recurrence rate after radiofrequency ablation or cryoablation balloon between patients with normal pattern pulmonary vein and patients with LCO. Methods and Results: Results were pooled using a fixed or random effect, at the discretion of heterogeneity (>25%), in addition, we associated subgroup analysis in these cases and when clinically indicated. Fourteen non-randomized studies totaling 3278 patients were included. In analyses using the two energies all patients: OR 1.01 (95% CI 0.84-1.23; P = .90, I 2 = 67%) and excluding patients with any type of persistent AF (PeAF) and those submitted to linear atrial lesion (LAL) OR 0.80 (95% CI 0.52-1.22; P = .30, I 2 = 71%). Using CRYO: all patients OR 1.34 (95% CI 1.03-1.74; P = .03, I 2 = 0%). Using RF: all patients-OR 0.55 (95% CI 0.32-0.95; P = .03, I 2 = 49%); excluding studies with long duration PeAF and the performance of LAL concomitant-OR 0.45 (95% CI 0.23-0.91; P = .03, I 2 = 44%). Conclusion: The results suggest a better prognosis in patients with LCO, submitted to PVI without additional LAL under RF energy in paroxysmal AF and short-duration PeAF. In patients undergoing CRYO, the presence of LCO suggests a worse prognosis.

Bidirectional Ventricular Tachycardia Due to Digitalis Intoxication

Bidirectional ventricular tachycardia (BDVT) is defined by beat-to-beat alternation of the QRS axis on the electrocardiogram. Its diagnosis is uncommon, and the most characteristic etiology is digitalis intoxication (DI). We report the case of a patient with heart failure of valve origin admitted for sepsis that progressed to BDVT and death, associated with DI.

Kawasaki-Like Disease, a New Phenotype in Sars-CoV-2?

Abstract The coronavirus disease (COVID-19), that assumed pandemic proportions in March 2020, mainly affects the respiratory tract, causing severe interstitial pneumonia in adults. Worldwide data indicate that COVID-19 tends to be more benign in children, which is evidenced by a high incidence of asymptomatic or mild upper airways' infection cases in this population. However, recent studies have been associating Kawasaki-like symptoms as a nonclassical presentation of coronavirus disease in pediatrics. It is suggested that the intense cytokine cascade, promoted by the SARS-CoV-2 infection, can trigger a multisystem inflammatory response as an atypical Kawasaki form in genetically predisposed individuals. In this context, patients may develop more severe clinical features with a greater predisposition to myocardial involvement, Macrophage Activation Syndrome, and Kawasaki Disease Shock Syndrome. Despite critical conditions, patients usually respond to conventional treatment of Kawasaki Disease with intravenous immunoglobulin. This article intends to provide an approach to the association between Kawasaki-Like Syndrome and COVID-19.

When an implantable cardioverter defibrillator can kill your patient!

Abstract Inappropriate therapy due to noise oversensing caused a true ventricular fibrillation (VF) and a life-threatening event in a patient. A 19-year-old patient with surgically corrected congenital heart disease and systolic dysfunction had an implantable cardioverter defibrillator implanted for primary prevention in 2013. This patient was admitted at the Emergency Department in June 2018 after receiving eight shocks from the device on the same day, with a prolonged syncope after the third shock. Another noise-induced VF detection occurred, and two inappropriate shocks followed sequentially, causing true VF. Four appropriate shocks were subsequently needed until sinus rhythm was finally restored.

Update on Management of Postoperative Atrial Fibrillation After Cardiac Surgery.

Postoperative atrial fibrillation (POAF) after cardiac surgery remarkably remains the most prevalent event in perioperative cardiac surgery, having great clinical and economic implications. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of POAF. This update is based on the latest current literature derived from articles and guidelines regarding atrial fibrillation.

Internal Validation of a Risk Score for Prediction of Postoperative Atrial Fibrillation after Cardiac Surgery

Abstract Background: Postoperative atrial fibrillation (POAF) after cardiac surgery has great clinical and economic implications. Many attempts have been made to identify risk factors aiming at a better evaluation of prophylactic treatment strategies. Objective: To perform an internal validation of a risk score for POAF. Methods: A prospective cohort of 1,054 patients who underwent myocardial revascularization and/or valve surgery was included. The risk score model was developed in 448 patients, and its performance was tested in the remaining 606 patients. Variables with a significance level of 5% in the cohort were included and subjected to a multiple logistic regression model with backward selection. Performance statistics was performed using the c-statistic, the chi-square and the Hosmer-Lemeshow (HL) goodness-of-fit, Pearson's correlation coefficient. Results: Four variables were considered predictors of outcome: age (≥ 70 years), mitral valve disease, the non-use or discontinuation of beta-blockers and a positive water balance (> 1,500 mL). The ROC curve was 0.76 (95% confidence interval [CI]: 0.72-0.79). The risk model showed a good ability according to the performance statistics - HL test x(2) = 0.93; p = 0.983 and r = 0.99 (Pearson's coefficient). There was an increase in the frequency of POAF with the increase of the score: very low risk = 0.0%; low risk = 3.9%; intermediate risk = 10.9%; and high risk = 60.0%; p < 0.0001. Conclusion: The predictive variables of POAF allowed us to construct a simplified risk score. This scoring system showed good accuracy and can be used in routine clinical practice.

Update on management of postoperative atrial fibrillation after cardiac surgery

Abstract Postoperative atrial fibrillation (POAF) after cardiac surgery remarkably remains the most prevalent event in perioperative cardiac surgery, having great clinical and economic implications. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of POAF. This update is based on the latest current literature derived from articles and guidelines regarding atrial fibrillation.

Medidas profiláticas para fibrilação atrial no pós-operatório de cirurgia cardíaca / Prevention of atrial fibrillation after cardiac surgery

A fibrilação atrial é a arritmia mais frequentemente encontrada após cirurgia cardíaca. Embora geralmente autolimitada, representa um importante preditor de aumento de morbimortalidade e de custos aos sistemas de saúde. Numerosos estudos tentaram determinar os mecanismos associados à fibrilação atrial no pós-operatório com resultados variados. Uma fisiopatologia multifatorial é sugerida, sendo o processo inflamatório e a ativação simpática adrenérgica do período pós-operatório reconhecidos como importantes fatores de contribuição. O tratamento é dificultado pela escassez de dados relativos aos resultados de diferentes intervenções terapêuticas nessa população. Este artigo analisa a literatura cujo foco sejam as intervenções para prevenir a fibrilação atrial no pós-operatório

Atrial fibrillation is the most commonly found arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation with different results. A multifactorial pathophysiology is suggested, with inflammation and postoperative adrenergic activation recognized as important contributing factors. The management is complicated by a lack of data on the outcomes of different therapeutic interventions in this population. This article reviews the literature focusing on interventions to prevent postoperative atrial fibrillation

Fibrilação atrial durante taquicardia por reentrada nodal atrioventricular: achado sugestivo da presença de via superiorcomum nodal / Atrial fibrillation during atrioventricular nodal reentry tachycardia: a suggestive finding favoring the presence of the upper common nodal pathway

Na taquicardia por reentrada nodal atrioventricular, a necessidade do átrio para a manutenção da taquicardia é controverso. Descrevemos um caso de fibrilação atrial ocorrendo durante taquicardia por reentrada nodal atrioventricular sem afetar o ciclo da arritmia, e discutimos as evidências favorecendo a presença de umavia comum superior.

In Atrioventricular Nodal Reentry Tachycardia the requirement of the atrium for the maintenance oftachycardia is controversial. We describe a case of atrial fibrillation that occurred during Atrioventricular Nodal Reentry Tachycardia without affecting the arrhythmia cycle, and discuss the evidences favoring the presence ofan upper common pathway.

Síndrome de Andersen-Tawil / Andersen-Tawil Syndrome

A síndrome de Andersen-Tawil é uma condição rara composta por arritmias ventriculares, paralisia periódica e dimorfismo. É uma doença de canal iônico cardíaco, possui herança de forma autossômica dominante e é classificada como tipo 7 da síndrome do QT longo congênito. A síndrome de Andersen-Tawil é a única canalopatia que une a excitabilidade dos músculos cardíaco e esquelético. Os pacientes podem ser assintomáticos ou minimamente sintomáticos, apesar da elevada carga de arritmia com ectopia ventricular frequente e taquicardia ventricular bidirecional. No entanto, continuam a ser pacientes com risco de arritmias potencialmente fatais, incluindo torsades de pointes e fibrilação ventricular, embora com menor frequência que as observadas em outras síndromes de arritmia genética. Nesta revisão a doença foi abordada sob o ponto de vista dos diagnósticos clínico e molecular, com ênfase nas manifestações cardíacas...

Andersen-Tawil syndrome is a rare condition consisting of ventricular arrhythmias, periodic paralysis, and dysmorphic features. It is a cardiac ion channel disease, with autosomal dominant inheritance and is classifiedas type 7 of the congenital long QT syndromes. Andersen-Tawil syndrome is a unique channelopathy which linkscardiac and skeletal muscle excitability. Patients may be asymptomatic, or minimally symptomatic despite a higharrhythmia burden with frequent ventricular ectopy and bidirectional ventricular tachycardia. However, patients remain at risk for life-threatening arrhythmias, including torsades de pointes and ventricular fibrillation, although less frequently than observed in other genetic arrhythmia syndromes. In this review we address the disease from the point of view of clinical and molecular diagnosis with emphasis on cardiac manifestations...

Prevalência de obesidade e seus fatores associados na população de Tubarão-SC / Obesity prevalency and its factors associates in Tubarãoãs population -SC

Objetivo: Determinar a prevalência de obesidade e os fatores a ela associados na população urbana adulta do município de Tubarão-SC. Metodologia: Estudo de delineamento transversal com 707 adultos maiores de 18 anos da região urbana, amostragem aleatória. Os dados foram obtidos no domicílio, através de questionário e medidas antropométricas. Resultados: A prevalência de obesidade (IMC maior ou igual a 30 Kg/m2) foi de 18,5%. As variáveis que se mantiveram associadas significativamente com obesidade foram: sexo feminino (p=0,01), mulheres com menor nível de instrução (p<0,01), estabilidade conjugal (p<0,01), grupo do sexo feminino com três ou mais gestações (p<0,01), não fumantes (p<0,01), história familiar para obesidade (p<0,01). A obesidade foi mais freqüente na faixa etária de 50 a 59 anos no sexo masculino e na faixa etária de 60 a 69 anos no sexo feminino (p<0,01). Foi demonstrada uma correlação positiva entre IMC e circunferência abdominal (r

Relato de caso - metástase de melanoma maligno para a vesícula biliar simulando colecistite aguda / Case report - metastasis of malignant melanoma for the gallbladder simulating ccute cholecystitis

O melanoma maligno é conhecido por sua propensão em metastatizar para quase todo o organismo. Dados de autopsia revelam que metástases para o trato gastrointestinal ocorrem em aproximadamente 50% dos casos. O envolvimento da vesícula biliar é infreqüente, apresentando taxas de prevalência entre 4% e 20% dos acometimentos gastrointestinais, sendo este causa rara de relevantes sintomas ou complicações durante a vida. O caso relatado é de um homem de 72 anos com clínica sugestiva de colecistite aguda e com exame ultra-sonográfico abdominal indicativo de neoplasia vesicularou empiema vesicular. Na história mórbida pessoal o paciente tinha realizado, há três anos, a exérese de melanoma maligno cutâneo, este apresentava limites cirúrgicos livres de tumor, no entanto, estadiamento de Breslow 7 mm, Clark nível V, TNM pT4. O paciente foi submetido a uma laparotomia e colescitectomia e o exame anatomopatológico confirmou a presença de lesão metastática compatível de melanoma maligno cutâneo...