MANEJO DO HIPERTENSO COM FIBRILAÇÃO ATRIAL. O QUE MUDOU NA PRÁTICA MÉDICA? / HYPERTENSION AND ATRIAL FIBRILLATION: RECENT ADVANCES

A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais comum na prática clínica. Estima se que 1 a 2% da população mundial seja acometida dessa arritmia e ainda se reconhece que este número está subestimado, dado que até um terço dos pacientes com FA são assintomáticos. Além dos fatores de risco clássicos como diabetes, doença valvar, infarto do miocárdio e insuficiência cardíaca, insuficiência renal crônica, obesidade e apneia obstrutiva do sono, a hipertensão tem um papel muito impactante no surgimento da FA pela sua alta prevalência, com isso sendo o fator de risco mais comum para o desenvolvimento de FA. O manejo adequado da HA é importante para prevenção da FA, controle do ritmo, insuficiência cardíaca e prevenção do acidente vascular cerebral (AVC). O tratamento deve ser integrado por equipe multidisciplinar, individualizando caso a caso, estando sujeito a mudanças ao longo do tempo, com o desenvolvimento de novos fatores de risco, sintomas, progressão da doença e com advento de novos tratamentos. Algumas drogas, tais como os BRAs e iECA parecem apresentar mecanismos específicos de atuação na redução do risco de arritmias. A ablação por cateter pode ser a estratégia mais eficaz para manutenção do ritmo sinusal, em paciente sintomáticos. O objetivo dessa revisão é resumir os dados atuais referente ao manejo do paciente hipertenso com fibrilação atrial.

Worldwide, AF is the most common sustained cardiac arrhythmia in adults. The currently estimated prevalence and incidence in the world are rising, owing to extended longevity and increased survival with chronic diseases. This multifactorial arrhythmia is intertwined with common concomitant cardiovascular diseases, which share classical cardiovascular risk factors, including hypertension, diabetes mellitus, heart failure (HF), coronary artery disease (CAD), chronic kidney disease (CKD), obesity, and obstructive sleep apnoea (OSA). The most common risk factor for AF in the general population is hypertension, and in these patients, left ventricular hypertrophy followed by left atrial enlargement creates the anatomical substrate for AF. Adequate management of hypertension is important for AF prevention, rhythm control, heart failure, and stroke prevention. Integrated management of AF patients requires a coordinated and agreed patient-individualized care pathway to deliver optimized treatment by an interdisciplinary team. The effect of some anti hypertensives, such as RAAS Inhibitors seems to be superior to other antihypertensive treatment to prevent AF recurrences in hypertensive patients with paroxysmal AF beyond the BP reduction. Guidelines suggest a more prominent role for radiofrequency ablation in the treatment of atrial fibrillation (AF), including its use as first-line therapy in recurrent symptomatic paroxysmal or persistent AF in whom a rhythm control strategy is chosen. The objective of this review is to summarize current data on the hypertension in relation to AF, their management, and ongoing research in the field.

Arritmias cardíacas na sala de emergência e UTI. Anticoagulação do paciente com FA aguda submetido a cardioversão: já podemos contar com os novos anticoagulantes orais? / Cardiac arrhythmias in the emergency room and ICU. Anticoagulation of the patient with acute af undergoing cardioversion: can we rely on the new oral antioagulants?

A fibrilação atrial (FA) é a arritmia cardíaca mais comum na população com uma prevalência de 1-2%, além disso, está associada a um risco, aproximadamente cinco vezes maior de acidente vascular cerebral do que na população em geral. A anticoagulação é a melhor maneira de prevenir os eventos tromboembólicos. A varfarina é utilizada há décadas como uma droga segura e eficaz, desde que rigorosamente controlada. Nos últimos anos, foram desenvolvidas novas classes de anticoagulantes orais: inibidores diretos da trombina e inibidores do fator Xa, conhecidos como anticoagulantes orais de ação direta (DOACs). Tanto a cardioversão elétrica quanto a cardioversão farmacológica estão associadas a um maior risco de eventos tromboembólicos durante o primeiro mês após o procedimento (5-7%). No entanto, com a utilização de nticoagulantes essa taxa é inferior a 1%. No presente artigo, faremos uma revisão das principais evidências científicas relacionadas ao uso da dabigatrana, rivaroxabana, apixabana e edoxabana durante a cardioversão e uma abordagem prática com o manejo antitrombótico em diferentes cenários clínicos (cardioversão em pacientes com uso prévio de DOACs, cardioversão em pacientes com FA com duração maior ou menor que 48 horas sem anticoagulação)

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice with a prevalence of 1-2%, and is associated with an almost 5-fold increase in the risk of stroke compared to the general population. Anticoagulation is the best way to prevent thromboembolic events. Warfarin has been used for decades as a safe and effective drug, provided it is strictly controlled. In recent years, new classes of oral anticoagulants have been developed: direct thrombin inhibitors and factor Xa inhibitors, known as direct oral anticoagulants (DOACs). Both electrical and pharmacological cardioversion are associated with an increased risk of thromboembolic events during the first month after the procedure (5-7%). However, with the use of anticoagulants, this rate is less than 1%. In this article, we will review the main scientific evidence related to the use of dabigatran, rivaroxaban, apixaban and edoxaban during cardioversion and a practical approach with antithrombotic management in different clinical scenarios (cardioversion of patients in previous use of DOACs, cardioversion of patients not using oral anticoagulants with episodes of AF longer or shorter than 48 h)

Diabetes and cardiovascular events in high-risk patients: Insights from a multicenter registry in a middle-income country.

AIMS: The aim of this study was to determine the rate of major clinical events and its determinants in patients with previous cardiovascular event or not, and with or without diabetes from a middle-income country. METHODS: REACT study is a multicenter registry conducted between July 2010 and May 2013 in Brazil. Patients were eligible if they were over 45years old and high cardiovascular risk. Patients were followed for 12months; data were collected regarding adherence to evidence-based therapies and occurrence of clinical events (all-cause mortality, non-fatal cardiac arrest, myocardial infarction, or stroke). RESULTS: A total of 5006 subjects was included and analyzed in four groups: No diabetes and no previous cardiovascular event, n=430; diabetes and no previous cardiovascular event, n=1138; no diabetes and previous cardiovascular event, n=1747; and diabetes and previous cardiovascular event, n=1691. Major clinical events in one-year follow-up occurred in 332 patients. A previous cardiovascular event was associated with a higher risk of having another event in the follow-up (HR 2.31 95% CI 1.74-3.05, p<0.001), as did the presence of diabetes (HR 1.28 95% CI 1.10-1.73, p=0.005). In patients with diabetes,failure to reach HbA1c targetswas related topoorer event-free survival compared to patients with good metabolic control (HR 1.70 95% CI 1.01-2.84, p=0.044). CONCLUSIONS: In Brazil, diabetes confers high risk for major clinical events, but this condition is not equivalent to having a previous cardiovascular event. Moreover, not so strict targets for HbA1c in patients with diabetes and previous cardiovascular events might be considered.

Rationale and design of the First Brazilian Cardiovascular Registry of Atrial Fibrillation: The RECALL study.

BACKGROUND: Atrial fibrillation (AF) is an important and growing public health problem worldwide, but data about its actual prevalence, therapeutic management, and clinical outcomes in middle- to low-income countries are scarce. DESIGN: The First Brazilian Cardiovascular Registry of Atrial Fibrillation (the RECALL study) will assess demographic characteristics and evidence-based practice of a representative sample of patients with AF in Brazil. The prospective, multicenter registry has a planned sample size of around 5,000 patients at approximately 80 sites. Eligibility criteria include age >18 years and permanent, paroxysmal, or persistent AF documented by electrocardiogram, 24-hour Holter monitoring, or device interrogation. Patients will be followed up through 1 year after enrollment. Information on laboratory tests, echocardiographic data, medication use, and clinical outcomes will be obtained. Various aspects of the population will be described, including demographic characteristics; antithrombotic therapies; antiarrhythmic agents; level of control of international normalized ratio (by average time within the therapeutic range) among patients using vitamin K antagonists; rates of warfarin discontinuation; outcomes such as death, stroke, systemic embolism, and major bleeding within 1 year after enrollment in the study; and rates of electrical cardioversion, percutaneous ablation of AF, ablation of the atrioventricular junction, and pacemaker/cardioverter-defibrillator implantation. SUMMARY: RECALL is the first prospective, multicenter registry of AF in Brazil. This study will provide important information about demographics, practice patterns, treatments, and associated outcomes in patients with AF. The results of this registry will also allow Brazilian data to be put in perspective with other AF registries across the world and provide opportunities to improve care of patients with AF in Brazil.

Correlation of accessory pathway location with gender and their manifest or concealed presentation.

BACKGROUND: Atrioventricular reentrant tachycardias account for approximately one third of cases referred for electrophysiological study (EPS). The anatomical substrate responsible for the reentry is an accessory pathway (AP) able to conduct the electrical stimulus in an anterograde, retrograde or bidirectional manner. OBJECTIVE: To evaluate the correlation of AP location with the male and female genders and AP clinical presentation, whether manifest or concealed. METHODS: Retrospective observational study including 942 consecutive patients, all diagnosed with EPS-confirmed AP from January 1994 to December 2008. APs were classified into eight anatomical groups: left lateral (LL), left posterior (LP), left posteroseptal (LPS), right posteroseptal (RPS), right midseptal (RMS), right anteroseptal (RAS), right lateral (RL), and right posterior (RP). RESULTS: Of the 942 patients, 52.6% were males. The mean age was 31.2±13.8years. As regards gender, APs were more prevalent among men. However, a statistically significant difference was observed only in the LPS (p=0.029) and RL (p=0.003) regions. In relation to the form of presentation of AP, the manifest form was more frequent than the concealed form in six of the eight regions studied, except for the LL and LPS regions. CONCLUSION: AP predominated in males and the manifest form was more frequent than the concealed form in most of the regions studied.

Correlation of electrocardiographic left ventricular hypertrophy criteria with left ventricular mass by echocardiogram in obese hypertensive patients.

INTRODUCTION: Left ventricular hypertrophy (LVH) and obesity are important cardiovascular risk factors. This study evaluates the influence of obesity on the diagnostic performance of the most used electrocardiographic criteria for LVH in hypertensive patients. METHODS: One thousand two hundred four outpatients from the Hypertensive Unit of the Hospital São Paulo, São Paulo, SP, Brazil, were studied. All underwent 12-lead electrocardiogram and echocardiogram. The most known electrocardiographic criteria for LVH were assessed and compared with the left ventricular mass index obtained by echocardiogram in obese and nonobese groups of hypertensive patients. RESULTS: The population's mean age was 57.4 +/- 4.7 years; 351 were men (29.1%) and 853 women (70.8%). Cornell voltage, Cornell duration, Sokolow-Lyon voltage, Romhilt-Estes criteria, and R wave in aVL 11 mm or higher showed a positive correlation with left ventricular mass index (P < .05). Notwithstanding, there were no changes regarding specificity for obese or nonobese characteristics. However, sensitivity had a statistically significant decrease in obese patients in regard to Sokolow-Lyon voltage and Romhilt-Estes criteria and strain pattern (P < .05). CONCLUSION: Cornell voltage and Cornell duration criteria, Perugia score, R wave in aVL, and QTc variable had no significant changes in diagnostic sensitivity in the obese patients.

Diagnostic value of color flow mapping and Doppler echocardiography in the quantification of mitral regurgitation in patients with mitral valve prolapse or rheumatic heart disease.

OBJECTIVES: The objective was to analyze the diagnostic value of the echocardiographic methods used for quantification of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) or rheumatic heart disease (RHD). METHODS: The study included 50 patients with MR (mean age of 46.1 years; 35 women), 27 (54%) with RHD and 23 (46%) with MVP. Quantification of the mitral valve regurgitation was obtained by regurgitant orifice area (ROA) and regurgitant volume (RV) by the flow convergence region (FCR) and two-dimensional Doppler echocardiographic methods, regurgitant fraction, jet area (JA), jet area/left atrial area ratio (JA/LAA), and vena contracta (VC). Patients were clinically followed to identify cardiovascular events. Data were analyzed by Pearson, kappa, and receiver operator characteristic curve tests; significance was defined as a P value less than .05. RESULTS: The correlation between the two methods for ROA and RV were r = 0.79 and r = 0.80, respectively, and between these parameters and regurgitant fraction, VC, JA, and JA/LAA varied from r = 0.54 to r = 0.94 (P lt; .05); the agreement varied from kappa = 0.19 to kappa = 0.83. The highest accuracy to identify patients with clinically significant MR (events at follow-up) was 96% for ROA by FCR, 94% for VC, 86% for RV by FCR, and 86% for JA. No method showed a significant difference between MVP and RHD. CONCLUSIONS: The methods analyzed had significant correlation and good agreement. ROA by FCR and VC had the best performance to identify severe MR; no significant difference between MVP and RHD was observed.

Fibrilacao atrial em pacientes sem historia de cardiopatia / Atrial fibrillation in patients without heart disease

A fibrilacao atrial pode ocorrer mesmo em pessoaos sem cardiopatia evidente, sendo frequentemente denominada, nesses casos, fibrilacao atrial isolada. Embora seja responsavel por uma porporcao maior dos casos de fibrilacao atrial em jovens, sua incidencia global na populacao se eleva com a idade. Sob o ponto de vista eletrofisiologico, a fibrilacao atrial isolada comumnete esta associada a retardos de conducao intra-atrial. Fibrilacsao atrial paroxistica e frequentemente documentada em individuos com crises de taquicardia paroxistica supraventricular sem doenca cardiaca estrutural. Estreita relacao com o balaco autonomico tem sido relatada em alguns casos. Diversos fatores e condicoes podem predispor a sua instalacao, tais como disturbios hidroeletroliticos, estresse fisico e emocional, infeccoes, hipertireoidismo, uso de alguns medicamentos e o consumo excessivo de bebidas alcoolicas. O risco de fenomenos tromboembolicos parece ser baixo quando a fibrilacao atrial isolada incide em pacientes jovens sob a forma paroxistica, aumentando significativamente em pacientes idosos portadores da forma cronica. A conduta terapeutica nso casos de fibrilacao atrial paroxistica isolada deve piorizar a identificacao e correcao de eventuais fatores desencadeantes. tratamento profilatico geralmente nao se faz necessario quano a arritmia ocorre como um episodio isolado. qaundo a fibrilacao atrial isolada apresenta carater recorrente, o tratamento com drogas antiarritmicas, como a quinidina, parece ser notadamente eficaz para a manutencao do ritmo sinusal.