Inês Rangel

Iron deficiency status irrespective of anemia: a predictor of unfavorable outcome in chronic heart failure patients.

Objective: To assess the prognostic significance of iron deficiency (ID) in a chronic heart failure (CHF) outpatient population. Methods and Results: We prospectively evaluated 127 patients with stable CHF and left ventricular ejection fraction ≤45%. Clinical and analytical data as well as information regarding the occurrence of the composite endpoint of overall mortality and nonfatal cardiovascular events were assessed. Among the 127 patients enrolled [81% men, median age: 62 years (25th-75th percentile: 53-68)], 46 (36%) patients had ID. Women, patients with higher plasma brain natriuretic peptide levels (>400 pg/ml) and with right ventricular systolic dysfunction presented ID more frequently (p < 0.05 for all). At 225 ± 139 days of follow-up, the composite endpoint occurred in 15 (12%) patients. It was more frequent in ID (24 vs. 5%, p = 0.001) and anemic patients (25 vs. 8%, p = 0.014). In a Cox regression analysis, ID was associated with a higher likelihood of composite endpoint occurrence (HR 5.00, 95% CI 1.59-15.78, p = 0.006). In a multivariable analysis adjusted for clinical variables, including the presence of anemia, ID remained a significant predictor of the composite endpoint (HR 5.38, 95% CI 1.54-18.87, p = 0.009). Conclusion: In a CHF outpatient population, ID carried a higher risk of unfavorable outcome, irrespectively of the presence of anemia.

The usefulness of the head-up tilt test in patients with suspected epilepsy.

PURPOSE It is estimated that approximately 20-30% of patients diagnosed with epilepsy have been misdiagnosed, and neurocardiogenic syncope (NCS) might frequently be the real cause of transient loss of consciousness (TLOC) episodes. We assessed the role of the head-up tilt test (HUTT) in patients previously diagnosed with refractory epilepsy to evaluate the ability of this test to correctly diagnose patients with NCS. METHOD We retrospectively analysed the clinical records of 107 consecutive patients with a previous diagnosis of refractory epilepsy that were taking antiepileptic drugs and who were referred for HUTT between January 2000 and December 2010. During the subsequent follow-up, we recorded the treatments performed and the recurrence of symptoms. RESULTS Complete follow-up data were available for 94 (88%) patients, and the mean follow-up period was 80±36 months. The HUTT was positive in 54% of patients. Thirty-one (33%) patients were misdiagnosed with epilepsy, and 20 (21%) patients had a dual diagnosis of NCS and epilepsy. The recurrence of TLOC was reported in 55% of the patients, but it was significantly lower in the misdiagnosed group (42% versus 64%; P=0.039). CONCLUSION NCS is an important cause of epilepsy misdiagnosis. The HUTT is often critical for making an accurate diagnosis and subsequently selecting the appropriate treatment for patients presenting with TLOC. The diagnostic overlap between epilepsy and NCS is not uncommon, suggesting that electroencephalographic monitoring during a HUTT may play an important role in diagnosing patients with recurrent, undiagnosed TLOC episodes.

Embolic complication of left ventricular non-compaction as an unusual cause of acute myocardial infarction

One of the greatest challenges in medicine consists of arriving at a correct diagnosis despite different presentations of the disease. We present a case in which, notwithstanding the initial diagnosis, the search for the etiology was essential for clinical guidance. Left ventricular non-compaction (LVNC) was first described by Chin et al. in 1990. This relatively new entity is characterized by excessive thickening of the myocardial wall, formed of a thin epicardial layer and a substantially thicker non-compacted endocardial layer. The clinical presentation is highly variable but it must always be borne in mind that heart failure, atrial and ventricular arrhythmias and embolic events are common complications of LVNC.

Toxic dilated cardiomyopathy: recognizing a potentially reversible disease.

The use of illicit drugs has increased in recent years1. Related to this increase, there is a growing need to recognise and properly treat the adverse effects associated with the consumption of these drugs. These substances can induce several cardiovascular (CV) complications, being this acute or chronic1. Some of them are the ischemic and arrhythmic events, the development of dilated cardiomyopathy (DCM) and the left ventricular systolic dysfunction (LVSD). There are several types of drugs with different pharmacological and pathophysiological properties, and synergism is described between them1. Among these, cocaine and heroin stand out. The key to a successful intervention towards one of these adverse effects is the high index of suspicion and early intervention.

Post-cardiac injury syndrome following transvenous pacing: Case report

Post-cardiac injury syndrome (PCIS) is an inflammatory process involving the pericardium secondary to cardiac injury. It can develop after cardiac trauma, cardiac surgery, myocardial infarction, and, rarely, after certain intravascular procedures. We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed inflammatory pericardial effusion after pacemaker implantation. A comprehensive literature review on this topic is provided.

Hipocalcemia como uma causa reversível de insuficiência cardíaca

Calcium plays a key role in heart muscle contraction and relaxation. Hypocalcemic heart failure is a rare and potentially reversible disturbance, which reflects this intrinsic relationship. The authors present the case of a 35-year-old woman who developed acute heart failure during the early postoperative period following total thyroidectomy. The echocardiogram showed severe global left ventricular dysfunction. Laboratory tests showed severe hypocalcemia and new-onset hypoparathyroidism. Cardiac catheterization showed angiographically normal coronary arteries. After clinical, hemodynamic and metabolic stabilization, a repeat echocardiogram revealed recovery of left ventricular function. Subsequently, cardiac magnetic resonance imaging was performed, which also showed no alterations. The patient was discharged asymptomatic, medicated with calcium carbonate, calcitriol and levothyroxine. This case highlights the importance of considering hypocalcemia as a cause of reversible myocardial dysfunction.

Inotrópicos na abordagem da insuficiência cardíaca aguda e sua repercussão renal – serão todos iguais?

Heart failure (HF) is a clinical syndrome with a significant public health burden worldwide due to its high prevalence, morbidity and mortality. Its prevalence is predicted to increase by 25% by 2030. In developed countries, acute HF is the leading cause of hospitalization in individuals aged over 65 years, and is a life-threatening condition that requires urgent assessment and treatment. In Portugal, HF is responsible for the highest in-hospital mortality of all cerebrovascular and cardiovascular diseases. Since it is a systemic disease, HF can cause dysfunction in various organs, particularly the kidneys. The term cardiorenal syndrome (CRS) was coined to describe a range of clinical situations involving concomitant worsening of renal and cardiac function. Studies have established the prognostic implications of this syndrome, which is associated with longer hospital stay, higher in-hospital and post-discharge mortality, and higher rehospitalization rates. The conventional explanation for the worsening of renal function in HF --

The lost needle of a seamstress

A 61-year-old seamstress with hypertension, dyslipidemia and diabetes was referred to our hospital for chest pain and a positive exercise test. The ECG and transthoracic echocardiogram were normal. Coronary angiography revealed 60% stenosis in the proximal right coronary artery and 70% stenosis in the posterolateral branch (Figure 1A). A sewing needle was detected in the left hemithorax (Figure 1B and C). Further investigation by thoracic computed tomography (CT) confirmed the location of the needle in the apical segment of the left inferior lobe (Figure 1D and E). When questioned, she mentioned an

A agulha perdida de uma costureira

A 61-year-old seamstress with hypertension, dyslipidemia and diabetes was referred to our hospital for chest pain and a positive exercise test. The ECG and transthoracic echocardiogram were normal. Coronary angiography revealed 60% stenosis in the proximal right coronary artery and 70% stenosis in the posterolateral branch (Figure 1A). A sewing needle was detected in the left hemithorax (Figure 1B and C). Further investigation by thoracic computed tomography (CT) confirmed the location of the needle in the apical segment of the left inferior lobe (Figure 1D and E). When questioned, she mentioned an

Acute coronary syndrome in a patient with multifocal coronary vasospasm

Vasospastic angina results from temporary spasm of one or more coronary segments. Although prognosis of patients presenting with coronary vasospasm appears to be generally good, multivessel coronary vasospasm may increase the risk of life-threatening cardiac events. We present a case of a 51-year-old man admitted to the emergency room due to severe retrosternal pain, who was documented with multifocal coronary vasospasm. <Learning objective: The case described illustrates the importance of recognizing coronary vasospasm as a cause of reversible ischemia. Although vasospastic angina is associated with a favorable prognosis, multivessel involvement may increase the risk of life-threatening cardiac events.>.