Lluís Recasens

Hyperkalemia Mimicking a Pattern of Brugada Syndrome

A 70-year-old patient with a history of hypertension and dyslipidemia was receiving treatment with enalapril, simvastatin, and hydrochlorothiazide. He was referred to our hospital for presyncope and suspected acute myocardial infarction in an anterior location. The first electrocardiogram (Fig. 1A) showed a saddlebag-type ST segment elevation in V1 to V3. Echocardiography excluded a segmental wall motion abnormality. Despite the patient’s advanced age and the absence of previous episodes of syncope or a family history of sudden death, the presumptive diagnosis was Brugada syndrome. The initial analyses showed creatinine 4.88 mg/dL, Na 127 mEq/L, K 7.53 mEq/L, pH 7.22, and troponin T <0.01 ng/mL. The patient was treated for hyperpotassemia and was hospitalized to investigate renal failure. Once the potassium concentration had normalized, a new electrocardiographic study was carried out (Fig. 1B), in which the Brugada pattern had disappeared. Nonetheless, a flecainide test was performed, with negative results. Various situations have been described in which an electrocardiographic pattern of Brugada syndrome is manifested, such as drug-related conditions, heart diseases, acute myocardial infarction with ST segment elevation, muscular dystrophy, and hypothermia. Although hyperpotassemia can display diverse manifestations on electrocardiography, a presentation mimicking a Brugada pattern is very unusual. Figure 1.

Iron Deficiency Is a Determinant of Functional Capacity and Health-related Quality of Life 30 Days After an Acute Coronary Syndrome.

BACKGROUND AND OBJECTIVES Iron deficiency (ID) is a prevalent condition in patients with ischemic heart disease and heart failure. Little is known about the impact of ID on exercise capacity and quality of life (QoL) in the recovery phase after an acute coronary syndrome (ACS). METHODS Iron status and its impact on exercise capacity and QoL were prospectively evaluated in 244 patients 30 days after the ACS. QoL was assessed by the standard EuroQoL-5 dimensions, EuroQoL visual analogue scale, and Heart-QoL questionnaires. Exercise capacity was analyzed by treadmill/6-minute walk tests. The effect of ID on cardiovascular mortality and readmission rate was also investigated. RESULTS A total of 46% of the patients had ID. These patients had lower exercise times (366±162 vs 462±155seconds; P<.001), metabolic consumption rates (7.9±2.9 vs 9.3±2.6 METS; P=.003), and EuroQoL-5 dimensions (0.76±0.25 vs 0.84±0.16), visual analogue scale (66±16 vs 72±17), and Heart-QoL (1.9±0.6 vs 2.2±0.6) scores (P<.05). ID independently predicted lower exercise times (OR, 2.9; 95%CI, 1.1-7.6; P=.023) and worse QoL (OR, 1.9; 95%CI, 1.1-3.3; P<.001) but had no effect on cardiovascular morbidity or mortality. CONCLUSIONS ID, a prevalent condition in ACS patients, results in a poorer mid-term functional recovery, as measured by exercise capacity and QoL.

QT Interval in Newborns of Different Ethnic Origin: Usefulness of Neonatal ECG Screening

The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 at-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79+/-28.47 ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.

Long-term outcome of transitory "reversible" complete atrio-ventricular block unrelated to myocardial ischemia.

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Brugada Phenocopy Emerging as a New Concept. Response

The authors appreciate the interest in the case report we published in Revista Española de Cardiologı́a concerning the observation of the Brugada electrocardiographic (ECG) pattern in a patient with hyperkalemia. We likewise welcome the introduction of the concept of phenocopy, an expression with which our finding is compatible.We also consider it opportune to stress that both the latest consensus on ECG diagnosis of Brugada syndrome and the introduction of the term phenocopy are more recent than the online publication of our case report in 2011. The definitions of the ECG patterns that are typical of Brugada syndrome and those that mimic this syndrome in the presence of serum electrolyte disturbances were introduced subsequent to our publication. It is important to highlight reasons for attributing the changes observed in the ECG to hyperkalemia rather than to the acidosis and hyponatremia also observed in our patient. Reports of Brugada phenocopy associated with hyponatremia and acidosis have described the development of pseudo J waves in the QRS complex and ST segment depression in leads other than right precordial leads. These are precisely the features that differentiate this ECG pattern from type 1 Brugada pattern. Other possible causes (hyperglycemia, drugs, fever, and myocardial ischemia) were ruled out in the case discussed in our report. We appreciate any contribution that aids in the understanding of the mechanisms involved in the induction of ECG patterns mimicking Brugada syndrome (phenocopies) and other patterns, such as early repolarization, which can also be associated with the risk of sudden cardiac death. Finally, we agree with Dr. Anselm on the importance of performing a challenge test with flecainide to rule out Brugada syndrome. Until the prognosis of patients presenting with Brugada phenocopy has been established, it is advisable to perform pharmacological challenge tests and, if appropriate, to induce ventricular arrhythmias by means of an electrophysiological study.

Reduction in door-to-needle time to meet clinical guideline recommendations. Outcomes after 1 year.

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P< .01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.