Luís Elvas

Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score

BackgroundFast and accurate chest pain risk stratification in the emergency department (ED) is critical. The HEART score predicts the short-term incidence of major adverse cardiac events (MACE) in this population, dividing it in three risk categories. We aimed to describe the population with chest pain, to characterize the subgroup of patients with acute coronary syndrome (ACS) and to assess the prognostic value of Manchester triage system and of HEART score.MethodsRetrospective observational study including patients admitted to the ED of a tertiary hospital with chest pain as the presenting symptom. The primary outcome was a composite of all-cause mortality, myocardial infarction or unscheduled revascularization at 6xa0weeks.ResultsWe enrolled 233 patients (age 58u2009±u200919; 55.4xa0% males). The most common final diagnosis was non-specific chest pain (nu2009=u200986, 36.9xa0%), followed by ACS (nu2009=u200922, 9.4xa0%). Male gender, smoking and chronic kidney disease were associated with higher risk of ACS. According to Manchester triage system, chest pain patients stratified with red or orange priority had a higher incidence of ACS (16.5xa0% vs. 3.8xa0%, pu2009=u20090.006). The application of HEART score showed that most patients were in low risk category (56.3xa0%). The six-week incidence of MACE in each category was 2xa0%, 15.6xa0% and 76.9xa0% (pu2009<u20090.001). HEART score accurately predicted the short-term incidence of MACE in chest pain patients (c-statistic 0.880; 95xa0% CI, 0.807–0.950, pu2009<u20090.001).ConclusionsChest pain patients have very different levels of severity and the discriminatory power of Manchester triage system should be used in the assessment of this population. The HEART score seems to be an effective tool for risk stratification in the ED.

Criteria to predict carriers of a novel SCN5A mutation in a large Portuguese family affected by the Brugada syndrome

AIMSnBrugada syndrome (BrS) is a life-threatening arrhythmia disorder associated with autosomal-dominant mutations in the SCN5A gene. We aimed to characterize the diagnostic challenges and clinical manifestations of a novel SCN5A mutation associated with BrS.nnnMETHODS AND RESULTSnFrom a novel SCN5A mutation (c.664C>T; p.Arg222X) identified in a proband with the characteristic electrocardiographic pattern and the history of sudden collapse, 122 family members were studied including 40 carriers of the mutation. The electrocardiographic diagnosis of BrS requires type 1 Brugada electrocardiogram (ECG) pattern in >1 right precordial lead (V1-V3), but recently an isolated lead with coved-type ECG was proposed to be enough for the diagnosis. In this family, these proposed criteria (PC) were more sensitive in detecting mutation carriers than the conventional criteria without repercussion on the specificity. Carriers had, on average, longer P-wave duration, PR, and QRS intervals and higher transmural dispersion of repolarization. The prevalence of late potentials was higher in carriers, and individual signal average ECG (SAECG) parameters (QRSf, LAS, and RMS40) also were related to SCN5A gene mutation. Three non-carriers were found to be affected by BrS, two with a spontaneous type 1 ECG with alternative placement of the precordial electrodes, and one only after the pharmacological provocative test, suggesting that other genes may play a role in the pathophysiology of this disease.nnnCONCLUSIONnThe PC for BrS diagnosis should be implemented. Some parameters from the spontaneous ECG and the SAECG are more effective tools than the characteristic repolarization pattern to discriminate between carriers of SCN5A mutations.

Ablação de taquicardia auricular em cardiopatia congénita operada

The authors describe the case of a 57-year-old woman with surgically treated superior vena cava sinus-venosus atrial septal defect who underwent an electrophysiology study with the CARTO ® 3 mapping system (Biosense Webster, J&J) due to recurrent episodes of tachycardia. The patient was found to be in narrow QRS-complex tachycardia, with a cycle length of 310 ms and concentric activation sequence in the coronary sinus (Figure 1A and 1B), suggesting atrial tachycardia (AT) originating from the right atrium (RA). High-density electroanatomical mapping of the RA was performed using the PentaRay catheter (Figure 2C). The AT activation map (Figure 2B) indicated microreentry and centrifugal activation mainly on the lateral RA wall (Figure 2B), coinciding with the border zone of the scar (Figure 2C) and reveals ≥75% of the tachycardia cycle on the PentaRay catheter (Figure 2A). Radio frequency was applied with the SmartTouch ablation catheter in the initial activation region, resulting in conversion to sinus rhythm (SR).

Unsafe Drug Use and Arrhythmic Events in Brugada Patients with ICD: Results of a Long-Term Follow-Up

PurposeBrugada syndrome is a hereditary disease linked with an increased risk of sudden death that may require an implantable cardioverter-defibrillator (ICD) in order to halt the arrhythmic events. The aim of this study was to identify possible triggers for appropriate ICD therapies in patients with Brugada syndrome, focusing on their past and current therapeutic profiles.MethodsThirty patients with high-risk Brugada syndrome, with ICD implanted at the Coimbra Hospital and University Center, were enrolled. Patients were questioned about their Brugada syndrome history, previous cardiac events, comorbidities, present and past medications, and physical activity. Patients were followed up during 5.8u2009±u20095.3xa0years. The ICD was interrogated, and arrhythmic events and device therapies were recorded. The cohort who received appropriate ICD therapies was compared with the remaining patients to determine the potential link between clinical variables and potentially fatal arrhythmic events.ResultsMore than half of the patients (53.3%) took at least one non-recommended drug, and 16.7% received appropriate ICD therapies, with a long-term rate of 4.0%/year. There was a tendency for more appropriate ICD therapies in patients who took unsafe drugs (85.7 versus 45.5%, pu2009=u20090.062), and the mean time between unsafe drug intake and appropriate ICD therapies was 3.8u2009±u20097.5xa0days.ConclusionsThis study revealed that the medical community is still unaware of the pharmacological restrictions imposed by Brugada syndrome. Patients who took non-recommended drugs seem to have a higher risk of ventricular arrhythmic events.

Who still remains at risk of arrhythmic death at time of implantable cardioverter-defibrillator generator replacement?: MADEIRA et al.

Implantable cardioverter‐defibrillator (ICD) is associated with reduction in arrhythmic mortality. However, at the time of generator replacement (GR) some patients had not experienced therapies and had a different clinical profile. Therefore, the risk‐benefit ratio of ICD may have changed. Our aim was to determine the proportion of patients with ICD implanted in primary prevention that maintain guideline‐derived indications at the time of GR and assess predictors of therapies in the postreplacement period. We evaluate the long‐term benefit of ICD after GR in nonischemic cardiomyopathy (NICM) versus ischemic cardiomyopathy (ICM).