Marta Madeira

Estimating glomerular filtration rate in acute coronary syndromes: Different equations, different mortality risk prediction

Aims: Renal dysfunction is a powerful predictor of adverse outcomes in patients hospitalized for acute coronary syndrome. Three new glomerular filtration rate (GFR) estimating equations recently emerged, based on serum creatinine (CKD-EPIcreat), serum cystatin C (CKD-EPIcyst) or a combination of both (CKD-EPIcreat/cyst), and they are currently recommended to confirm the presence of renal dysfunction. Our aim was to analyse the predictive value of these new estimated GFR (eGFR) equations regarding mid-term mortality in patients with acute coronary syndrome, and compare them with the traditional Modification of Diet in Renal Disease (MDRD-4) formula. Methods and results: 801 patients admitted for acute coronary syndrome (age 67.3±13.3 years, 68.5% male) and followed for 23.6±9.8 months were included. For each equation, patient risk stratification was performed based on eGFR values: high-risk group (eGFR<60ml/min per 1.73m2) and low-risk group (eGFR⩾60ml/min per 1.73m2). The predictive performances of these equations were compared using area under each receiver operating characteristic curves (AUCs). Overall risk stratification improvement was assessed by the net reclassification improvement index. The incidence of the primary endpoint was 18.1%. The CKD-EPIcyst equation had the highest overall discriminate performance regarding mid-term mortality (AUC 0.782±0.20) and outperformed all other equations (ρ<0.001 in all comparisons). When compared with the MDRD-4 formula, the CKD-EPIcyst equation accurately reclassified a significant percentage of patients into more appropriate risk categories (net reclassification improvement index of 11.9% (p=0.003)). The CKD-EPIcyst equation added prognostic power to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of mid-term mortality. Conclusion: The CKD-EPIcyst equation provides a novel and improved method for assessing the mid-term mortality risk in patients admitted for acute coronary syndrome, outperforming the most widely used formula (MDRD-4), and improving the predictive value of the GRACE score. These results reinforce the added value of cystatin C as a risk marker in these patients.

Two‐dimensional speckle tracking cardiac mechanics and constrictive pericarditis: systematic review

Transthoracic echocardiography has a pivotal role in the diagnosis of constrictive pericarditis (CP). In addition to the classic M‐mode, two‐dimensional and Doppler indices, newer methodologies designed to evaluate myocardial mechanics, such as two‐dimensional speckle tracking echocardiography (2DSTE), provide additional diagnostic and clinical information in the context of CP. Research has demonstrated that cardiac mechanics can improve echocardiographic diagnostic accuracy of CP and aid in differentiating between constrictive and restrictive ventricular physiology. 2DSTE can also be used to assess the success of pericardiectomy and its impact on atrial and ventricular mechanics. In the course of this review, we describe cardiac mechanics in patients with CP and summarize the influence of pericardiectomy on atrial and ventricular mechanics assessed using 2DSTE.

Padrão de Brugada tipo 1 induzido pela febre

Brugada syndrome, first described over 20 years ago, is characterized by a typical electrocardiographic pattern with coved-type ST-segment elevation in the right precordial leads and a high risk of sudden death in otherwise healthy young adults. The electrocardiographic pattern is sometimes intermittent, and fever is a possible trigger. The authors present the case of a 68-year-old woman who came to the emergency department with fever and syncope. A diagnosis of community-acquired pneumonia was made. The electrocardiogram performed when the patient had fever revealed a type 1 Brugada pattern, which disappeared after the fever subsided. After other causes of Brugada-like pattern were excluded, Brugada syndrome was diagnosed and a cardioverter-defibrillator was implanted. This case demonstrates that this entity can be diagnosed at more advanced ages and highlights the usefulness of electrocardiography in a febrile state.

Device entrapped in subvalvular apparatus: A surprising result

( u ( S E t l m S d p 58 days after admission (one month after the procedure). This case illustrates a rare and dramatic complication of percutaneous leak closure, but without significant hemodynamic impact on mitral valve and LV function. A 72-year old woman with a history of mechanical aortic prosthesis since 2010 and early infective prosthetic endocarditis (medical treatment) was hospitalized for acute heart failure in February 2015. Transesophageal echocardiography showed a severe paravalvular leak in the posterior portion of the aortic prosthesis (Figure 1A, arrow) and a pseudoaneurysm with fistulization to the left ventricle (LV) and aorta (Figure 1B, arrow), moderate mitral regurgitation and mild LV systolic dysfunction. Surgery was considered high risk and percutaneous closure of the paravalvular leak was attempted. The procedure was guided by fluoroscopy and transesophageal echocardiography. After confirming the stability of the device (Amplatzer ® Vascular Plug II 12 mm/9 mm) and reduction of the paravalvular leak without functional compromise of the mechanical prosthesis

Does percutaneous left atrial appendage closure affect left atrial performance

Mailing Address:: Marta Madeira Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra Quinta dos Vales, S. Martinho do Bispo. Postal Code: 3045-043, Coimbra Portugal E-mail: marta.jesus.madeira@gmail.com Does Percutaneous Left Atrial Appendage Closure Affect Left Atrial Performance? Marta Madeira,*1,2 Rogério Teixeira,*1,2 Liliana Reis,1 Paulo Dinis,1 Luís Paiva,1,2 Ana Botelho,1 Marco Costa,1 Lino Gonçalves1,2 Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra Hospital Geral,1 Coimbra Portugal Faculdade de Medicina da Universidade de Coimbra,2 Coimbra Portugal * Both authors contributed equally to the paper

Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy: What has Changed in The Guidelines?

Background The new European Society of Cardiology guidelines for hypertrophic cardiomyopathy (HCM) define the estimation of sudden cardiac death (SCD) risk as an integral part of clinical management. An implantable cardioverter defibrillator (ICD) is recommended (class IIa) when the risk is ≥ 6%. Objectives To compare the SCD risk stratification according to the 2011 and 2014 recommendations for ICD implantation in patients with HCM. Methods Retrospective study including 105 patients diagnosed with HCM. The indication for ICD was assessed using the 2011 and 2014 guidelines. Statistical analysis was performed using SPSS software version 19.0.0.2®. The tests performed were bilateral, considering the significance level of 5% (p < 0.05). Results Regarding primary prevention, according to the 2011 ACCF/AHA recommendations, 39.0% of the patients had indication for ICD implantation (level of evidence IIa). Using the 2014 guidelines, only 12.4% of the patients had an indication for ICD implantation. Comparing the two risk stratification models for patients with HCM, we detected a significant reduction in the number of indications for ICD implantation (p < 0.001). Of the 41 patients classified as IIa according to the 2011 recommendations, 68.3% received a different classification according to the 2014 guidelines. Conclusion Significant differences were found when comparing the SCD risk stratification for ICD implantation in the two guidelines. The current SCD risk score seems to identify many low-risk patients who are not candidates for ICD implantation. The use of this new score results in a significant reduction in the number of ICD implanted.

Inotropes and cardiorenal syndrome in acute heart failure – A retrospective comparative analysis

Introduction Cardiorenal syndrome (CRS) is common in acute heart failure (AHF), and is associated with dire prognosis. Levosimendan, a positive inotrope that also has diuretic effects, may improve patients’ renal profile. Published results are conflicting.

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).

Uma causa rara de isquemia subendocárdica

Figure 1 Transthoracic echocardiography showing: (A) mechanical aortic valve (21-mm Medtronic with mild regurgitation, possibly periprosthetic; (B) elevated transvalvular gradients (maximum 51 mmHg and mean 24 mmHg); acceleration time 89 ms, left ventricular outflow tract velocity time integral/aortic velocity time integral 0.29 and area index 0.83 cm/m, suggestive of mismatch and/or increased flow.