Sílvia Ribeiro

New-onset atrial fibrillation during acute coronary syndromes: Predictors and prognosis

INTRODUCTION New-onset atrial fibrillation (AF) frequently complicates myocardial infarction, with an incidence of 6-21%. OBJECTIVE To assess the predictors and prognosis of new-onset AF during acute coronary syndromes (ACS). METHODS We performed a retrospective observational cohort study including 902 consecutive patients (mean age 64 years, 77.5% male) admitted to a single center over a two-year period, with a six-month follow-up. RESULTS AF rhythm was identified in 13.8% patients, of whom 73.3% presented new-onset AF and 26.8% pre-existing AF. New-onset AF was more frequent in older (p<0.001) and hypertensive patients (p=0.001) and in those with previous valvular heart disease (p<0.001) and coronary artery bypass grafting (p=0.049). During hospitalization, patients with new-onset AF more often had respiratory infection (p=0.002) and heart failure (p<0.001), and higher values of NT-proBNP (p=0.007) and peak creatinine (p=0.001). On echocardiography they had greater left atrial (LA) diameter (p<0.001) and more frequent significant mitral regurgitation (p<0.001) and left ventricular ejection fraction (LVEF) ≤40% (p<0.001) and were less likely to have significant coronary lesions (p=0.009) or to have undergone coronary revascularization (p<0.001). In multivariate analysis, age (OR 1.06, p=0.021), LVEF ≤40% (OR 4.91, p=0.002) and LA diameter (OR 1.14, p=0.008) remained independent predictors of new-onset AF. Together with age, diabetes and maximum Killip class, this arrhythmia was an independent predictor of overall mortality (OR 3.11, p=0.032). CONCLUSIONS Age, LVEF ≤40% and LA diameter are independent predictors of new-onset AF during ACS. This arrhythmia is associated with higher overall mortality (in-hospital and in follow-up).

Cardiac Memory, an Underdiagnosed Condition

Cardiac memory, also termed Chatterjee phenomenon, is a known yet uncommonly recognized entity in which myocardial repolarization is altered after abnormal ventricular activation, such as with artificial pacemakers, intermittent left bundle branch block, ventricular premature beats, ventricular pre-excitation or episodes of tachycardia.1 This phenomenon is characterized by persistent but reversible T-wave changes on surface electrocardiogram (ECG) induced by an abnormal electrical activation pattern. The extent and direction of T-wave deviation depend on the duration and direction of abnormal electrical activation and can persist for several weeks. Rosenbaum et al.2 found that the T-wave “resembled” the abnormal QRS vector. The pathophysiology underlying cardiac memory is still complex and evolving, but alterations in the transient outward potassium current — Ito1 — and changes in the phosphorylation status of the cAMP responsive element binding protein (CREB) have been reported.3 Although it seems that cardiac memory is a relatively benign pathophysiologic finding, it may lead to unnecessary and invasive diagnostic investigation if it is not recognized. Here we report a patient presenting deep T-wave inversion after implantation of cardiac pacemaker. Case report

Síndrome do QT longo: mutação trigénica, um caso raro

Congenital long QT syndrome (LQTS) is a rare hereditary disease, with an incidence of 1 in 2000, characterized by prolonged ventricular repolarization and malignant ventricular tachyarrhythmias. We report the case of a 30-year-old woman, previously diagnosed with neurocardiogenic syncope, in whom LQTS was identified. The patient received an implantable cardioverter-defibrillator due to polymorphic ventricular tachycardia under beta-blocker therapy. Molecular genetic testing identified three mutations in heterozygosity in the KCNH2, KCNQ1 and SCN5A genes, which is a rare finding and is associated with worse prognosis.

Pheochromocytoma diagnosed after anticoagulation for atrial fibrillation ablation procedure: A giant in disguise

Pheochromocytoma is a rare catecholamine-producing tumor, discovered incidentally in 50% of cases. We present the case of a 44-year-old male with a history of paroxysmal palpitations. Baseline ECG, transthoracic echocardiogram and ECG stress test showed no relevant alterations. Paroxysmal atrial fibrillation was detected on 24-hour Holter ECG. After antiarrhythmic therapy, the patient remained symptomatic, and was accordingly referred for electrophysiological study and atrial fibrillation ablation. Anticoagulation was initiated before the procedure. After ablation and still anticoagulated, he complained of hematospermia. The abdominal and pelvic imaging study showed a 10-cm left adrenal mass, predominantly cystic, compatible with pheochromocytoma, which was confirmed after biochemical tests (increased urine metanephrines and plasma catecholamines). Metaiodobenzylguanidine scintigraphy scanning confirmed localized disease in the adrenal gland, excluding other uptake foci. Following appropriate preoperative management, surgical resection of the giant mass was performed successfully and without complications.

Avaliação das propriedades dinâmicas da pressão arterial em mulheres com antecedentes de pré‐eclâmpsia

BACKGROUND We investigated viscoelastic properties of the arterial wall in women with previous preeclampsia (PE) compared to those with normal pregnancy (NP). METHODS In a cross-sectional study 45 women with previous PE and 55 with NP were included, matched for age (PE 38±6 vs. NP 38±5 years, NS) and body mass index: (PE 25±4 vs. NP 26±4 kg/m(2), NS) studied, respectively, 76±34 and 86±48 months after delivery. We assessed arterial distensibility - pulse wave velocity (PWV, Complior) and reflected waves (augmentation pressure [AP], mmHg) and augmentation index (AIx) - in the central pressure wave and blood pressure (BP) on 24-h ambulatory BP monitoring (ABPM). RESULTS PE showed higher (p<0.01) peripheral systolic blood pressure (SBP): PE 131±18 vs. NP 121±19, and central SBP: PE 122±18 vs. NP 110±19 mmHg, with less amplification of central-peripheral pressure: PE 10±4 vs. NP 12±5, p=0.041, and higher (p<0.05) AP: PE 10±3 vs. NP 8±2, and AIx: PE 26±5 vs. NP 20±5 mmHg, but PE and NP did not differ in pulse wave velocity. On ABPM, PE (n=39) vs. NP (n=33) had higher nighttime SBP: PE 121±10 vs. NP 108±10 mmHg and lower percentage nocturnal SBP fall: PE 11±6 vs. NP 18±11%, both p<0.02. During follow-up, the need for antihypertensive medication was seven times higher in PE than in NP. CONCLUSION Women with previous PE have a greater risk of hypertension, higher nighttime BP values, blunted nocturnal BP fall and changes in central pressure suggestive of increased reflected waves and peripheral vascular resistance. These factors may contribute to their higher cardiovascular risk after pregnancy.

Chest stab wound—A rare cause of late ventricular tachycardia

A 67-year-old man with a history of systemic arterial hypertension and a chest stab trauma with emergent cardiothoracic surgery 38 years previously was admitted to our cardiology department for sustained monomorphic ventricular tachycardia. At admission to the emergency department the patient complained of palpitations, sweating and general malaise. He was hemodynamically stable. The admission electrocardiogram showed regular wide complex tachycardia with right bundle branch block pattern consistent with ventricular tachycardia (Figure 1A). Chemical cardioversion with amiodarone was successfully performed. The baseline ECG demonstrated sinus rhythm with Q waves in DI, aVL and V3--V6. Laboratory tests, including troponin, were unremarkable. The transthoracic echocardiogram revealed normal global left ventricular systolic function with anterolateral hypokinesia. Coronary angiography excluded

Physical characteristics of the eggs of red-legged partridge (Alectoris rufa) reared in captivity

O objetivo do presente estudo foi avaliar os efeitos da idade das femeas (um, dois e tres anos) e do mes de postura (marco, abril e maio) sobre as caracteristicas fisicas dos ovos da perdiz vermelha (Alectoris rufa) criada em cativeiro. O peso (W), o comprimento maximo (L) e a largura maxima (B) de 2878 ovos foram determinados diretamente, enquanto o indice de forma (B/L), o volume (V) e a superficie (S) foram calculados com base nos parâmetros determinados diretamente. A analise mostrou diferencas significativas (P 0,05). Observaram-se diferencas significativas (P<0,01) na largura maxima e no indice de forma do ovo entre as diferentes classes de idades, com valores mais elevados nas femeas mais velhas e no periodo de postura mais tardio. O volume dos ovos estimados por meio de V1= 0,51LB2e V2=0,913W foi afetado significativamente (P<0,01) pela idade e pelo mes de postura, bem como as areas, S1=4.835W0,662, S2=4,951V10,666e S3=4,951V20,666, as quais apresentaram os mesmos efeitos.

Constrictive pericarditis: Insights from cardiac computed tomography

a v d d c r w c t e Constrictive pericarditis is a rare disease, usually the result of long-standing pericardial inflammation leading to pericardial scarring with thickening, fibrosis, and calcification. The most frequent causes are mediastinal radiation, chronic idiopathic pericarditis, cardiac surgery, and tuberculous pericarditis. Nearly 9% of patients with acute pericarditis for any reason go on to develop constrictive physiology. We report the case of a 52-year-old man with a history of acute pericarditis 30 years ago, with a three-year evolution of fatigue, dyspnea and palpitations. Physical examination revealed jugular venous distension and hepatomegaly and a pericardial knock was audible on cardiac auscultation. The 12-lead electrocardiogram revealed atrial flutter

Acute coronary syndrome and endocarditis 20 years before: how do they match?

A 33-year-old woman with a past history of mitral infective endocarditis in childhood was admitted in our department due to unstable angina. Transthoracic echocardiography (TTE) showed posterior mitral leaflet prolapse originating severe regurgitation and coronary angiography revealed an 80% stenosis of the proximal segment of left anterior descending …