Ivabradina como apoyo a la contrapulsación aórtica en pacientes con insuficiencia cardíaca avanzada

Introducción. Los pacientes con insuficiencia cardíaca (IC) avanzada bajo tratamiento con inotrópicos tienden a la taquicardia sinusal, principalmente, por: 1) efecto compensador neuroendocrino, 2) efecto farmacológico, 3) imposibilidad del uso de beta bloqueantes por interferir en el efecto inotrópico. Objetivos. Evaluar mediante cateterismo pulmonar el efecto hemodinámico de la ivabradina en la taquicardia sinusal durante el tratamiento de la IC avanzada bajo contrapulsación aórtica. Material y métodos. Entre el 1° de Enero de 2014 y el 1° de Mayo de 2020, se incluyeron prospectivamente todos los pacientes admitidos al área de cardiología crítica por IC aguda de etiología isquémico-necrótica refractaria al tratamiento farmacológico vía oral e indicación de inotrópicos y contrapulsación intra-aórtica, en ritmo sinusal con más de 110 latidos por minuto (lpm) de frecuencia cardíaca. Resultados. El estudio incluyó a 55 pacientes (33 hombres) con edad promedio de 61,9 años. Post tratamiento con ivabradina, la frecuencia cardíaca bajó de 118±5 lpm a 93±8 lpm (p=0,0002), el volumen minuto cardíaco aumentó de 4637±610 ml a 5176±527 ml (p=0,03) y el volumen sistólico promedio se incrementó significativamente de 39,29±5,2 a 55,65±7,7 ml (p=0,002). No se observaron diferencias significativas pre y post tratamiento en los registros de las presiones de la aurícula derecha ni en las presiones capilar pulmonar, así como en los cálculos de resistencias vasculares sistémicas y pulmonares. No se observaron efectos adversos de las drogas hasta transcurridas cinco vidas medias luego de suspenderla. Conclusiones. La ivabradina mejora la efectividad de la contrapulsación aórtica evaluada mediante catéter de Swan Ganz en paciente con IC avanzada tratada con agentes inotrópicos.

Background. Patients with advanced heart failure (HF) under inotropic treatment tend to sinus tachycardia, mainly due to: 1) neuroendocrine compensatory effect, 2) pharmacological effect, 3) impossibility of using beta-blockers because they interfere with the inotropic effect. Objectives. To evaluate the hemodynamic effect of ivabradine on sinus tachycardia during the treatment of advanced HF under aortic balloon pump using pulmonary catheterization. Material and methods. Between January 1, 2014 and May 1, 2020, all patients admitted to the critical cardiology area for acute HF of ischemic-necrotic etiology refractory to oral pharmacological treatment and indication of inotropic drugs and aortic balloon pump were prospectively included, in sinus rhythm with more than 110 beats per minute (bpm) of heart rate. Results. The study included 55 patients (33 men) with a mean age of 61.9 years. Post-treatment with ivabradine, the heart rate decreased from 118±5 bpm to 93±8 bpm (p=0.0002), the cardiac minute volume increased from 4637±610 ml to 5176±527 ml (p=0.03) and mean stroke volume increased significantly from 39.29±5.2 to 55.65±7.7 ml (p=0.002). No significant differences were observed before and after treatment in the recordings of the pressures of the right atrium or in the pulmonary capillary pressures, as well as in the calculations of systemic and pulmonary vascular resistance. No adverse effects of the drugs were observed until five half-lives after stopping it. Conclusions. Ivabradine improves the effectiveness of aortic balloon pump evaluated by means of a Swan Ganz catheter in patients with advanced HF treated with inotropic agents.

Introdução. Pacientes com insuficiência cardíaca (IC) avançada em tratamento inotrópico tendem a apresentar taquicardia sinusal, principalmente devido a: 1) efeito compensatório neuroendócrino, 2) efeito farmacológico, 3) impossibilidade de uso de betabloqueadores por interferirem no efeito inotrópico. Objetivo. Avaliar o efeito hemodinâmico da ivabradina na taquicardia sinusal durante o tratamento da IC avançada sob contrapulsação aórtica por cateterismo pulmonar. Material e métodos. Entre 1º de Janeiro de 2014 e 1º de Maio de 2020, foram incluídos prospectivamente todos os pacientes admitidos na área de cardiologia crítica por IC aguda de etiologia isquêmico-necrótica refratária ao tratamento farmacológico oral e indicação de inotrópicos e de balão de contrapulsação intra-aórtico, em ritmo sinusal com mais de 110 batimentos por minuto (bpm) de frequência cardíaca. Resultados. O estudo incluiu 55 pacientes (33 homens) com idade média de 61,9 anos. Após o tratamento com ivabradina, a frequência cardíaca caiu de 118±5 bpm para 93±8 bpm (p=0,0002), o volume minuto cardíaco aumentou de 4637±610 ml para 5176±527 ml (p=0,03) e o volume sistólico médio aumentou significativamente de 39,29±5,2 para 55,65±7,7 ml (p=0,002). Não foram observadas diferenças significativas antes e após o tratamento nos registros das pressões do átrio direito ou nas pressões capilares pulmonares, bem como nos cálculos da resistência vascular sistêmica e pulmonar. Nenhum efeito adverso dos medicamentos foi observado até cinco meias-vidas após a descontinuação. Conclusões. A ivabradina melhora a eficácia da contrapulsação aórtica avaliada por meio de um cateter de Swan Ganz em pacientes com IC avançada tratados com agentes inotrópicos.

Wolff-Parkinson-White syndrome in a man presenting with palpitation – A case report

Wolff-Parkinson-White (WPW) syndrome is not a common presentation, but physicians get to see cases with pre-excitation syndrome. WPW is characterized by the existence of an accessory pathway that predisposes patients to tachyarrhythmias and sudden death. Patients with WPW syndrome are at greater risk of hazardous ventricular arrhythmias. The majority of the cases never present with an underlying structural cardiac disease. It is always controversial to manage asymptomatic patients with WPW syndrome. Here, we discuss an uncommon case of a 48-year-old man with WPW syndrome after being evaluated for palpitation and giddiness.

A clinical study of hemodynamically significant arrhythmias and QTc interval associated with thrombolysed and non thrombolysed acute myocardial infarction patients

Background: Arrhythmias are a common occurrence in acute myocardial infarction. Objectives of this study the hemodynamically significant arrhythmias and QTc interval in thrombolysed and non thrombolysed acute myocardial infarction patients.Methods: Two hundred patients of AMI were enrolled. ECG and cardiac parameters were examined. Arrhythmias and its various parameters like its incidence, type, frequency associated with site of infarction were recorded in thrombolysed and non thrombolysed patients of AMI.Results: AMI was more prevalent in the males (63.3%) and those with 41-50 years of age. Hypertension (35.7%), smoking (34.2%), and diabetes (23.1%) were the major risk factor. Incidence of AWMI (30.7%) is higher than IWMI (25.1%). Out of 200 subjects 130 were thrombolysed. Arrhythmias was observed in total 164 patients while 36 patients has no documentation of arrhythmias. Mean QTc was prolonged (546.88ms vs 404.33ms) in patients documented with arrhythmia compared with those who has no arrhythmia. Out of all arrhythmias, ventricular tachycardia was seen in 38% cases with 50% mortality and preponderance to antero lateral MI. Sinus Tachycardia was seen in 22% of cases with preponderance to Antero Lateral MI and persistence of Sinus Tachycardia was a prognostic sign, mortality being 12%. Complete Heart Block were seen with IWMI, incidence being 26%. Bundle Branch Block was common in AWMI (31%) than IWMI (10%).Conclusion: Tachyarrhythmias are common with AWMI and bradyarrhythmia’s in IWMI. Reperfusion arrhythmias are a benign phenomenon and good indicator of successful reperfusion.

Interpretation of consensus statement collects recommendations on arrhythmia management of autonomic nervous system / 中国综合临床

Currently we are still unclear in the aspect of etiology and mechanisms,and lack of medical advice based on evidence-based medicine on postural tachycardia syndrome,inappropriate sinus tachycardia and vasovagal syncope.It also prompts clinical research direction of the three special arrhythmia in future.Based on this,it is very necessary to interpret the management consensus of these three types of arrhythmia.

Inappropriate Sinus Tachycardia

Since inappropriate sinus tachycardia (IST) occurs due to various reasons, it can be diagnosed after exclusion of all causes and diseases that may result in sinus tachycardia. In particular, it is important to differentiate postural orthostatic tachycardia syndrome (POTS), and a multidisciplinary approach is necessary for differentiating psychiatric events. In addition, whether the clinical symptoms coincide with tachycardia events should be checked before treatment. β-adrenergic blocker is the most effective drug, and exercise training is recommended for controlling clinical symptoms. Furthermore, discontinuation of smoking and alcohol consumption, and decrease in caffeine intake may be useful. Recently, ivabradine has been found effective, and catheter ablation can be considered in cases of drug refractory IST presenting with clinical symptoms.

Evolución clínica y evaluación hemodinámica de pacientes tratados con ivabradina durante la infusión de inotrópicos endovenosos / Clinical evolution and hemodynamic assessment of patients treated with ivabradina during infusion of intravenous inotropic / Evolução clínica e avaliação hemodinâmica dos pacientes tratados com ivabradina durante a infusão intravenosa de inotrópicos

Objetivo. Evaluar el efecto hemodinámico de la ivabradina utilizada para reducir la taquicardia sinusal durante el tratamiento de la insuficiencia cardíaca avanzada bajo terapia inotrópica. Material y métodos. Entre Enero de 2011 y Marzo de 2015 se trataron con ivabradina prospectivamente pacientes en ritmo sinusal con más de 100 lpm de frecuencia cardíaca admitidos al área de cardiología crítica por insuficiencia cardíaca estadio D de etiología isquémico necrótica refractaria al tratamiento oral y endovenoso convencional con indicación de terapia inotrópica endovenosa con, al menos, una sumatoria de 10 γ/Kg/minuto y, al menos, 2,2 litros/ m²superficie corporal de índice cardíaco. Se excluyeron pacientes en shock o que requirieran asistencia respiratoria mecánica o asistencia circulatoria mecánica. Se realizaron mediciones con catéter de Swan Ganz antes y tres horas después de la administración de 15 mg de ivabradina, vía enteral. Resultados. El estudio incluyó a 61 pacientes (39 hombres y 22 mujeres) con edad promedio de 65,8 años. La fracción de eyección del ventrículo izquierdo fue del 31,8%. La dosis promedio de fármaco inotrópico endovenoso fue de 15,2 γ/Kg/minuto. Tres horas después de la ivabradina la frecuencia cardíaca bajó de 121 ± 6 a 98 ± 7 (p=0,00002), leve aumento del volumen minuto cardíaco medido por termodilución de 4597 ± 550 mL/min a 4825 ± 535 mL/ min (p=0,041). El rendimiento cardíaco evaluado por el índice cardíaco aumentó en el límite de la significación estadística de 2,21 ± 0,3 a 2,33 ± 0,3 L/m² superficie corporal (p=0,052). El volumen sistólico promedio se incrementó significativamente de 37,9 ± 5 a 49,3 ± 8 mL (p=0,00002). No se observaron diferencias significativas en los registros de presiones de aurícula derecha, ni en las presiones capilares pulmonares, así como en los cálculos de resistencias vasculares sistémicas y pulmonares. No se observaron efectos adversos de las drogas hasta transcurridas cinco vidas medias, luego de suspenderla. La mortalidad a 30 días de este grupo de paciente fue del 8,1%. Conclusiones. La ivabradina es útil para moderar la taquicardia sinusal en la insuficiencia cardíaca avanzada durante la terapia inotrópica.

Objective. To evaluate the hemodynamic effect of ivabradine used to reduce sinus tachycardia for the treatment of advanced heart failure under inotropic therapy. Material and methods. Between January 2011 and March 2015 we treated prospectively with ivabradine patients in sinus rhythm with over 100 pm of heart rate admitted to the critical cardiology unit for stage D heart failure with indication intravenous inotropic therapy with at least a sum of 10 γ/Kg/minute and at least 2.2 L/m² body surface of cardiac index. Shock patients were excluded or requiring mechanical ventilation or mechanical circulatory support. Measurements were made with Swan Ganz catheter before and three hours after administration of 15 mg of ivabradine enterally. Results. The study included 61 patients (39 men and 22 women) with a mean age of 65.8 years. The ejection fraction of the left ventricle was 31.8% .The average dose of intravenous inotropic drug was 15.2 γ/Kg/minute. Three hours after administration of ivabradine heart rate decreased from 121 ± 6 to 98 ± 7 (p=0.00002), slight increase cardiac output measured by thermodilution measured 4597 ± 550 mL/min to 4825 ± 535 mL/min (p=0.041). Cardiac performance measured by the cardiac index increased by the limit of statistical significance of 2.21 ± 0.3 to 2.33 ± 0.3 L/m² body surface area (p=0.052). The mean stroke volume increased significantly from 37.9 ± 5 to 49.3 ± 8 mL (p=0.00002). No significant difference in pressures records right atrium or pulmonary capillary pressures were observed; as well as calculations of systemic and pulmonary vascular resistance. No adverse drug effects were observed up to five halflives elapsed after suspending it. The 30-day mortality in this group of patients was 8.1%. Conclusions. Ivabradine is useful to moderate sinus tachycardia in advanced heart failure during inotropic therapy.

Objetivo. Avaliar o efeito hemodinâmico da ivabradina utilizado para reduzir taquicardia sinusal para o tratamento da insuficiência cardíaca avançada sob terapia inotrópica. Material e métodos. Entre Janeiro de 2011 e Março de 2015, prospectivamente foram tratados com ivabradina pacientes em ritmo sinusal, com mais de 100 bpm frequência cardíaca admitidos na área de cardiologia crítica por insuficiência cardíaca estádio D de etiologia isquêmica necrótica refratada ao tratamento intravenoso e oral convencional, com indicação de terapia inotrópica intravenosa com, pelo menos, uma dose de 10 γ/Kg/min e, pelo menos, 2,2 L/m² de superfície corporal do índice cardíaco. Os pacientes em estado de choque foram excluídos ou necessidade de ventilação mecânica ou suporte circulatório mecânico. As medições foram feitas com cateter de Swan Ganz antes e três horas após a administração de 15 mg de ivabradina via enteral. Resultados. O estudo incluiu 61 pacientes (39 homens e 22 mulheres), com idade média de 65,8 anos. A fração de ejeção do ventrículo esquerdo foi de 31,8%. A dose média de droga inotrópica intravenosa foi de 15,2 γ/kg/min. Três horas após a administração de ivabradina ritmo cardíaco diminuiu de 121 ± 6 para 98 ± 7 bpm (p=0,00002), ligeiro aumento do débito cardíaco medido por termodiluição de 4597 ± 550 mL/min para 4825 ± 535 mL/min (p=0,041). O desempenho cardíaco medido pelo índice cardíaco aumentou no limite de significância estatística de 2,21 ± 0,3 para 0,3 ± 2.33 L/m² de área de superfície corporal (p=0,052). O volume sistólico médio aumentou significativamente de 37,9 ± 5 para 49,3 ± 8 mL (p=0,00002). Não foram observadas diferenças significativas nos registros de pressão do átrio direito, nem nas pressões capilares pulmonares; assim como nos cálculos de resistência vascular sistêmica e pulmonar. Não foram observados efeitos adversos da droga até ter transcorreram cinco meias-vidas após sua suspensão. A mortalidade aos 30 dias, neste grupo de pacientes foi de 8,1%. Conclusões. A ivabradina é útil para moderar taquicardia sinusal na insuficiência cardíaca avançada durante a terapia inotrópica.

Prevalencia de disfunción cardiaca contráctil y tiroidea en pacientes con taquicardia sinusual inapropiada / Cardiac contractile and thyroid dysfunction in patients with inappropriate sinus tachycardia

El síntoma palpitaciones es frecuente en la consulta médica. Se valoró retrospectivamente la prevalencia de disfunción contráctil miocárdica y de disfunción tiroidea en un grupo de pacientes con taquicardia sinusal inapropiada. Material y métodos: De todos los registros electrocardiográficos de 24 horas (Holter) realizados en el servicio de cardiología del Hospital México, Costa Rica, en el año 2006, se eligieron los que resultaron con taquicardia sinusal inapropiada, definida como frecuencia cardiaca promedio mayor de 80 latidos por minuto (1pm) o bien la presencia de múltiples episodios de taquicardia sinusal sin correlación fisiológica. Se analizaron los factores demográficos, la presencia de disfunción contráctil miocárdica por ecocardiograma y la función tiroidea (medición de T3, T4, TSH). Se excluyeron del análisis a los pacientes con cardiopatía estructural conocida de previo. Resultados: Se seleccionaron 105 registros (81 mujeres, 24 hombres) de un total de 380 (27,6 por ciento). La edad promedio fue 38,97 años (rango de 9-81 años). La frecuencia cardiaca promedio fue 86,23 1pm (108-71), la máxima promedio 143,19 1pm (189-111) y la mínima promedio 55,7 1pm (89-22). En 49 pacientes, se documentó la fracción de eyección, encontrándose un valor promedio normal (0,6 rango 0,7-0,45); en 29 pacientes se obtuvieron los resultados de función tiroidea, en promedio, T4 libre y TSH estuvieron en límites normales (1,48 ng/dL y 1,7 mUI/L respectivamente). Conclusión: La mayoría de los pacientes que consulta por palpitaciones cuyo resultado del Holter es taquicardia sinusal inapropiada, no tiene disfunción contráctil miocárdica ni disfunción tiroidea. Por tanto, en este grupo de pacientes no se justifica valorar estos parámetros en forma rutinaria.

Palpitations are a frequent complaint during medical consultation. In a group of patients with inappropriate sinus tachycardia, we retrospectively, assessed the prevalence of cardiac contractile and thyroid dysfunction Materials and methods: We selected from all 24 hour Holter studies performed during 2006 at the Cardiology Service of the México Hospital (Costa Rica) those of patients with inappropriate sinus tachycardia, defined as mean heart rate equal o greater than 80 beats per minute (bpm) or multiple episodes of sinus tachycardia without physiologic explanation. We analyzed demographicdata, echocardiographic presence or absence of systolic cardiac dysfunction and thyroid function by means of TSH and total T3-4. We excluded from the analysis those patients with knowncardiac disease. Results: We selected 105 Holter registries from 380 studies, 27,6% or 81 were women, and 24men. Mean age was 38,97 years old (range 9-81). The mean heart rate was 86,23 bpm (108-71), mean maximal heart rate 143,19 (189-111) and mean minimal heart rate 55,7 (89-22) bpm. In 49 patients an ejection fraction was available; a normal mean value of 0,6 (0,7-0,45) was reported. In 29 patients thyroid function tests were obtained and the mean value of free-T4 y TSH werebetween normal limits (1,48 ng/dL and 1,7 mUI/L respectively). Conclusion: The majority of patients consulting for palpitations and in whom a Holter analysis results in inappropriate sinus tachycardia, have no cardiac contractility nor thyroid dysfunction.Therefore, in this group of patients it is not justified to evaluate these parameters routinely.

New Proposal for Adlt's Normal Sinus Heart Rates

BACKGROUND: The normal sinus heart rate standard of 60 to 100 beats per minute was set by the NYHA(New York Heart Association) in 1928. It has long been accepted to physicians, but clinical studies and experience suggest that both these limits are too high. Thus we reexamined to define operationally normal sinus heart rate that are scientifically and clinically acceptable. METHODS: Total 1,930 subjects(aged 20 to 92 years) were analyzed and evaluated for age, sex, body mass index(BMI), systolic blood pressure, diastolic blood pressure, and resting heart rates by electrocardiogram. We used Pearson's correlation test and t-test to analyze these data. RESULTS: Among 1930 subjects, 982 cases were male(51%) and 948 cases were female (49%), whose mean age was 48 years in male and 51 years in female. For the entire sample, mean heart rate and standard deviation was 68 +/- 11 beats/min. There was statistically significant difference between male(67+/-11 beats/min) and female(68+/-10 beats/min)(P<0,05). The prevalence of sinus tachycardia and bradycardia, calculated by current normal standard of 60 to 100 beats/min, was 22.0% (424 cases) and 0.9% (18 cases). Mean +/- two standard deviation yields rounded extremes of 46 to 89 beats/min for normal sinus heart rate. A positive correlations between resting heart rate and age(r=0.11), systolic blood pressure(r =0.17), diastolic blood pressure(r=0.12) were found(P<0.01). CONCLUSIONS: Two extremes of the normal sinus heart rate standard of 60 to 100 beats/min are set too high. They result in lower sensitivity for tachycardia and lower specificity for bradycardia. We propose that normal range for sinus heart rate should be 50 to 90 beats/min which is statistically justified, more realistic for clinical investigation.

A Case of Unusual Form of Williams Syndrome

Williams syndrome is a progressive and multisystemic disorder. We experienced one case of Willams syndrome which was characterized by elfin facies, mental retardation, diffuse aortic hypoplasia, mitral regurgitation and chronic nonparoxysmal sinus tachycardia. The tachycardia has been managing with beta-blocker successfully. We presented a case of unusual form of Williams syndrome with a reivew of literatures.