ABSTRACT
Resumen La taquicardia ectópica de la unión en su variante congénita es una taquiarritmia pediátrica poco frecuente, que por su naturaleza incesante y su refractariedad a los agentes farmacológicos tradicio nales lleva asociada una alta morbimortalidad. Se presentan los casos clínicos de dos pacientes pediátricos con diagnóstico de taquicardia ectópica de la unión congénita, que mostraron respuesta inadecuada a las alternativas de tratamiento habituales y que, en consecuencia, desarrollaron miocardiopatía dilatada y disfunción ventricular secundaria a la taquicardia sostenida. En ambos se utilizó ivabradina como alternativa farmacológica innovadora pare el control de ésta con excelente respuesta clínica.
Abstract The congenial form of junctional ectopic tachycardia is a rare variant of pediatric tachyarrhythmia that due to its incessant nature and its refractoriness to the traditionally used antiarrhythmic agents has a high morbimortality The clinical cases of two patients with a diagnosis of congenital junctional ectopic tachycardia with inadequate response to the regular pharmacological options, who developed dilated cardiomyopathy and ventricular dysfunc tion secondary to sustained tachycardia, are presented. In both ivrabadine, a new innovative option was used with excellent clinical response.
Subject(s)
Humans , Child , Tachycardia, Ectopic Junctional/drug therapy , Electrocardiography , Ivabradine/therapeutic use , Anti-Arrhythmia Agents/therapeutic useABSTRACT
Resumo A fibrilação atrial é a arritmia sustentada mais comum na prática clínica com predileção pelas faixas etárias mais avançadas. Com o envelhecimento populacional, as projeções para as próximas décadas são alarmantes. Além de sua importância epidemiológica, a fibrilação atrial é destacada por suas repercussões clínicas, incluindo fenômenos tromboembólicos, hospitalizações e maior taxa de mortalidade. Seu mecanismo fisiopatológico é complexo, envolvendo uma associação de fatores hemodinâmicos, estruturais, eletrofisiológicos e autonômicos. Desde os anos 1990, o estudo Framingham em análises multivariadas já demonstrou que, além da idade, a presença de hipertensão, diabetes, insuficiência cardíaca e doença valvar é preditor independente dessa normalidade do ritmo. Entretanto, recentemente, vários outros fatores de risco estão sendo implicados no aumento do número de casos de fibrilação atrial, tais como sedentarismo, obesidade, anormalidades do sono, tabagismo e uso excessivo de álcool. Além disso, as mudanças na qualidade de vida apontam para uma redução na recorrência de fibrilação atrial, tornando-se uma nova estratégia para o tratamento de excelência dessa arritmia cardíaca. A abordagem terapêutica envolve um amplo conhecimento do estado de saúde e hábitos do paciente, e compreende quatro pilares principais: mudança de hábitos de vida e tratamento rigoroso de fatores de risco; prevenção de eventos tromboembólicos; controle da frequência; e controle do ritmo. Pela dimensão de fatores envolvidos no cuidado ao paciente portador de fibrilação atrial, ações integradas com equipes multiprofissionais estão associadas aos melhores resultados clínicos.
Abstract Atrial fibrillation is the most common sustained arrhythmia in clinical practice, with a preference for older age groups. Considering population ageing, the projections for the next decades are alarming. In addition to its epidemiological importance, atrial fibrillation is evidenced by its clinical repercussions, including thromboembolic phenomena, hospitalizations, and a higher mortality rate. Its pathophysiological mechanism is complex and involves an association of hemodynamic, structural, electrophysiological, and autonomic factors. Since the 1990s, the Framingham study of multivariate analyses has demonstrated that hypertension, diabetes, heart failure, and valvular disease are independent predictors of this rhythm abnormality along with age. However, various other risk factors have been recently implicated in an increase of atrial fibrillation cases, such as sedentary behavior, obesity, sleep disorders, tobacco use, and excessive alcohol use. Moreover, changes in quality of life indicate a reduction in atrial fibrillation recurrence, thus representing a new strategy for excellence in the treatment of this cardiac arrhythmia. Therapeutic management involves a broad knowledge of the patient's health state and habits, comprehending 4 main pillars: lifestyle changes and rigorous treatment of risk factors; prevention of thromboembolic events; rate control; and rhythm control. Due to the dimension of factors involved in the care of patients with atrial fibrillation, integrated actions performed by interprofessional teams are associated with the best clinical results.
Subject(s)
Humans , Aged , Atrial Fibrillation/drug therapy , Atrial Fibrillation/therapy , Thromboembolism , Heart Failure/drug therapy , Quality of Life , Risk Factors , Anti-Arrhythmia Agents/therapeutic useABSTRACT
A cardiomiopatia arritmogênica do ventrículo direito é uma desordem hereditária caracterizada pela substituição fibrogordurosa do músculo cardíaco. O manejo clínico busca reduzir os riscos de morte súbita e melhorar a qualidade de vida, aliviando os sintomas arrítmicos e de insuficiência cardíaca. O ecocardiograma é o exame inicial para a investigação da cardiomiopatia arritmogênica do ventrículo direito, podendo apresentar dilatação das câmaras direitas e disfunção sistólica do ventrículo direito. Este relato chama atenção por envolver o diagnóstico de cardiomiopatia arritmogênica do ventrículo direito em paciente atleta. Mulher, 47 anos, maratonista, sem história familiar de morte súbita cardíaca, deu entrada na emergência com palpitação associada à pré-síncope. O eletrocardiograma da admissão mostrava taquicardia ventricular. O ecocardiograma revelou aumento de câmaras cardíacas direitas e disfunção sistólica do ventrículo direito. O cateterismo cardíaco não evidenciou doença coronária obstrutiva. A paciente foi orientada acerca da necessidade de suspensão de atividades físicas, porém, 3 meses depois, foi readmitida com instabilidade hemodinâmica por nova taquicardia ventricular, tendo sido cardiovertida. Realizou ressonância cardíaca, que evidenciou áreas de discinesia e formação de microaneurismas em ventrículo direito. Foi diagnosticada com cardiomiopatia arritmogênica do ventrículo direito, tendo sido com cardioversor desfibrilador implantável, amiodarona e betabloqueador. A diferenciação entre a cardiomiopatia arritmogênica do ventrículo direito e o coração do atleta representa um desafio, devido à sobreposição de alterações estruturais que coexistem nessas entidades, daí a importância da análise integrada de fatores clínicos, eletrocardiográficos e morfofuncionais.(AU)
Subject(s)
Humans , Female , Middle Aged , Death, Sudden, Cardiac , Tachycardia, Ventricular/diagnosis , Arrhythmogenic Right Ventricular Dysplasia/genetics , Arrhythmogenic Right Ventricular Dysplasia/mortality , Heart Failure , Genetic Diseases, Inborn , Electric Countershock/methods , Echocardiography/methods , Magnetic Resonance Spectroscopy/methods , Electrocardiography, Ambulatory/methods , Heart Transplantation/methods , Defibrillators, Implantable , Catheter Ablation/methods , Electrocardiography/methods , Amiodarone/administration & dosage , Anti-Arrhythmia Agents/therapeutic useABSTRACT
Resumo A Ranolazina (RANO), conhecida na clínica como Ranexa, é um fármaco que previne a arritmia cardíaca através da inibição da corrente de sódio tardia (INaT). Um gradiente de voltagem transmural do canal Nav1.5 encontra-se na parede ventricular esquerda do coração. Assim, investigamos os efeitos da RANO em cardiomiócitos saudáveis e em modelo celular da Síndrome do QT longo tipo 3 (SQTL tipo 3). Usamos células isoladas do endocárdio (ENDO) e do epicárdio (EPI) e um software de medição com detecção de bordas por vídeo e microscopia de fluorescência para monitorar os transientes de cálcio. A RANO (0,1, 1, 10 e 30 uM, a 25OC) em uma série de frequências de estimulação teve impacto pouco significativo sobre ambos os tipos de células, mas a RANO (30uM) a 35OC minimizou o encurtamento dos sarcômeros em ~21% para células do endocárdio. Em seguida, para simular a SQTL tipo 3, as células do ENDO e EPI foram expostas à toxina ATX-II da anêmona do mar, que aumenta a INaT. As arritmias celulares induzidas por ATX-II foram suprimidas com o uso da RANO (30 µM) a 35OC. Com base nesses resultados, podemos concluir que a RANO tem um impacto pouco significativo sobre o encurtamento dos sarcômeros de células saudáveis do ENDO e EPI. Além disso, ela suprime as arritmias induzidas por INaT para níveis semelhantes nas células do ENDO e EPI.
Abstract Ranolazine (RANO) prevents cardiac arrhythmia by blocking the late sodium current (INaL). A transmural gradient of Nav1.5 is found in the left ventricular wall of the heart. Thus, we investigated the effects of RANO in healthy cardiomyocytes and in a cellular model of type 3 long QT syndrome (LQT3). We used isolated endocardium (ENDO) and epicardium (EPI) cells and a video edge detection system and fluorescence microscopy to monitor calcium transients. RANO (0.1, 1, 10 and 30 uM, at 25oC) at a range of pacing frequencies showed a minor impact on both cell types, but RANO at 30uM and 35oC for ENDO cells attenuated sarcomere shortening by~21%. Next, to mimic LQT3, we exposed ENDO and EPI cells to anemone toxin II (ATX-II), which augments INaL. Cellular arrhythmias induced by ATX-II were abrogated by RANO (30 µM) at 35oC. Based on our results we can conclude that RANO has a minor impact on sarcomere shortening of healthy ENDO and EPI cells and it abrogates arrhythmias induced by INaLto a similar level in ENDO and EPI cells.
Subject(s)
Humans , Arrhythmias, Cardiac/drug therapy , Long QT Syndrome , Ranolazine/therapeutic use , Anti-Arrhythmia Agents/therapeutic use , Action Potentials , Cardiac Conduction System DiseaseABSTRACT
A paralisia periódica hipocalêmica tireotóxica é uma complicação inusitada do hipertireoidismo, porém é considerada urgência endocrinológica e ainda frequentemente subdiagnosticada. Sua apresentação clínica consiste na tríade de défice de potássio, tireotoxicose e fraqueza muscular sendo esse último sintoma comum em diversas patologias. Realizamos uma revisão bibliográfica e destacamos, por meio do relato de caso, a importância do diagnóstico precoce dessa doença, possibilitando uma evolução favorável ao paciente, independente de sua etnia, sexo ou região geográfica. Atentamos ainda ao tratamento da doença, que, apesar de sua simplicidade, acarreta muitos equívocos.
The thyrotoxic hypokalemic periodic paralysis is a rare complication of hyperthyroidism, but is considered an endocrinological urgency, and yet frequently underdiagnosed. Its clinical presentation consists of potassium deficit, thyrotoxicosis, and muscular weakness, with the latter symptom being very common in several pathologies. We performed a bibliographic review and highlight, through a case report, the importance of the early diagnosis of this disease to allow favorable progression to the patient, regardless of ethnicity, sex, or geographical region. We also reinforce the importance of the disease treatment which, despite its simplicity, leads to many mistakes.
Subject(s)
Humans , Male , Adult , Young Adult , Thyrotoxicosis/diagnosis , Hypokalemic Periodic Paralysis/diagnosis , Potassium Chloride/therapeutic use , Tachycardia/diagnosis , Tachycardia/drug therapy , Antithyroid Agents/therapeutic use , Thyroxine/therapeutic use , Thyrotoxicosis/drug therapy , Thyrotoxicosis/blood , Hypokalemic Periodic Paralysis/drug therapy , Hypothyroidism/chemically induced , Hypothyroidism/drug therapy , Iodine/adverse effects , Iodine/therapeutic use , Anti-Arrhythmia Agents/therapeutic useABSTRACT
Objective: To explore the practice patterns and the related factors of oral antiarrhythmic drug (AAD) treatment in Chinese patients with atrial fibrillation (AF), and to evaluate the compliance of AAD application to atrial fibrillation management guidelines. Methods: From August 2011 to August 2016, medical records from 18 014 patients with AF were analyzed based on data from the Chinese Atrial Fibrillation Registry trial. Patients were divided into AAD group (7 788 cases, 43.23%) and non-AAD group (10 226 cases, 56.77%) according to whether AAD was used at baseline or at the time of first use during follow-up. Amiodarone (4 129 cases, 53.02%) and propafenone (3 211 cases, 41.23%) were the mostly prescribed AAD and subgroup analysis was performed accordingly. Medical records were analyzed by random forest regression to evaluate the use of AAD and related factors in patients with AF, and the rationality of AAD was analyzed according to the guidelines for the management of atrial fibrillation. Result: A total of 18 014 patients were included in this study, of which 60.48% (10 895/18 014) were male patients, 22.65% (4 081/18 014) were elderly patients(≥75 years old), there were 7 788 patients (43.23%) in AAD group, and 10 226 patients(56.77%) in non-AAD group. Compared with the non-AAD group, the elderly patients (≥75 years old, 13.74%(1 070/7 788) vs. 29.44%(3 011/10 226)), persistent AF (28.95% (2 250/7 788) 45.80% (4 683/10 226)), heart failure(8.29% (646/7 788) vs. 21.95% (2 245/10 226)), stroke and (or) TIA(12.15% (946/7 788) vs. 19.95% (2 040/10 226)), renal dysfunction(16.36%(1 274/7 788) vs. 29.37% (3 003/10 226)), and high thromboembolism risk(60.17% (4 748/7 788) vs. 76.40% (7 813/10 226)) were less prevalent in the AAD subgroup (P<0.001). Multivariate analysis showed that patients in tertiary hospitals (OR=3.72, 95%CI 3.17-4.37) were more likely to use AAD, elderly patients (≥75 years old, OR=0.47, 95%CI 0.39-0.55), persistent atrial fibrillation (OR=0.66, 95%CI 0.60-0.72), and patients with heart failure (OR=0.54, 95%CI 0.47-0.63), stroke and (or) TIA (OR=0.77, 95%CI 0.68-0.87), renal dysfunction (OR=0.75, 95%CI 0.59-0.95) and high thromboembolism risk(OR=0.7, 95%CI 0.58-0.84) were more likely not to use AAD(P<0.05). In the AAD group, amiodarone and propafenone were the most commonly used AAD, accounting for 53.02% (4 129/7 788) and 41.23% (3 211/7 788), respectively. Multivariate analysis showed that patients with persistent atrial fibrillation (OR=4.57, 95%CI 3.94-5.29) and coronary heart disease (OR=4.14, 95%CI 3.03-5.64), heart failure (OR=2.07, 95%CI 1.48-2.89), non-ischemic cardiomyopathy (OR=4.84, 95%CI 2.41-9.73) were more likely to use amiodarone, and those with normal left ventricular ejection fraction (OR=0.31, 95%CI 0.15-0.65) and low thromboembolism risk (OR=0.78, 95%CI 0.63-0.97) were more likely to use propafenone (P<0.001). The overall incidence of AAD treatment, which was not indicated by the guidelines was 6.5% (480/7 340); 5.1% (212/4 129) in the amiodarone group and 8.3% (268/3 211) in the propafenone group, respectively. Compared with the rational AAD use group, the proportion of irrational drug use was higher in the elderly (≥75 years old) (20.4% (98/480) vs. 12.9% (887/6 860)), patients of high thromboembolism risk (77.1% (379/480) vs. 59.0% (4 047/6 860)), and in non-tertiary hospitals (7.1% (34/480) vs. 3.3% (299/6 860)), but lower in men(50.8% (244/480) vs. 64.5% (4 427/6 860)), P<0.001. Conclusions: The patients with paroxysmal atrial fibrillation, who were treated with AAD, were mostly patients with fewer complications, and the patients who were treated with amiodarone were mostly patients with persistent atrial fibrillation, patients were more likely to complicate with organic heart disease. The incidence of AAD that do not comply with the guidelines was low, and it was more common in non-tertiary hospitals and the elder patients with high thromboembolism risk.
Subject(s)
Aged , Humans , Male , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/drug therapy , Clinical Trials as Topic , Practice Patterns, Physicians' , Registries , Stroke Volume , Treatment Outcome , Ventricular Function, LeftABSTRACT
Objective: We aimed to explore the impact of digoxin use on outcomes in Chinese patients with atrial fibrillation (AF). Methods: We used the dataset from the Chinese Atrial Fibrillation Registry, a prospective, multicenter, hospital-based registry study. According to the inclusion and exclusion criteria, 10 472 eligible patients enrolled from August 2011 to December 2016 were included in this ancillary study. The patients were classified into three groups according to the status of digoxin use at study enrollment, patients already receiving digoxin before registry were represented as continuous group, patients initiated on digoxin for the first time were represented as newly group, and patients without digoxin prescription at enrollment were represented as control group. Patients were followed by telephone or outpatient service every 6 months. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to investigate the association of digoxin use with adverse outcomes (all-cause death, cardiovascular death and cardiovascular hospitalization). Results: In the overall study population, men accounted for 42.8%, and the average age was (66.9±11.8) years. There were 777(7.42%)patients in continuous group, 375 (3.58%) patients in newly group, and 9 320 (89.00%) patients in control group. Compared with the control group, the patients in the newly group and the continuous group were older, had faster heart rate, lower estimated glomerular filtration rate, higher proportion of persistent atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, ischemic stroke, coronary heart disease, vascular disease and bleeding history. At the same time, the patients in the newly group and the continuous group were treated more often with anticoagulants, antiplatelet drugs, ACE inhibitors or angiotensin receptor blockers, beta-receptor blockers while the proportion of antiarrhythmic drugs was lower as compared to control group (P<0.05). During a median follow-up of 36 months (interquartile range: 18-48 month), risk of all-cause mortality was significantly higher in newly group compared to control group (7.3% vs. 4.7%, P<0.05), the rates of all-cause mortality, cardiovascular death and cardiovascular hospitalization were all higher in continuous group than in control group (8.0% vs. 4.7%; 4.7% vs. 3.0%; 16.7% vs. 11.8%; P all<0.05). After adjustment for age, male, body mass index, blood pressure, heart rate, renal function, AF type, history of stroke, heart failure, diabetes, coronary artery disease and other drugs treatment, the association between newly group and adverse outcomes was not significant, however, digoxin use was associated with increased all-cause mortality (HR 1.26; 95%CI 1.04-1.56; P=0.019), cardiovascular death (HR 1.38; 95%CI 1.08-1.77, P =0.01), and cardiovascular hospitalization (HR 1.10; 95%CI 1.06-1.52, P=0.02) in continuous group. Conclusion: Continuous digoxin use is associated with a significant increase in adverse outcomes among Chinese patients with atrial fibrillation.
Subject(s)
Aged , Humans , Male , Middle Aged , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/drug therapy , Digoxin , Prospective Studies , Risk Factors , StrokeABSTRACT
BACKGROUND@#Post hoc analysis of the landmark atrial fibrillation follow-up investigation of rhythm management trial revealed that amiodarone was associated with higher risks of mortality, intensive care unit admission, and non-cardiovascular death. We aim to evaluate the association between amiodarone use and patient survival under updated medical mode and level using data from the China Atrial Fibrillation (China-AF) Registry study.@*METHODS@#Clinical data of 8161 non-valvular atrial fibrillation (NVAF) patients who were antiarrhythmic drug (AAD)-naive before enrollment into the China-AF Registry, recruited between August 2011 and February 2017, were collected. The primary outcome was all-cause mortality. A Cox proportional hazard regression model was used to evaluate the association between amiodarone use and the outcome. We also calculated the rate of sinus rhythm maintenance at the penultimate follow-up.@*RESULTS@#Compared with 6167 patients of non-AAD group, 689 patients of the amiodarone group were younger (mean age 65.6 vs. 68.6 years), more frequently completed high school education, had fewer comorbidities such as chronic heart failure, prior bleeding, and stroke, and were more likely to be treated in tertiary hospitals while less hospitalization. The proportion of persistent AF was much lower among users of amiodarone, who were also less likely to be taking oral anticoagulants. The patients in the amiodarone group had a statistically insignificant lower incidence of all-cause mortality (2.44 vs. 3.91 per 100 person-years) over a mean follow-up duration of 300.6 ± 77.5 days. After adjusting for potential confounders, amiodarone use was not significantly associated with a lower risk of all-cause mortality (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42-1.49). Sub-group analysis revealed the consistent results. The rate of sinus rhythm maintenance at the penultimate follow-up in the amiodarone group was significantly higher than in the non-AAD group.@*CONCLUSIONS@#Our study indicated that amiodarone use was not significantly associated with a lower risk of 1-year all-cause mortality compared with a non-AAD strategy in "real-world" patients with NVAF.
Subject(s)
Aged , Humans , Amiodarone/therapeutic use , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/drug therapy , China , Prospective Studies , RegistriesABSTRACT
Abstract Background: D-limonene (DL) is a monoterpene and is the major component in the essential oil of citrus fruit. It presents antihyperglycemic and vasodilatation activities. Objectives: This study evaluated the cardiovascular effects and potential antiarrhythmic of DL in rats. Methods: Hemodynamic and electrocardiographic (ECG) parameters were measured in male Wistar rats, which under anesthesia had been cannulated in the abdominal aorta and lower vena cava and had electrodes subcutaneously implanted. In the in vitro approach, the heart was removed and perfused using the Langendorff technique. The significance level adopted was 5% (p < 0.05). Results: DL, in doses of 10, 20, and 40 mg/kg (i.v), produced intense and persistent bradycardia associated with hypotension. Bradycardia with prolonged QTc was observed in the ECG in vivo recording. In the in vivo model of arrhythmia induced by Bay K8644, DL (10 mg/kg) decreased the arrhythmia score from 15.33 ± 3.52 to 4.0 ± 2.64 u.a (p < 0.05, n = 4). In isolated perfused hearts, DL (10-3 M) promoted significant reductions in heart rate (from 228.6 ± 8.5 ms to 196.0 ± 9.3 bpm; p < 0.05) and left ventricular development pressure (from 25.2 ± 3.4 to 5.9 ± 1.8 mmHg; n = 5, p < 0.05). Conclusions: DL produces bradycardia and antiarrhythmic activity in rat heart.
Resumo Fundamento: O D-limoneno (DL) é um monoterpeno e o principal componente do óleo essencial de frutas cítricas. Ele apresenta atividades anti-hiperglicêmicas e vasodilatadoras. Objetivos: Este estudo avaliou os efeitos cardiovasculares e antiarrítmicos potenciais do DL em ratos. Métodos: Os parâmetros hemodinâmicos e eletrocardiográficos (ECG) foram mensurados em ratos Wistar machos que, sob anestesia, tiveram a aorta abdominal e a veia cava inferior canuladas e receberam eletrodos implantados subcutaneamente. Na abordagem in vitro, o coração foi removido e perfundido utilizando a técnica de Langendorff. O nível de significância adotado foi de 5% (p < 0,05). Resultados: DL, nas doses de 10, 20 e 40 mg/kg (i.v), produziu bradicardia intensa e persistente associada à hipotensão. A bradicardia com QTc prolongado foi observada no registro in vivo do ECG. No modelo in vivo de arritmia induzida por Bay K8644, DL (10 mg / kg) houve diminuição do escore da arritmia de 15,33 ± 3,52 para 4,0 ± 2,64 u.a (p < 0,05, n = 4). Em corações perfundidos isolados, o DL (10-3 M) promoveu reduções significativas na frequência cardíaca (de 228,6 ± 8,5 ms para 196,0 ± 9,3 bpm; p < 0,05) e na pressão desenvolvida do ventrículo esquerdo (de 25,2 ± 3,4 para 5,9 ± 1,8 mmHg; n = 5, p < 0,05). Conclusões: O DL produz bradicardia e atividade antiarrítmica no coração de ratos.
Subject(s)
Animals , Male , Arrhythmias, Cardiac/drug therapy , Bradycardia/drug therapy , Limonene/therapeutic use , Anti-Arrhythmia Agents/therapeutic use , Arrhythmias, Cardiac/diagnosis , Arrhythmias, Cardiac/chemically induced , Blood Pressure/drug effects , Bradycardia/diagnosis , Rats, Wistar , Ventricular Pressure/drug effects , Models, Animal , Electrocardiography , Isolated Heart Preparation , Limonene/pharmacology , Heart Rate/drug effects , Hemodynamics/drug effects , Hypotension , Anti-Arrhythmia Agents/pharmacologyABSTRACT
La fibrilación auricular (FA) es la arritmia sostenida más frecuente que puede presentarse en una amplia variedad de condiciones clínicas. A pesar de los progresos en el tratamiento de los pacientes con FA, esta arritmia sigue siendo una de las más importantes causas de accidente cerebrovascular, insuficiencia cardiaca, muerte súbita y morbilidad cardiovascular en todo el mundo. El objetivo del tratamiento con fármacos antiarrítmicos es mejorar los síntomas relacionados con la FA, y buscar un equilibrio entre la carga sintomática, la posibilidad de reacciones farmacológicas adversas y las preferencias del paciente. El control de la frecuencia cardiaca a corto y largo plazo se puede lograr con bloqueadores beta, digoxina, bloqueadores de los canales del calcio o tratamiento combinado. Si bien otros fármacos antiarrítmicos de clase III también tienen un efecto limitador de la frecuencia, solo deben emplearse para el control del ritmo cardiaco. Restaurar y mantener el ritmo sinusal también es una parte integral del tratamiento de la FA. Los fármacos antiarrítmicos de clase III duplican la tasa de pacientes en ritmo sinusal. El tratamiento para el control del ritmo está indicado para mejorar los síntomas de los pacientes con FA que siguen sintomáticos a pesar del tratamiento adecuado para el control de la frecuencia cardiaca. La combinación de antiarrítmicos que prolongan el intervalo QT no se debe emplear para el control del ritmo cardiaco en la FA(AU)
Atrial fibrillation (AF) is the most frequent sustained arrhythmia that can occur in a wide variety of clinical conditions. Despite progress in the treatment of patients with AF, this arrhythmia remains one of the most important causes of stroke, heart failure, sudden death and cardiovascular morbidity worldwide. The aim of treatment with antiarrhythmic drugs is to improve the symptoms related to AF, and to look for a balance between the symptomatic load, the possibility of adverse pharmacological reactions and the patient preferences. The short and long term heart rate control can be achieved with beta blockers, digoxin, calcium channel blockers or combination therapy. Although other class III antiarrhythmic drugs also have a frequency-limiting effect, they should only be used for the control of heart rhythm. Restoring and maintaining sinus rhythm is also an integral part of the treatment of AF. Class III antiarrhythmic drugs double the rate of patients who maintain their sinus rhythm. Treatment for rhythm control is indicated to improve the symptoms of patients with AF who remain symptomatic despite adequate treatment for heart rate control. The combination of antiarrhythmics that prolong the QT interval should not be used to control heart rhythm in AF(AU)
Subject(s)
Humans , Atrial Fibrillation/drug therapy , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/diagnosis , Heart Rate/drug effectsABSTRACT
A prevenção da fibrilação atrial (FA) envolve uma abordagem individualizada, multidisciplinar e integrada do paciente, que vai além da arritmia per se. Por se tratar de uma arritmia multifatorial e com fisiopatologia complexa, os pacientes com FA devem ser avaliados em sua integralidade, que inclui aspectos eletrocardiográficos, eletrofisiológicos, medidas comportamentais e otimização de tratamento de doenças crônicas, como hipertensão arterial e insuficiência cardíaca. Neste artigo descrevere-mos as principais intervenções estudadas na literatura com benefício na prevenção da fibrilação atrial
AF (atrial fibrillation) prevention involves an ndividualized, multidisciplinary and integrated approach taken by the patient, which emcompasses more than just arrhy- thmima per se. Because it is a multifactorial arrhythmia with complex physiopathology, patients with AF should undergo a complete assessment, including electrocardiographic and electrophysiological aspects, behavioral measures and optimization of the treatment of chronic diseases, such as hypertension and heart failure. In this article we describe the main interventions studied in literature that are beneficial in the prevention of atrial fibrillation
Subject(s)
Humans , Male , Female , Atrial Fibrillation/prevention & control , Anti-Arrhythmia Agents/therapeutic use , Arrhythmias, Cardiac/therapy , Sleep Wake Disorders/complications , Sleep Wake Disorders/diagnosis , Tobacco Use Disorder , Comorbidity , Risk Factors , Diabetes Mellitus , Secondary Prevention/methods , Heart Failure , Hypertension , ObesitySubject(s)
Humans , Male , Female , Middle Aged , Aged , Quality of Life , Atrial Fibrillation/drug therapy , Catheter Ablation , Hospitalization/statistics & numerical data , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/surgery , Atrial Fibrillation/complications , Stroke/prevention & control , Heart Arrest/prevention & control , Hemorrhage/prevention & control , Anti-Arrhythmia Agents/adverse effectsABSTRACT
ABSTRACT Objectives: To compare warfarin and dabigatran for thromboembolic event prevention in patients with nonvalvular atrial fibrillation or atrial flutter. Methods: This was a retrospective cohort of participants with nonvalvular atrial fibrillation or atrial flutter using either warfarin or dabigatran in a reference center in Brazil. Results: There were 112 patients (mean age 65.5 years), with 55.3% using warfarin. The median duration of follow-up was 1.9 years for warfarin and 1.6 years for dabigatran (p = 0.167). Warfarin patients had a higher median of medical appointments per year (8.3 [6.8-10.4] vs 3.1 [2.3-4.2], p < 0.001) and the frequency of minor bleeding was more than four times higher (17.7% vs 4.0%, p = 0.035). Among patients with prior stroke, those using warfarin had 2.6 times more medical appointments for person-years of follow-up (8.5 vs 3.3). There was no major bleeding or embolic event during follow-up period. Conclusion: The dabigatran group had a lower frequency of minor bleeding and number of medical appointments than the warfarin group, without more embolic events or major bleeding.
RESUMO Objetivos: Comparar varfarina e dabigatrana para prevenção de eventos tromboembólicos em pacientes com fibrilação atrial não valvar ou flutter (FA). Métodos: Coorte retrospectiva de pacientes com FA em uso de varfarina ou dabigatrana em serviço especializado no Brasil. Resultados: Foram avaliados 112 pacientes (média idade 65,5), com 55,3% no grupo varfarina. A mediana do tempo de seguimento foi de 1,9 anos para o grupo varfarina e 1,6 para dabigatrana (p = 0,167). No grupo varfarina houve maior mediana de consultas médicas (CM) por ano (8,3[6,8-10,4] vs. 3,1[2,3-4,2], p < 0,001), com frequência de sangramento menor quatro vezes maior (17,7% vs. 4,0%, p = 0,035). Nos pacientes com acidente vascular cerebral isquêmico prévio, o grupo varfarina teve 2,6 vezes mais CM por pessoas-ano de seguimento (8,5 vs. 3,3). Não houve sangramento maior ou eventos embólicos no período de seguimento. Conclusão: Pacientes em uso de dabigatrana tiveram menor número de sangramento menor e CM que aqueles em uso de varfarina, sem aumentar eventos embólicos ou sangramentos maiores.
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Atrial Fibrillation/prevention & control , Atrial Flutter/prevention & control , Thromboembolism/prevention & control , Warfarin/therapeutic use , Dabigatran/therapeutic use , Anticoagulants/therapeutic use , Atrial Fibrillation/complications , Atrial Flutter/complications , Thromboembolism/etiology , Brazil , Retrospective Studies , Risk Factors , Follow-Up Studies , Treatment Outcome , Statistics, Nonparametric , Stroke/etiology , Stroke/prevention & control , Ambulatory Care Facilities , Hemorrhage/prevention & control , Anti-Arrhythmia Agents/therapeutic useABSTRACT
Introdução: A cardiopatia chagásica crônica (CCC) engloba complexo espectro de apresentações, não sendo incomuns episódios de morte arrítmica em portadores de função ventricular esquerda preservada (FVEP) ou quase normal (FVEQN). Métodos: Avaliação retrospectiva de 7 portadores de CCC por 4 anos, com FVEP, submetidos a implante de cardiodesfibrilador implantável (CDI) devido taquicardia ou fibrilação ventricular (TV/FV). Foram realizadas avaliações clínica, estrutural e eletrocardiográfica. Resultados: Idade média: 57,5±4,45 anos e 71,4% do sexo masculino. Função ventricular esquerda (FVE) inicial foi de 56,14%±4,45, com alterações contrácteis em 100% e hipocinesia inferior em 85,7%. Classe funcional I: 100% sem modificações ao seguimento. Escore de Rassi avaliado previamente ao evento foi de 4,85±0,89. Síncope constituiu a apresentação inicial em 100%, média de 2 episódios por paciente e intervalo de 4 semanas entre os mesmos. Houve alterações em 85,71% dos eletrocardiogramas, sendo bloqueio de ramo direito a principal. TV sustentada foi encontrada em 100%; sítio epicárdico em 71,42% e saída anterolateral do ventrículo esquerdo em 57,14%. A FVE sequencial foi de 54%±3,31; sem alterações contráteis novas. Amiodarona e betabloqueadores foram os fármacos utilizados. Terapias apropriadas aconteceram em 100%; média de 2,1 choques por paciente, com 52,63% dos registros nos primeiros 14 meses. Não foram evidenciados óbitos, terapias inapropriadas ou tempestade elétrica. Conclusão: O elevado número de terapias corrobora o risco arrítmico desta população, ratifica a importância do dispositivo e alerta para a eficácia da terapia clínica. Síncope pode estar associada a maior risco de eventos arrítmicos na CCC
Introduction: Chronic chagasic cardiopathy (CCC) encompasses a complex spectrum of presentations, and episodes of arrhythmic death in patients with preserved left ventricular (PLVF) or near normal (VFNN) are not uncommon. Methods: Retrospective evaluation of 7 patients with PLVF, submitted for implantation of implantable cardioverter defibrillator (ICD) due to tachycardia or ventricular fibrillation (VT / VF). Clinical, structural and electrocardiographic evaluations were performed. Results: Mean age was 57.5±4.45 years. Male sex comprised 71.4%. Left ventricular function (LVF) was 56.14%±4.45 with contractile changes in 100% and lower hypokinesia in 85.7%. Functional class I was evidenced in 100% without changes in follow-up. The Rassi score evaluated before the event was 4.85±0.89. Syncope was the initial presentation in 100%, average of 2 episodes per patient and interval of 4 weeks between them. Electrocardiogram showed alterations in 85.71% being right bundle branch block. Sustained VT was evidenced in 100%; epicardial site in 71.42% and left ventricular anterolateral outlet in 57.14%. The sequential LVF was 54%±3.31; without new contractile changes. Amiodarone and beta-blockers were the drugs used. Appropriate therapies occurred in 100%; average of 2.1 shocks per patient with 52.63% of the records in the first 14 months. There were no deaths, inappropriate therapies or electrical storm. Conclusion: The high number of therapies corroborates the arrhythmic risk of this population, ratifies the importance of the device and disputes the effectiveness of clinical therapy. Syncope may be associated with an increased risk of arrhythmic events in CCC
Subject(s)
Humans , Male , Female , Adult , Chagas Cardiomyopathy/complications , Chagas Cardiomyopathy/therapy , Ventricular Function , Death, Sudden, Cardiac/prevention & control , Defibrillators, Implantable , Secondary Prevention/methods , Arrhythmias, Cardiac/complications , Arrhythmias, Cardiac/diagnosis , Stroke Volume , Syncope , Bundle-Branch Block/complications , Bundle-Branch Block/diagnosis , Echocardiography/methods , Sex Factors , Chronic Disease , Retrospective Studies , Chagas Disease/therapy , Amiodarone/therapeutic use , Anti-Arrhythmia Agents/therapeutic useSubject(s)
Humans , Male , Female , Atrial Fibrillation/therapy , Catheter Ablation/methods , Balloon Occlusion/methods , Arrhythmias, Cardiac/complications , Thromboembolism/therapy , Angiography/methods , Magnetic Resonance Spectroscopy/methods , Tomography, X-Ray Computed/methods , Risk Factors , Echocardiography, Transesophageal/methods , Atrial Appendage , Drug Therapy/methods , Anti-Arrhythmia Agents/therapeutic use , Anticoagulants/therapeutic useABSTRACT
La fibrilación auricular (FA) es la arritmia cardiaca más frecuente en la práctica clínica, se caracteriza por presentar una frecuencia auricular desorganizada mayor a 200 latidos por minuto, asociado a una respuesta ventricular variable. La FA se puede clasificar en tres tipos distintos de acuerdo a su presentación: FA paroxística, FA persistente y FA permanente. La FA paroxística es aquella que se presenta como episodios súbitos que se autolimitan y tienen como máximo una duración de una semana. La FA persistente es aquella en la que la alteración del ritmo persiste por más de una semana, luego de ese tiempo se puede autolimitar o puede responder a tratamiento. Por otro lado, la FA permanente es aquella condición donde por consenso del médico y paciente debido a las características clínicas del paciente y la propia arritmia se decide seguir solo las estrategias de control de frecuencia para el control de síntomas, no siendo de interés restaurar el ritmo sinusal del paciente. Tanto la FA paroxística como la persistente pueden convertirse en FA permanente (1). Otro concepto importante es el de FA valvular, definido como FA en portadores de prótesis valvular mecánica o padecen de estenosis mitral moderada o severa, los cuales tendrían mayor riesgo de eventos tromboembólicos (2). Existen diversas técnicas que pueden ser útiles para el diagnóstico de FA, entre ellos se encuentra la palpación del pulso que posee una sensibilidad de 0.92 (IC 95%: 0.85 a 0.96) y una especificidad de 0.82 (IC 95%: 0.76 a 0.88) (3). La baja especificidad de la palpación del pulso significa un aumento de falsos positivos por lo que esta técnica debería ser utilizada solo en pacientes con sospecha de FA como aquellos que presentan: falta de aire/disnea, palpitaciones, síncope/mareos, dolor o disconfort de pecho y desorden cerebrovascular (DCV) isquémico. Por este motivo se considera que la palpación del pulso puede ser útil para identificar pulso irregular en pacientes con síntomas sugestivos de FA. El uso de electrocardiograma (ECG) tiene una sensibilidad de 0.91 (IC 95%: 0.86 a 0.94) y una especificidad de 0.95 (IC 95%: 0.92 a 0.97) para detectar R-R irregulares cuando es interpretado por enfermeras, médicos generales o cardiólogos (3). Por este motivo este método es útil para diagnosticar FA en todos los pacientes, sintomáticos o no, en los que se sospeche fibrilación auricular debido a la detección de pulso irregular.
Subject(s)
Humans , Atrial Fibrillation/diagnosis , Risk Index , Thromboembolism/drug therapy , Electric Countershock/methods , Hemorrhage/prevention & control , Anti-Arrhythmia Agents/therapeutic useABSTRACT
Resumen Introducción y objetivos: Dronedarona y flecainida son antiarrítmicos de primera elección para reducir recurrencias de fibrilación auricular (FA), sin existir estudios que los comparen entre sí. Nuestro objetivo es comparar la eficacia en cuanto a prevención de recurrencias y seguridad de ambos fármacos. Métodos: Estudio retrospectivo en el que se incluyeron 123 pacientes de forma consecutiva en tratamiento con flecainida o dronedarona desde octubre de 2010 hasta febrero de 2013 por FA paroxística (76.4%) y FA persistente (23.6%). Se realizó cardioversión eléctrica en un 7.3% de los pacientes y farmacológica en un 16.3%. La mediana (rango intercuartílico) de seguimiento fue de 301 días (92-474), con una media de 2.8 revisiones por paciente. Se realizó análisis de tiempo hasta el primer evento mediante Kaplan-Meier y regresión de Cox ajustada por un índice de propensión. Resultados: De entre los 123 sujetos incluidos con FA, 71 fueron tratados con flecainida y 52 con dronedarona. Durante el seguimiento se registraron 36 recurrencias y 20 efectos adversos. Se documentaron un 36.6% de recurrencias en los pacientes tratados con flecainida en comparación con un 21% en los tratados con dronedarona (p = 0.073). En el análisis multivariante, dronedarona se mostró al menos tan eficaz como flecainida para prevenir recurrencias de FA (HR: 0.53, IC 95%: 0.20-1.44, p = 0.221) y demostró un perfil de seguridad comparable al de flecainida (HR: 0.68, IC 95%: 0.18-2.53, p = 0.566). Conclusiones: Según nuestra experiencia, dronedarona resulta al menos tan eficaz como flecainida para el mantenimiento de ritmo sinusal, con un buen perfil de tolerabilidad, a pesar de pautarse en pacientes con un perfil clínico más desfavorable.
Abstract Introduction and objectives: Dronedarone and flecainide are the first pharmacological choice to reduce recurrence of atrial fibrillation (AF); however, there are no studies comparing them. A study was performed to compare the efficacy in terms of recurrence of AF and safety of both drugs. Methods: A retrospective cohort study was conducted that included 123 consecutive patients treated with flecainide or dronedarone due to paroxysmal AF (76.4%) or persistent AF (23.6%), from October 2010 to February 2013. Electrical cardioversion was performed in 7.3% of patients and pharmacological cardioversion in 16.3%. The median (interquartile range) follow-up was 301 days (92-474) with a mean of 2.8 reviews per patient. Time to first event analysis was performed using Kaplan-Meier and Cox regression, adjusted for propensity score. Results: Of the 123 consecutive patients with AF included, 71 were on dronedarone and 52 on flecainide. During the follow-up, there were 36 AF recurrences and 20 safety events. There were recurrences in 36.6% of patients treated with flecainide, compared with 21% of those receiving dronedarone (P = .073). Dronedarone showed to be at least as effective as flecainide in preven- ting recurrence of atrial fibrillation (HR: 0.53, 95% CI: 0.20-1.44, P = .221), and demonstrated an acceptable safety profile when compared with flecainide (HR: 0.68, 95% CI: 0.18-2.53, P = .566). Conclusions: In our experience, dronedarone has been at least as effective and safe as flecainide, despite it was most frequently prescribed in patients with worse baseline risk profile.
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Atrial Fibrillation/drug therapy , Flecainide/therapeutic use , Dronedarone/therapeutic use , Anti-Arrhythmia Agents/therapeutic use , Recurrence , Atrial Fibrillation/physiopathology , Proportional Hazards Models , Retrospective Studies , Cohort Studies , Follow-Up Studies , Treatment Outcome , Kaplan-Meier Estimate , Anti-Arrhythmia Agents/adverse effectsABSTRACT
Instabilidade elétrica atrial é um termo recentemente incorporado na prática médica para descrever o amplo espectro de arritmias atriais que se sobrepõem. Essa relação já era intuitiva entre flutter atrial e fibrilação atrial (que deu berço ao anteriormente chamado "fibrilo-flutter"), e, mais recentemente, associou taquicardias atriais e fibrilação atrial. Essa relação é de suma importância, posto que o diagnóstico de fibrilação atrial implica estratégias para prevenção de eventos embólicos. Com novos métodos de rastreio, o diagnóstico de fibrilação atrial se mostrou mais frequente (monitorização prolongada, monitores implantáveis, telemetria de marcapassos). A presença de extrassistolia atrial e taquicardia atrial se torna um desafio: apesar da relação intuitiva de maior risco para fibrilação atrial e eventos cerebrovasculares, a evidência científica para tal se tornou mais robusta recentemente. Este artigo tem a intenção de agregar a evidência de melhor qualidade disponível para facilitar a seleção da estratégia adequada ante um paciente portador de taquicardia e extrassistolia atrial e avaliar adequadamente seu risco
Atrial electrical instability is a recently incorporated term in medical practice to describe the broad spectrum of overlapping atrial arrhythmias. This relationship was already intuitive between atrial flutter and atrial fibrillation (which gave birth to the so-called "fibril-flutter"), and has more recently been related to atrial tachycardias and atrial fibrillation. This relationship is extremely important, since the diagnosis of atrial fibrillation implies in strategies to prevent embolic events. With new screening methods, the diagnosis of atrial fibrillation has become more frequent (prolonged monitoring, implantable monitors, pacemaker telemetry). The presence of atrial extrasystoles and atrial tachycardia is a challenge: despite the intuitive relationship of higher risk for atrial fibrillation and cerebrovascular events, the scientific evidence became more robust recently. This article intends to aggregate the best quality evidence available to facilitate the choice of an appropriate strategy for a patient with tachycardia and atrial extrasystoles and to adequately assess their risk