Efficacy, Safety, and Performance of Isolated Left vs. Right Ventricular Pacing in Patients with Bradyarrhythmias: A Randomized Controlled Trial / Eficácia, Segurança e Desempenho da Estimulação Ventricular Esquerda versus Direita em Pacientes com Bradiarritmias: Ensaio Clínico Randomizado

Abstract Background: Considering the potential deleterious effects of right ventricular (RV) pacing, the hypothesis of this study is that isolated left ventricular (LV) pacing through the coronary sinus is safe and may provide better clinical and echocardiographic benefits to patients with bradyarrhythmias and normal ventricular function requiring heart rate correction alone. Objective: To assess the safety, efficacy, and effects of LV pacing using an active-fixation coronary sinus lead in comparison with RV pacing, in patients eligible for conventional pacemaker (PM) implantation. Methods: Randomized, controlled, and single-blinded clinical trial in adult patients submitted to PM implantation due to bradyarrhythmias and systolic ventricular function ≥ 0.40. Randomization (RV vs. LV) occurred before PM implantation. The main results of the study were procedural success, safety, and efficacy. Secondary results were clinical and echocardiographic changes. Chi-squared test, Fisher's exact test and Student's t-test were used, considering a significance level of 5%. Results: From June 2012 to January 2014, 91 patients were included, 36 in the RV Group and 55 in the LV Group. Baseline characteristics of patients in both groups were similar. PM implantation was performed successfully and without any complications in all patients in the RV group. Of the 55 patients initially allocated into the LV group, active-fixation coronary sinus lead implantation was not possible in 20 (36.4%) patients. The most frequent complication was phrenic nerve stimulation, detected in 9 (25.7%) patients in the LV group. During the follow-up period, there were no hospitalizations due to heart failure. Reductions of more than 10% in left ventricular ejection fraction were observed in 23.5% of patients in the RV group and 20.6% of those in the LV group (p = 0.767). Tissue Doppler analysis showed that 91.2% of subjects in the RV group and 68.8% of those in the LV group had interventricular dyssynchrony (p = 0.022). Conclusion: The procedural success rate of LV implant was low, and the safety of the procedure was influenced mainly by the high rate of phrenic nerve stimulation in the postoperative period.

Resumo Fundamento: Considerando-se os potenciais efeitos deletérios da estimulação do ventrículo direito (VD), a hipótese desse estudo é que a estimulação unifocal ventricular esquerda pelo seio coronário é segura e pode proporcionar melhores benefícios clínicos e ecocardiográficos aos pacientes com bradiarritmias que apresentam função ventricular normal, necessitando apenas da correção da frequência cardíaca. Objetivos: Avaliar a segurança, a eficácia e os efeitos da estimulação do ventrículo esquerdo (VE), utilizando um cabo-eletrodo com fixação ativa, em comparação à estimulação do VD. Métodos: Estudo clínico, randomizado, simples-cego em pacientes adultos com indicação de marca-passo (MP) devido a bradiarritmias e função ventricular sistólica ≥ 0,40. A randomização aleatória (VD vs VE) ocorreu antes do procedimento. Os desfechos primários do estudo foram: o sucesso, a segurança e a eficácia do procedimento proposto. Os desfechos secundários foram: a evolução clínica e alterações ecocardiográficas. Empregou-se os testes Qui-quadrado, Exato de Fisher e t de Student, com nível de significância de 5%. Resultados: De junho de 2012 a janeiro de 2014 foram incluídos 91 pacientes, sendo 36 no grupo VD e 55 no grupo VE. As características basais dos pacientes dos dois grupos foram similares. O implante de MP foi realizado com sucesso e sem nenhuma intercorrência em todos os pacientes do grupo VD. Dos 55 pacientes inicialmente alocados para o grupo VE, o implante do cabo-eletrodo em veias coronárias não foi possível em 20 (36,4%) pacientes. Dentre os 35 pacientes que permaneceram com o cabo-eletrodo no VE, a estimulação frênica foi a complicação mais frequente e foi detectada em 9 (25,7%) pacientes. Na fase de seguimento clínico, não houve hospitalizações por insuficiência cardíaca. Reduções superiores a 10% na fração de ejeção do VE foram observadas em 23,5% dos pacientes do grupo VD e em 20,6% dos pacientes do grupo VE (p = 0,767). A análise feita pelo Doppler tecidual mostrou que 91,2% dos indivíduos do grupo VD e 68,8% dos do grupo VE apresentaram dissincronia interventricular (p = 0,022). Conclusões: A taxa de sucesso do implante no VE foi baixa e a segurança do procedimento foi influenciada, principalmente, pela alta taxa de estimulação frênica no pós-operatório.

Trastornos de la conducta alimentaria: alteraciones cardiovasculares al ingreso y evolución a 3 meses / Female adolescents with eating disordes: cardiac abnormalities

Background: Cardiovascular complications can occur in up to 80% of adolescent patients with eating disorders (ED) and account for 30% of their mortality. Aim: To evaluate cardiovascular complications in adolescents with ED and their evolution after refeeding. Patients and Methods: In adolescents with ED admitted to treatment, we assessed the nutritional status, weight loss prior to consultation, presence of bradycardia (BC, defined as heart rate < 60 bpm), we performed an electrocardiogram (ECG) and an echocardiography and measured thyroid hormones. Results: We studied 53 women aged 16.4 ± 2.3 years. Fifteen had a diagnosis of Anorexia Nervosa (AN), seven of Bulimia (BN), eight a not otherwise specified ED (ED-NOS), four a Binge Eating Disorder (BED), sixteen an Atypical Anorexia (AAN) and three an Atypical Bulimia (ABN). Thirty four percent were malnourished and 3.8% overweight. The most common cardiac problem was BC in 51%. In eight of 26 patients in whom an echocardiogram was done, it was abnormal. Six had a decreased ventricular mass, three a pericardial effusion and three valvular involvement. There was a significant association between bradycardia and malnutrition, weight loss and low free triiodothyronine levels. BC was significantly more common in patients with AN, but it also occurred in half of the patients with AAN and in one of three patients with other types of ED. At follow up, bradycardia significantly improved with refeeding. Conclusions: There is an association between all types of ED and bradycardia, as well as anatomical and functional cardiac anomalies.

Compromiso de conciencia y bradicardia / Unconciousness and bradycardia

Resumen: Mujer de 71 años, institucionalizada con antecedentes de esquizofrenia y tabaquismo. Consulta en el servicio de urgencias tras ser encontrada a la intemperie comprometida de conciencia. Al llegar la ambulancia se constata mal perfundida, bradipsíquica y bradicárdica, siendo trasladada al servicio de Urgencia. A su ingreso el ECG mostró bradicardia sinusal con trastorno de la conducción intraventricular y prolongación del intervalo QT. Los exámenes de laboratorio al ingreso resultaron dentro de límites normales. La historia clínica y los trazados electrocardiográficos son presentados, siendo discutidos junto al manejo médico.

Abstracts: A 71year old woman, institutionalized with a history of schizophrenia and smoking. She was transported to a local emergency room after being found laying outside unconscious. She was hypoperfused, bradypsychic and bradycardic, being transferred to the emergency service. On admission, the ECG showed sinus bradycardia with intraventricular conduction delay and QT prolongation. Laboratory tests were normal. Clinical history, physical examination and ECG tracings are presented and management is discussed.

Alteraciones electrocardiográficas en anorexia nervosa: revisión crítica de la literatura / Electrocardiographic abnormalities in anorexia nervosa: a critical review of the literature

Introducción: La anorexia nervosa (AN) es un trastorno de la conducta alimentaria y, entre sus causas de mortalidad, las arritmias cardiacas y la muerte súbita son frecuentes, por lo que es indispensable la monitorización electrocardiográfica. Se han descrito muchos hallazgos con resultados contradictorios, por lo que es necesaria una revisión crítica de la literatura científica. Metodología: Revisión de los estudios relevantes sobre cambios electrocardiográficos en AN, consultados en PubMed desde 1974 hasta febrero de 2014, utilizando los términos MeSH: Eating disorders, nervosa anorexia, sinusal bradycardia, QT prolongation, QT dispersion, electrocardiography, EKG, electrocardiogram. Resultados y discusión: Las dos alteraciones más comunes reportadas incluyen la bradicardia sinusal y los cambios en la repolarización evidenciados en prolongación del QT e incremento de su dispersión. Los trastornos electrolíticos parecen ser la causa de estas alteraciones en algunos pacientes, pero otras razones se discuten en detalle, como la desviación del eje del QRS a la derecha, la alteración en variabilidad de la frecuencia cardiaca, R en derivación V6 de bajo voltaje, disminución de la amplitud del QRS y onda T y alargamiento del QRS. La mayoría de los autores hablan de reversibilidad de los cambios después del tratamiento. Conclusiones: Estos resultados siguen apoyando la necesidad de valorar a los pacientes con AN con electrocardiogramas inicial y de seguimiento, para el diagnóstico temprano y tratamiento de alteraciones cardiovasculares relacionadas con alta morbimortalidad. También apoyan la necesidad del uso racional de psicofármacos para no aumentar el riesgo de arritmias cardiacas y muerte súbita.

Background: Anorexia nervosa is an eating disorder in which cardiac arrhythmias and sudden death are frequent causes of mortality, which makes electrocardiographic monitoring indispensable in these patients. There are many suggestive findings but results are contradictory, making a critical review of the scientific literature is necessary. Methods: The most relevant studies on electrocardiographic (EKG) changes in patients with AN, found in PubMed from 1974 to February 2014, were reviewed using the MeSH terms: eating disorders, nervosa anorexia, sinus bradycardia, QT prolongation, QT dispersion, electrocardio graphy, EKG, and electrocardiogram. Findings and discussion: The two most common EKG findings reported in the literature are sinus bradycardia and changes in depolarization, as shown by prolongation and increased dispersion of the QT interval. Electrolyte disturbances seem to be the cause of these disturbances in some patients, but other reasons are also discussed in detail, such as QRS right axis deviation, disturbances of heart rate variability, low R wave voltage in V6, amplitude decrease of the QRS and T wave, and QRS prolongation. The majority of authors report that these changes are reversible after treatment of AN. Conclusions: These findings support the need for initial and follow-up EKGs in patients with AN and for early diagnosis and treatment of cardiovascular disturbances that are associated with morbidity and mortality. They also support the need for the rational use of psychop harmacology, and that does not increase the risk of arrhythmias and sudden death in these patients.

Alteraciones electrocardiográficas en hipotermia severa accidental: Caso clínico y revisión de la literatura / Electrocardiographic manifestations of severe accidental hypothermia: Report of one case

We report a 77-year-old female patient who was admitted to the Emergency Department with impairment of consciousness, hypotension, bradycardia and hypothermia. She required endotracheal intubation and transfer to Intensive Care Unit (ICU). Computed tomography of the brain showed no lesions. Electrocardiogram showed abnormalities suggestive of severe hypothermia (bradycardia, marked elevation of J point associated with ST depression, a negative T wave in V2 to V6 and prolongation of QTc), which was confirmed with a pulmonary artery catheter. Myxedema coma, infections and neurological diseases were discarded. The cause of severe hypothermia was unclear, and the probable source was suspected to be accidental. After intensive treatment the patient improved, achieving normalization of electrocardiographic changes, recovery of organic functions and she was discharged home after 22 days.

[Trigemino-cardiac reflex during skull-base neurosurgeries: a case report]

The Trigemino-cardiac reflex [TCR] has been studied as a phenomenon including; bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve. We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine [0.5mg/IV] and did not happen again. The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

Fetal Heart Rate Regresses toward the Mean in the Third Trimester

The purpose of this study was to investigate the feasibility of different fetal heart rate (FHR) ranges in the nonstress test (NST) and to better understand the meaning of mild bradycardia and/or tachycardia without non-reassuring patterns. We employed the heredity to show that mild bradycardia (100-119 beats per minute, bpm) and mild tachycardia (161-180 bpm) regressed to the normal FHR range (120-160 bpm). We used linear regression to analyze FHR data from FHR tracings recorded 10 min before (NST, as the predictor) and 10 min after vibroacoustic stimulation testing (as the dependent variable). Acceleration for 15 bpm-15 seconds (Acc1515) and deceleration for 15 bpm-15 seconds (Dec1515) in the NST were also analyzed for each group. The slope of the best-fit line was the largest in the mild bradycardia group and the smallest in the normal range group. Dec1515 was most prominent in mild tachycardia and both the mild bradycardia and tachycardia groups regressed towards the mean FHR range. Therefore, we propose that both mild bradycardia and tachycardia of FHR in non-acute situations (range between 100 and 180 bpm) are not regarded a pathologic signal for clinical use.

Cardiac and renal effects induced by different exercise workloads in renovascular hypertensive rats

We examined the effect of exercise training (Ex) without (Ex 0 percent) or with a 3 percent workload (Ex 3 percent) on different cardiac and renal parameters in renovascular hypertensive (2K1C) male Fisher rats weighing 150-200 g. Ex was performed for 5 weeks, 1 h/day, 5 days/week. Ex 0 percent or Ex 3 percent induced similar attenuation of baseline mean arterial pressure (MAP, 119 ± 5 mmHg in 2K1C Ex 0 percent, N = 6, and 118 ± 5 mmHg in 2K1C Ex 3 percent, N = 11, vs 99 ± 4 mmHg in sham sedentary (Sham Sed) controls, N = 10) and heart rate (HR, bpm) (383 ± 13 in 2K1C Ex 0 percent, N = 6, and 390 ± 14 in 2K1C Ex 3 percent, N = 11 vs 371 ± 11 in Sham Sed, N = 10,). Ex 0 percent, but not Ex 3 percent, improved baroreflex bradycardia (0.26 ± 0.06 ms/mmHg, N = 6, vs 0.09 ± 0.03 ms/mmHg in 2K1C Sed, N = 11). Morphometric evaluation suggested concentric left ventricle hypertrophy in sedentary 2K1C rats. Ex 0 percent prevented concentric cardiac hypertrophy, increased cardiomyocyte diameter and decreased cardiac vasculature thickness in 2K1C rats. In contrast, in 2K1C, Ex 3 percent reduced the concentric remodeling and prevented the increase in cardiac vasculature wall thickness, decreased the cardiomyocyte diameter and increased collagen deposition. Renal morphometric analysis showed that Ex 3 percent induced an increase in vasculature wall thickness and collagen deposition in the left kidney of 2K1C rats. These data suggest that Ex 0 percent has more beneficial effects than Ex 3 percent in renovascular hypertensive rats.

Central 5-HT2A receptors modulate the vagal bradycardia in response to activation of the von Bezold-Jarisch reflex in anesthetized rats

Activation of 5-hydroxytryptamine (5-HT) 5-HT1A, 5-HT2C, 5-HT3, and 5-HT7 receptors modulates the excitability of cardiac vagal motoneurones, but the precise role of 5-HT2A/2B receptors in these phenomena is unclear. We report here the effects of intracisternal (ic) administration of selective 5-HT2A/2B antagonists on the vagal bradycardia elicited by activation of the von Bezold-Jarisch reflex with phenylbiguanide. The experiments were performed on urethane-anesthetized male Wistar rats (250-270 g, N = 7-9 per group). The animals were placed in a stereotaxic frame and their atlanto-occipital membrane was exposed to allow ic injections. The rats received atenolol (1 mg/kg, iv) to block the sympathetic component of the reflex bradycardia; 20-min later, the cardiopulmonary reflex was induced with phenylbiguanide (15 µg/kg, iv) injected at 15-min intervals until 3 similar bradycardias were obtained. Ten minutes after the last pre-drug bradycardia, R-96544 (a 5-HT2A antagonist; 0.1 µmol/kg), SB-204741 (a 5-HT2B antagonist; 0.1 µmol/kg) or vehicle was injected ic. The subsequent iv injections of phenylbiguanide were administered 5, 20, 35, and 50 min after the ic injection. The selective 5-HT2A receptor antagonism attenuated the vagal bradycardia and hypotension, with maximal effect at 35 min after the antagonist (pre-drug = -200 ± 11 bpm and -42 ± 3 mmHg; at 35 min = -84 ± 10 bpm and -33 ± 2 mmHg; P < 0.05). Neither the 5-HT2B receptor antagonists nor the vehicle changed the reflex. These data suggest that central 5-HT2A receptors modulate the central pathways of the parasympathetic component of the von Bezold-Jarisch reflex.

The Role of the Calcium and the Voltage Clocks in Sinoatrial Node Dysfunction

Recent evidence indicates that the voltage clock (cyclic activation and deactivation of membrane ion channels) and Ca2+ clocks (rhythmic spontaneous sarcoplasmic reticulum Ca2+ release) jointly regulate sinoatrial node (SAN) automaticity. However, the relative importance of the voltage clock and Ca2+ clock for pacemaking was not revealed in sick sinus syndrome. Previously, we mapped the intracellular calcium (Cai) and membrane potentials of the normal intact SAN simultaneously using optical mapping in Langendorff-perfused canine right atrium. We demonstrated that the sinus rate increased and the leading pacemaker shifted to the superior SAN with robust late diastolic Cai elevation (LDCAE) during beta-adrenergic stimulation. We also showed that the LDCAE was caused by spontaneous diastolic sarcoplasmic reticulum (SR) Ca2+ release and was closely related to heart rate changes. In contrast, in pacing induced canine atrial fibrillation and SAN dysfunction models, Ca2+ clock of SAN was unresponsiveness to beta-adrenergic stimulation and caffeine. Ryanodine receptor 2 (RyR2) in SAN was down-regulated. Using the prolonged low dose isoproterenol together with funny current block, we produced a tachybradycardia model. In this model, chronically elevated sympathetic tone results in abnormal pacemaking hierarchy in the right atrium, including suppression of the superior SAN and enhanced pacemaking from ectopic sites. Finally, if the LDCAE was too small to trigger an action potential, then it induced only delayed afterdepolarization (DAD)-like diastolic depolarization (DD). The failure of DAD-like DD to consistently trigger a sinus beat is a novel mechanism of atrial arrhythmogenesis. We conclude that dysfunction of both the Ca2+ clock and the voltage clock are important in sick sinus syndrome.

Heart rate analysis differentiates dialeptic complex partial temporal lobe seizures from auras and non-epileptic seizures

The distinction of non-epileptic from epileptic events is difficult even for experienced neurologists. We retrospectively evaluated 59 dialeptic events from 27 patients admitted for video EEG monitoring to check whether heart rate (HR) analysis could help in differentiating dialeptic complex partial temporal lobe seizures (TLS) from dialeptic simple partial TLS, and non-epileptic dialeptic events. Baseline HR was increased in the simple partial TLS in comparison to complex partial TLS and non-epileptic groups (p<0.05). HR increase accompanied each individual dialeptic complex partial TLS (100 percent of the events, p<0.05) bur HR returned to baseline in the post-ictal phase. Ictal HR was not altered in the non-epileptic or simple partial TLS groups. Our findings suggest that ictal centrally mediated tachycardia is characteristic of dialeptic TLS (both tachycardia and bradycardia have been reported during TLS). This finding may be used as a criterion to distinguish dialeptic complex partial TLS from simple partial and non-epileptic dialeptic events.

A distinção entre eventos não epilépticos de epilépticos é difícil mesmo para neurologistas experientes. Analisamos 59 eventos dialéticos de 27 pacientes internados para monitorização por video-EEG para checar se a análise da frequência cardíaca (FC) poderia auxiliar na diferenciação de crises dialépticas parciais complexas de crises dialépticas parciais simples e eventos dialépticos não epilépticos. A freqüência cardíaca basal estava aumentada nos pacientes com crises parciais simples em comparação com o período basal dos grupos parcial complexa e não epiléptico (p<0,05). Houve aumento da freqüência cardíaca em cada crise dialéptica parcial complexa (100 por cento dos eventos, p<0,05), mas a FC retornou aos níveis basais na fase pós-ictal. A FC ictal não foi alterada nos grupos de crises não epiléticas e nos pacientes com crises parciais simples. Nossos achados sugerem que a taquicardia ictal com mediação central é característica de crises parciais complexas dialépticas (tanto taquicardia quanto bradicardia têm sido relatados durante crises temporais parciais complexas). Tal achado poderá ser utilizado como critério para diferenciar crises dialépticas parciais complexas de crises dialépticas parciais simples e eventos dialépticos não epilépticos.

The bradycardic and hypotensive responses to serotonin are reduced by activation of GABA A receptors in the nucleus tractus solitarius of awake rats

We investigated the effects of bilateral injections of the GABA receptor agonists muscimol (GABA A) and baclofen (GABA B) into the nucleus tractus solitarius (NTS) on the bradycardia and hypotension induced by iv serotonin injections (5-HT, 2 æg/rat) in awake male Holtzman rats. 5-HT was injected in rats with stainless steel cannulas implanted bilaterally in the NTS, before and 5, 15, and 60 min after bilateral injections of muscimol or baclofen into the NTS. The responses to 5-HT were tested before and after the injection of atropine methyl bromide. Muscimol (50 pmol/50 nl, N = 8) into the NTS increased basal mean arterial pressure (MAP) from 115 ± 4 to 144 ± 6 mmHg, did not change basal heart rate (HR) and reduced the bradycardia (-40 ± 14 and -73 ± 26 bpm at 5 and 15 min, respectively, vs -180 ± 20 bpm for the control) and hypotension (-11 ± 4 and -14 ± 4 mmHg, vs -40 ± 9 mmHg for the control) elicited by 5-HT. Baclofen (12.5 pmol/50 nl, N = 7) into the NTS also increased basal MAP, but did not change basal HR, bradycardia or hypotension in response to 5-HT injections. Atropine methyl bromide (1 mg/kg body weight) injected iv reduced the bradycardic and hypotensive responses to 5-HT injections. The stimulation of GABA A receptors in the NTS of awake rats elicits a significant increase in basal MAP and decreases the cardiac Bezold-Jarisch reflex responses to iv 5-HT injections.

Loss of resting bradycardia with detraining is associated with intrinsic heart rate changes

The mechanisms underlying the loss of resting bradycardia with detraining were studied in rats. The relative contribution of autonomic and non-autonomic mechanisms was studied in 26 male Wistar rats (180-220 g) randomly assigned to four groups: sedentary (S, N = 6), trained (T, N = 8), detrained for 1 week (D1, N = 6), and detrained for 2 weeks (D2, N = 6). T, D1 and D2 were treadmill trained 5 days/week for 60 min with a gradual increase towards 50 percent peak VO2. After the last training session, D1 and D2 were detrained for 1 and 2 weeks, respectively. The effect of the autonomic nervous system in causing training-induced resting bradycardia and in restoring heart rate (HR) to pre-exercise training level (PET) with detraining was examined indirectly after cardiac muscarinic and adrenergic receptor blockade. T rats significantly increased peak VO2 by 15 or 23.5 percent when compared to PET and S rats, respectively. Detraining reduced peak VO2 in both D1 and D2 rats by 22 percent compared to T rats, indicating loss of aerobic capacity. Resting HR was significantly lower in T and D1 rats than in S rats (313 ± 6.67 and 321 ± 6.01 vs 342 ± 12.2 bpm) and was associated with a significantly decreased intrinsic HR (368 ± 6.1 and 362 ± 7.3 vs 390 ± 8 bpm). Two weeks of detraining reversed the resting HR near PET (335 ± 6.01 bpm) due to an increased intrinsic HR in D2 rats compared with T and D1 rats (376 ± 8.8 bpm). The present study provides the first evidence of intrinsic HR-mediated loss of resting bradycardia with detraining in rats.

Relationship between cardiovascular dysfunction and hyperglycemia in streptozotocin-induced diabetes in rats

Streptozotocin (STZ)-induced diabetes in rats is characterized by cardiovascular dysfunction beginning 5 days after STZ injection, which may reflect functional or structural autonomic nervous system damage. We investigated cardiovascular and autonomic function, in rats weighing 166 ± 4 g, 5-7, 14, 30, 45, and 90 days after STZ injection (N = 24, 33, 27, 14, and 13, respectively). Arterial pressure (AP), mean AP (MAP) variability (standard deviation of the mean of MAP, SDMMAP), heart rate (HR), HR variability (standard deviation of the normal pulse intervals, SDNN), and root mean square of successive difference of pulse intervals (RMSSD) were measured. STZ induced increased glycemia in diabetic rats vs control rats. Diabetes reduced resting HR from 363 ± 12 to 332 ± 5 bpm (P < 0.05) 5 to 7 days after STZ and reduced MAP from 121 ± 2 to 104 ± 5 mmHg (P = 0.007) 14 days after STZ. HR and MAP variability were lower in diabetic vs control rats 30-45 days after STZ injection (RMSSD decreased from 5.6 ± 0.9 to 3.4 ± 0.4 ms, P = 0.04 and SDMMAP from 6.6 ± 0.6 to 4.2 ± 0.6 mmHg, P = 0.005). Glycemia was negatively correlated with resting AP and HR (r = -0.41 and -0.40, P < 0.001) and with SDNN and SDMMAP indices (r = -0.34 and -0.49, P < 0.01). Even though STZ-diabetic rats presented bradycardia and hypotension early in the course of diabetes, their autonomic function was reduced only 30-45 days after STZ injection and these changes were negatively correlated with plasma glucose, suggesting a metabolic origin.

Swimming training increases cardiac vagal activity and induces cardiac hypertrophy in rats

The effect of swimming training (ST) on vagal and sympathetic cardiac effects was investigated in sedentary (S, N = 12) and trained (T, N = 12) male Wistar rats (200-220 g). ST consisted of 60-min swimming sessions 5 days/week for 8 weeks, with a 5 percent body weight load attached to the tail. The effect of the autonomic nervous system in generating training-induced resting bradycardia (RB) was examined indirectly after cardiac muscarinic and adrenergic receptor blockade. Cardiac hypertrophy was evaluated by cardiac weight and myocyte morphometry. Plasma catecholamine concentrations and citrate synthase activity in soleus muscle were also determined in both groups. Resting heart rate was significantly reduced in T rats (355 ± 16 vs 330 ± 20 bpm). RB was associated with a significantly increased cardiac vagal effect in T rats (103 ± 25 vs 158 ± 40 bpm), since the sympathetic cardiac effect and intrinsic heart rate were similar for the two groups. Likewise, no significant difference was observed for plasma catecholamine concentrations between S and T rats. In T rats, left ventricle weight (13 percent) and myocyte dimension (21 percent) were significantly increased, suggesting cardiac hypertrophy. Skeletal muscle citrate synthase activity was significantly increased by 52 percent in T rats, indicating endurance conditioning. These data suggest that RB induced by ST is mainly mediated parasympathetically and differs from other training modes, like running, that seems to mainly decrease intrinsic heart rate in rats. The increased cardiac vagal activity associated with ST is of clinical relevance, since both are related to increased life expectancy and prevention of cardiac events.

Papel do estudo eletrofisiológico nas indicações para implante de marcapassos e desfibriladores automáticos / Paper of eletrofisiology study in indications for implantation pacemakers and automatics desfibrilators

Em diversas síndromes bradicárdicas e taquicárdicas, torna-se necessário o implante de marcapassos e/ou cardiodesfibriladores automáticos. Sua indicação baseia-se geralmente em dados de história clínica e em exames complementares não invasivos. Em certas situações específicas, entretanto, são necessários dados mais consistentes obtidos por meio do estudo eletrofisiológico invasivo. Nesta revisão, são abordadas, de maneira sistemática, as bradiarritmias e as taquiarritmias associadas ou nao a cardiopatias estruturais, em que o estudo eletrofisiológico invasivo é de grande utilidade e, às vezes, essencial

Noções básicas e novos recursos dos marcapassos e desfibriladores de interesse do cardiologista / Basic knowledge and new resources of pacemakers and desfibrillators interest of cardiology

Atualmente, os marcapassos e os desfibriladores são próteses que corrigem a bradicardia, promovem a resposta de freqüência ao esforço, corrigem o sincrinismo atrioventricular , ressincronizam as paredes ventriculares, medem o limiar de comando e os sinais intracardíacos, previnem a fibrilação atrial, revertem taquicardias ventriculares e desfibrilam os ventrículos. A grande evolução da tecnologia tem permitido expandir as indicações e aumentar a eficiência e a segurança dos marcapassos. O progresso começou trazendo os sistemas de demanda e logo continuou com o surgimento dos marcapassos bicamerais, dos sistemas programáveis, da telemetria, dos biossensores, dos eletrodos de fixação ativa, dos eletrodos com corticóides, dos geradores microprocessados, dos geradores com memória para armazenamento de dados e de eletrocardiogramas, dos desfibriladores, dos marcapassos para tratamento de insuficiência cardíaca (também conhecidos como ressincronizadores) e culminando, recentemente, como surgimento dos desfibriladores-ressincronizadores. Não obstante, além de todos esses grandes recursos ultimamente uma grande novidade deverá instituir novos rumos num futuro próximo: o advento dos marcapassos que enviam automaticamente para o médico relatórios detalhados das condições técnicas da estimulação e de eventos detectados pela monitoração do ritmo ou diretamente pelo paciente colocando um imã sobre a loja do gerador