Aspirin plus verapamil relieves angina and perfusion abnormalities in patients with coronary microvascular dysfunction and Chagas disease: a pilot non-randomized study

Abstract INTRODUCTION: Most patients with chronic cardiomyopathy of Chagas disease (CCCD) harbor a secondary cause of coronary microvascular dysfunction (CMD), for which there is no evidence-based therapy. We evaluated the impact of verapamil plus aspirin on symptoms and perfusion abnormalities in patients with CCCD and CMD. METHODS: Consecutive patients with angina pectoris, who had neither coronary artery obstructions nor moderate-severe left ventricular dysfunction (left ventricular ejection fraction > 40%) despite showing wall motion abnormalities on ventriculography, were referred for invasive angiography and tested for Chagas disease. Thirty-two patients with confirmed CCCD and ischemia on stress-rest SPECT myocardial perfusion scintigraphy (MPS) were included. Clinical evaluation, quality of life (EQ-5D/ Seattle Angina Questionnaire), and MPS were assessed before and after 3 months of treatment with oral verapamil plus aspirin (n=26) or placebo (n=6). RESULTS: The mean patient age was 64 years, and 18 (56%) were female. The ischemic index summed difference score (SDS) in MPS was significantly reduced by 55.6% after aspirin+verapamil treatment. A decrease in SDS was observed in 20 (77%) participants, and in 10 participants, no more ischemia could be detected. Enhancements in quality of life were also detected. No change in symptoms or MPS was observed in the placebo group. CONCLUSIONS: This low-cost 3-month treatment for patients diagnosed with CCCD and CMD was safe and resulted in a 55.6% reduction in ischemic burden, symptomatic improvement, and better quality of life.

Arritmias na sala de emergência e UTI. Taquicardias de QRS estreito: fundamentos para a abordagem / Arrythmias in the emergency room and ICU Narrow QRS rachycardias: bases for clinical approach

As taquicardias de QRS estreito apresentam origem supraventricular. O histórico clínico, exame físico e eletrocardiograma na sala de emergência constituem-se nas principais ferramentas para o tratamento do quadro. As taquicardias que apresentam instabilidade hemodinâmica devem ser, imediatamente, revertidas através de cardioversão elétrica sincronizada. Aquelas que se apresentam como estáveis hemodinamicamente podem, se regulares, ser tratadas através de manobras vagais ou através do uso de fármacos endovenosos. Se irregulares, podem caracterizar fibrilação e flutter atrial, sendo, então, avaliados a duração do episódio e o risco de tromboembolismo para determinar não apenas a necessidade de anticoagulação, mas também a estratégia para tratamento do quadro, seja através do controle da frequência cardíaca ou do controle do ritmo, este último podendo ser alcançado através do uso de fármacos (propafenona oral ou amiodarona endovenosa) ou da cardioversão elétrica sincronizada. Dessa forma, o papel do clínico na sala de emergência é fundamental para garantir a condução adequada dos episódios de taquicardia supraventricular, especialmente, na prevenção ou pronta intervenção em caso de deterioração hemodinâmica relacionada ao quadro

Narrow QRS tachycardias are supraventricular in origin. The clinical history, physical exam, and electrocardiogram in the emergency room are the main tools used to manage this condition. Tachycardias that present haemodynamic instability must be promptly reverted through synchronized electrical cardioversion. Those that present haemodynamic stability may be treated with vagal maneuvers or intravenous drugs. If irregular, they may take the form of atrial fibrillation or atrial flutter, and in this case, the duration of the episode and the thromboembolic risk are evaluated to determine not only the need for anticoagulation, but also the treatment strategy, whether through heart rate or rhythm control. The latter may be achieved through the use of drugs (oral propafenone or intravenous amiodarone) or synchronized electrical cardioversion. The role of the clinician in the emergency room is therefore fundamental in ensuring adequate conduct of episodes of supraventricular tachycardia, especially in prevention or prompt intervention in case of haemodynamic deterioration related to the condition

Arritmias ventriculares sustentadas: a tempestade chegou / Sustained ventricular arrhythmias: the storm has arrived

Um dos grandes desafios no atendimento dos pacientes nas unidades de emergência é o tratamento das arritmias ventriculares, principalmente, quando sustentadas e recorrentes, pois são de difícil tratamento e estão associadas à alta mortalidade. O principal mecanismo envolvido na sustentação das taquicardias ventriculares é o mecanismo de reentrada, devido às cicatrizes miocárdicas secundárias a diversas cardiopatias estruturais. A tempestade elétrica pode ser séria quando ocorre em portadores de desfibriladores automáticos, provocando múltiplos choques correspondentes fora do ambiente hospitalar. Nesses casos é necessária a internação hospitalar, onde medidas específicas e escalonadas de tratamento são realizadas, indo desde o manejo clínico até intervenções específicas, como programação de dispositivos eletrônicos, intervenções eletrofisiológicas ou cirúrgicas

One of the biggest challenges in the care of patients in emergency units is the treatment of ventricular arrhythmias, particularly when sustained and relapsing, as they are difficult to treat and are associated with high mortality. The main mechanism involved in the maintenance of ventricular tachycardias is the mechanism of reentry, due to myocardial scars secondary to various structural heart diseases. The electrical storm may be serious when it occurs in patients with automatic defibrillators, causing multiple corresponding shocks outside the hospital setting. In these cases, admission to hospital is necessary, where specific and stepwise treatment measures are performed, ranging from clinical management to specific interventions, such as programming of electronic devices, and electrophysiological or surgical interventions

Verapamilo en conjunto con las prendas de compresión en el tratamiento de la cicatriz patológica causada por quemadura / Verapamil in conjunction with pressure therapy in the treatment of pathologic scar due burn injury

Abstract Introduction: Keloids and hypertrophic scars are dermal fibro-proliferative disorders unique to humans. Their treatment is a true challenge with multiple options, but not all the time with good results. Unfortunatelythis problem is not uncommon in patients with history of burn injury. Aim: To evaluate use of verapamil andpressure garments in patients with hypertrophic or keloid scar caused by burn injury. methods: We includedpatients with a hypertrophic or keloid scar caused by burn injury that report non-response to treatment withpressure garment. The pathologic scars were evaluated by serial photographic records, Vancouver and Posasscales. The scales of Vancouver and Posas were compared with t Student. Results: We included 13 scars in11 patients. Four scars were located in the legs, 4 in the arms, 4 in the face-neck and 1 in the abdomen. Thedose of verapamil was calculated 0.03 mg per kg. Injections were scheduled every 7 to 10 days until complete 6 sessions. Taking in count Posas scale, patients referred improvement in pigmentation (0.01), thickness(0.005), pliability (0.01), pruritus (0.003) and irregular surface (0.004). In the Vancouver scale the observers mentioned improvement in elevation (0.008), pigmentation (0.014), vascularity (0.022) and flexibility (0.014).No adverse effects were found in verapamil injection. Conclusion: Verapamil was useful in conjunction withpressure garment to improve the condition of the keloid and hypertrophic scar caused by burn.

Resumen Introducción: La cicatriz queloide o la cicatriz hipertrófica son desórdenes fibro-proliferativos únicos de los humanos, cuyo tratamiento representa un reto en donde existen pocas opciones con buenos resultados.Objetivo: Evaluar el uso de verapamilo y las prendas de compresión en pacientes con cicatrización patológicacomo consecuencia de quemadura. material y método: Incluimos pacientes con cicatrización patológica,ya sea queloide o hipertrófica, causada por quemadura que mencionaron no haber tenido beneficio con el usode prendas de compresión. La cicatriz fue evaluada con fotografías seriadas, escala de Vancouver y Posas.Los resultados fueron comparados con la prueba de t de Student. Resultados: Incluimos 13 cicatrices en 11pacientes. La localización de las cicatrices fue en brazos 4, piernas 4, cara y cuello 1, y abdomen 1. La dosisde verapamilo se calculó a 0,03 mg por kg. Las inyecciones se aplicaron intralesionales y se administraroncada 7 a 10 días hasta completar 6 sesiones. Encontramos mejoría en los siguientes parámetros de la escalade Posas: pigmentación (0,01), pliabilidad (0,01), endurecimiento o grosor (0,005), prurito (0,003) e irregular (0,004). En la escala de Vancouver elevación (0,008), pigmentación (0,014), vascularidad (0,022) yflexibilidad (0,014). No encontramos efectos adversos con la administración de verapamilo. Conclusión: Elverapamilo fue útil en conjunto con las prendas de compresión para mejorar las condiciones de la cicatrizqueloide e hipertrófica causadas por lesiones por quemadura.

Idiopathic left ventricular tachycardia in children.

BACKGROUND: Idiopathic left ventricular tachycardia (ILVT) is a rare but well-recognized clinical entity. The clinical characteristics and prognosis of this form of ventricular tachycardia (VT) in Thai children is not known. OBJECTIVE: To define clinical presentations, drug therapies, roles of radiofrequency (RF) catheter ablation, and the short-term outcome of these children in Thailand. PATIENTS AND METHOD: From April 1999 to June 2007, 10 patients were diagnosed as ILVT by specific electrocardiographic features and therapeutic response. All patients had a structurally normal heart. Data were collected retrospectively. Baseline clinical information, 12-lead electrocardiography (ECG) during VT, responses to drug therapy, results of RF catheter ablation therapy, and outcome were determined. RESULTS: Median age at presentation was 9.5 years (range, 3.8 to 14.0 years). Three patients (30%) were male. Eight patients (80%) were diagnosed as supraventricular tachycardia (SVT) before ILVT diagnosis. Median duration from SVT diagnosis to the correct diagnosis was 1.5 years (range, 0 to 6.0 years). Palpitation and chest pain were usual clinical manifestations while congestive heart failure was the presentation in one due to incessant tachycardia. Two patients had recurrent VT episodes during acute febrile illnesses. The majority of patients responded to intravenous verapamil. RF catheter ablation was performed in 3 patients with recurrence of the VT in one. CONCLUSION: Prompt recognition of the ILVTespecially in the emergency department is very important. Verapamil is effective for acute termination as well as prevention of VT recurrence. When VT is refractory to medical therapy, RF catheter ablation is safe and effective. The short-term prognosis was good.

Cefaléias: como eu trato? / Headache: how I treat

As cefaléias figuram entre as queixas mais comuns em unidades de atendimento primário. Ocupam o primeiro lugar entre os transtornos "benignos" incapacitantes, segundo dados da Organização Mundial de Saúde, com forte impacto socioeconômico. No artigo é descrito o manejo das diversas causas da cefaléia, com suas diferentes apresentações clínicas. A cefaléia tensional é a cusa primária mais comum, seguida pela cefaléia enxaquecosa.

Cefaléia em salvas durante a gravidez: um desafio a mais no tratamento / Cluster headache during pregnancy: an extra challenge for treatment

Cefaléia em salvas é uma cefaléia trigêmino-autonômica relativamente rara. Sua ocorrência na gravidez e as possíveis abordagens terapêuticas são apresentadas.

Comparative study of angiotensin converting enzyme inhibitor and calcium channel blocker in the treatment of steroid-resistant idiopathic nephrotic syndrome.

BACKGROUND: The aim of this study was to evaluate and compare the anti-proteinuric effect of ramipril and verapamil in patients with steroid-resistant idiopathic nephrotic syndrome. Twenty one (21) cases of steroid-resistant idiopathic nephrotic syndrome were randomized to receive ramipril (11) and verapamil (10) and were followed up for 12 months; monthly for the 1st 3 months and then every 3 months for the remaining study period. The degree of reduction of proteinuria, blood pressure, serum creatinine, serum albumin and side effects were noted between the two groups. The comparison within the groups over different time periods was made using paired 't' test and between the groups for specific time period by unpaired 't' test. The level of significance was taken as 5% or below. RESULTS: Seventeen patients (nine in the ramipril group and eight in the verapamil group) completed the study. The mean age of the patients, duration of illness, 24 hours urinary excretion of protein, mean arterial pressure, serum creatinine, cholesterol and albumin were similar in both the groups at time of randomization. The 24 hours urinary protein excretion decreased from 6319.44 +/- 1971.70 mg/day to 1852.44 +/- 1813.74 mg/day in patients receiving ramipril and from 5332.87 +/- 1947.47 mg /day to 2759.37 +/- 1929.6 mg/day in patients treated with verapamil after 12 months. There was no statistically significant difference in the reduction of proteinuria between the two groups. However, reduction in proteinuria was statistically significant from 2nd month onwards in Ramipril group and reduction was sustained throughout the study period. Reduction in mean arterial pressure was better achieved in Ramipril groups. The change in the serum potassium, creatinine, cholesterol and albumin were similar in either group of patients. Cough (2), hypotension (1) and reversible rise in serum creatinine (1) were observed with ramipril and no side effect was noted with verapamil. CONCLUSION: Both ramipril and verapamil can reduce proteinuria in patients suffering from steroid-resistant idiopathic nephrotic syndrome. However, ramipril had a better and sustained reduction in proteinuria with well-controlled mean arterial pressure. Verapamil can be considered as an alternative to ramipril when the use of the latter is not tolerated because of side effects and/or worsening of renal function in patients with chronic renal insufficiency.

Acute management of atrial fibrillation: the commonest arrhythmia in clinical practice.

Atrial fibrillation is the commonest arrhythmia encountered in clinical practice. Whereas in western countries it is the elderly population who are at risk, however in countries like India, where rheumatic heart disease is rampant it is common cause of mortality and morbidity in the young. It is thus important that treatment of this disorder be disseminated to the level of the primary care giver. This would not only be beneficial to the patients who shall be getting the appropriate care dose at hand, but also reduce the burden of tertiary care centres who deal with more complex arrhythmias.

Angina inestable: los calcibloqueantes sin betabloqueantes no previenen la recurrencia de la angina, los procedimientos intervencionistas, ni la insuficiencia cardíaca / Calcium channel bloquer agentes, not associated to betabloquers, do not prevent recurrent angina, further invasive procedures or pump failure in patients hospitalized for unstable angina

Antecentes. Los calciantagonistas (CA) deberían ser eficaces en reducir la mortalidad y el infarto (IAM) no fatal en la angina inestable (AI). Se ha demostrado que los CA proporcionan alivio sintomático y mejor evolución. Objetivo. Investigar si los CA en la AI disminuyen la muerte y el IAM no fatal, previenen la recurrencia de la angina y mejoran la evolución. Material y métodos. Análisis en la base de datos del estudio ENAI (Enalapril en la Angina Inestable) que sigue durante 7 días a 1022 pacientes con AI. Indicación de betabloqueantes (BB) y CA a criterio de los participantes. Resultados. La angina recurrente y los procedimientos invasivos no son diferentes en la AI previamente tratada con CA (RR 1,02; IC95 0,74 - 1,40; P 0,8958). En 1022 pacientes los eventos secundarios aumentan en los no tratados (53,3 por ciento en 629) en relación a los tratados con CA cuando se asocian a los BB (46,7 por ciento en 392; RR 1,39; IC95 1,19 - 1,62; P 0,00003) Para Diltiazem-BB los eventos secundarios disminuyen desde un 61,3 por ciento al 38,7 por ciento (RR 1,74; ; IC95 1,39 - 2,18; P 0,0000), similar con otros CA-BB. Reducen los eventos secundarios del 66 por ciento al 34 por ciento en el grupo con SD del ST/ST normal (RR del 1,92; IC95 1,05 - 3,51; P 0,0335). Conclusiones. La indicación de CA sin BB en AI no disminuye los eventos isquémicos secundarios ni el desarrollo de insuficiencia cardíaca. Indicados en AI con SD del ST.

Verapamil COER-24 180/240mg na hipertensäo arterial leve a moderada em dose única diária avaliado pela monitorizaçäo ambulatorial da pressäo arterial / Single daily dose of verapamil (COER-24 180/24 mg) in mild and moderate hypertension evaluated by ambulatory blood pressure monitoring

OBJECTIVE: To evaluate the anti-hypertensive effecft of verapamil COER-24 180/240 mg in a single dose at bedtime as single therapy in mild to moderate hypertensives. METHODS: A multicentric, open, placebo controlled study of 81 hypertensive patients older than 20 years-old followed to 8 weeks. Blood pressure was measured in doctor's office and by 24h ambulatory monitoring (ABPM). RESULTS: We observed a decreased in systolic and diastolic blood pressure in doctor's office at 4th and 8th weeks. ABPM showed that both systolic, diastolic and mean blood pressure, heart rate and the mean 24-hour blood pressure load decreased after the 8-week treatment. In addition, there was a reduction of the double-product, especially in the morning and 68 per cent of the patients didn't have any adverse events. CONCLUSION: The theraphy verapamil COER-24 180/240mg in a single dose is useful for mild and moderate hypertensive patients, with significant pressure decrease in both office blood pressure measurements and in the ABPM/24 hours, as well as showing good tolerability.

Taquicardia congénita de la unión A-V. Respuesta favorable a los antiarrítmicos / Congenital junctional ectopic tachycardia

La taquicardia congénita de la unión A-V es muy rara, con manifestación clínica temprana, pobre respuesta a los diferentes fármacos antiarrítmicos y con una gran morbimortalidad infantil (mortalidad del 35 por ciento). Merece una especial atención tanto en su oportuna detección como en su adecuado manejo con los diferentes procedimientos terapéuticos farmacológicos y no farmacológicos disponibles actualmente. Nosotros reportamos los casos de dos enfermos cuya edad de presentación de la taquiarritmia fue a los tres meses y cuya peculiaridad fue la buena respuesta a los fármacos antiarrítmicos. El Verapamilo y posteriormente la Propafenona intravenosa se usaron para las etapas agudas y una combinación de Propafenona más propranolol inicialmente para la fase crónica. Por manifestaciones de intolerancia, fue necesario cambiar después de un año tal combinación por Sotalol y Digital, con buena respuesta. Hacemos además una revisión de la literatura disponible hasta el momento sobre esta entidad

Individual or combined effects of enalapril and verapamil on chronic cyclosporine nephrotoxicity in rats

Previous studies have demonstrated that enalapril and verapamil seem to attenuate the cyclosporine nephrotoxicity. However, the mechanisms have not been completely understood, especially on molecular events. The aim of this study was to examine the effect of individual or combined treatment on osteopontin, TGF-beta, endothelin-1 and procollagen alpha 1(I) mRNA expressions. Enalapril (50 mg/L in drinking water) and verapamil (0.5 mg/kg/day, subcutaneously), alone or in combination, were administered to rats with chronic cyclosporine nephrotoxicity (cyclosporine, 25 mg/kg/day, subcutaneously) (n = 5 each). Five rats treated with olive oil vehicle were used as control. After 4 weeks, biochemical parameters were measured, and renal cortical mRNA levels were evaluated by Northern blot analysis. Cyclosporine reduced renal creatinine clearance significantly and induced renal cortical osteopontin, TGF-beta, endothelin-1 and procollagen alpha 1(I) gene expressions around 13.5 +/- 1.3, 2.4 +/- 0.2, 1.5 +/- 0.1, 1.9 +/- 0.1 folds, respectively. Individual treatment with enalapril or verapamil significantly suppressed the osteopontin and TGF-beta mRNA expression, but not endothelin-1 and procollagen alpha 1(I). Combined treatment also inhibited the osteopontin and TGF-beta mRNA expression but there was no difference between combined and individual treatment. In conclusion, enalapril or verapamil significantly blunted the cyclosporine-induced osteopontin and TGF-beta gene expressions. However, combined treatment did not show any additive effect.

Taquicardia ventricular fascicular izquierda: reporte de 2 casos / Left ventricular fascicular tachycardia: report of 2 cases

La taquicardia ventricular fascicular izquierda se describe en pacientes jóvenes con corazón sano, episodios de arritmia sostenida y diversa sistematología. El electrocardiograma de la arritmia muestra taquicardia regular con QRS estrecho e imagen de bloqueo de rama derecha y fascicular anterior izquierdo y con frecuencia disociación auriculoventricular (AV). Se presentaron 2 pacientes, uno de 20 y otro de 10 años de edad, masculinos, remitidos por presentar taquicardias muy frecuentes, de horas de duración, presincopales en el mayor e incesante de días de evolución en el niño que no respondían a diversos fármacos. El electrocardiograma de ambos mostró la morfología típica de esta entidad, disociación AV en el adulto y conducción retrógada en el niño. Al adulto se le realizó estudio electrofisiológico, y previa topoestimulación (estimulación desde el posible sitio de la taquicardia) se anestesió, y se emitió un choque de 350J. Se ha mantenido asintomático por 2 años y medio. Al niño se le administró 2,5 mg de verapamilo EV lo que hizo que se enlenteciera la arritmia y que presentara disociación AV, capturas, fusiones y pasó a ritmo sinusal. A los pocos minutos reinició de nuevo y se indicó tratamiento con verapamilo oral en dosis de 40 mg cada 8 horas. Doce horas después cesó la arritmia definitivamente. Actualmente se mantiene asintomático a los 7 meses de evolución con dosis de 120 mg de verapamilo al día. En un futuro se le realizará ablación del origen de la arritmia con radiofrecuencia. Aunque esta taquicardia es poco frecuente, casi siempre es confundida con arritmias supraventriculares por lo que es importante que sea reconocida para indicar un tratamiento farmacológico correcto así como su remisión a un centro especializado para lograr la curación por medio de la ablación con radiofrecuencia

Taquicardia ventricular por reentrada de rama a rama: otra arritmia con tratamiento definitivo / Bundle branch reentry ventricular tachycardia: another arrhythmia with a definitive treatment

La taquicardia ventricular por reentrada de rama a rama corresponde a un tipo de taquicardia ventricular monomorfa sostenida que se presenta en pacientes con miocardiopatía dilatada y transtornos de conducción del sistema His-Purkinje. Esta taquicardia produce compromiso hemodinámico y hasta un 75 por ciento de los pacientes debuta con síncope o muerte súbita. Con el desarrollo de la electrofisiología se ha comprendido su mecanismo, y la fulguración con radiofrecuencia permite un tratamiento definitivo mediante interrupción de la conducción por la rama derecha. Presentamos el caso clínico de un paciente con miocardiopatía dilatada de origen valvular, quien presentó taquicardia por reentrada de rama a rama y fue sometido a fulguración con radiofrecuencia