Exploración de las arterias coronarias de pacientes con síndrome de Tako-Tsubo con tomografía multislice: lesiones e inferencias fisiopatológicas / Assessment of Coronary Arteries of Patients with Takotsubo Syndrome using Multislice Computed Tomography: Lesions and Pathophysiological Inferences

Existen numerosos casos comunicados sobre la disfunción ventricular izquierda reversible precipitada por estrés emocional, pero su mecanismo no se conoce. En esta presentación se describe la evaluación de dos pacientes que consultaron con un cuadro clínico típico de síndrome de Tako-Tsubo, dolor precordial luego de un estrés emocional, disfunción ventricular izquierda transitoria y arterias coronarias angiográficamente normales. Con el objetivo de profundizar el conocimiento de las arterias coronarias y la fisiopatología de esta enfermedad, a ambas se les realizó una tomografía multislice, en la que se evidenciaron lesiones coronarias similares a las halladas en accidentes de placa responsables de síndromes coronarios agudos. Si bien estos hallazgos deben completarse con estudios posteriores con un número mayor de pacientes, sugieren que al menos un subgrupo de pacientes con síndrome de Tako-Tsubo tiene un sustrato fisiopatológico similar a los síndromes coronarios agudos.

The presence of reversible left ventricular dysfunction induced by emotional stress has been extensively reported; however, its mechanism still remains unknown. We describe two patients with the typical clinical picture of Takotsubo syndrome: chest pain following mental stress, transient left ventricular dysfunction and coronary arteriography with normal coronary arteries. Both patients underwent multislice computed tomography scans in order to explore the coronary arteries and to examine the physiopathology of the disease. The studies revealed the presence of coronary lesions similar to ruptured plaques found in acute coronary syndromes. Although these findings should be completed with subsequent studies in a greater number of patients, they suggest that the physiopathological substrate of at least one subgroup of patients with Takotsubo syndrome is similar to acute coronary syndrome.

Acompanhamento a longo prazo de pacientes com indicação de desfibrilador implantável como prevenção primária de morte súbita / Long-term follow-up of patients with indication for a implantable defibrillator for primary prevention of death

FUNDAMENTO: Os recentes estudos MADIT II e SCD-HeFT levaram a uma expansão das indicações do uso profilático de cardiodesfibrilador implantável (CDI) em pacientes com grave disfunção ventricular esquerda. Essa terapia não foi totalmente adotada em nosso sistema de saúde, sobretudo em virtude de seu alto custo. OBJETIVO: Avaliar a taxa de mortalidade global de pacientes da nossa prática diária que têm o mesmo perfil dos participantes do estudo SCD-HeFT, estão recebendo tratamento clínico otimizado e não foram submetidos a implante de CDI, e comparar essa taxa com a do grupo de placebo do estudo SCD-HeFT. MÉTODOS: Foram incluídos neste estudo pacientes com o mesmo perfil dos participantes do estudo SCD-HeFT identificados a partir de prontuários médicos. A taxa de mortalidade global foi avaliada por contato telefônico. A análise estatística foi realizada com o teste t de Student, teste de Mann-Whitney ou teste de qui-quadrado, dependendo do tipo de variável. As taxas cumulativas de mortalidade foram calculadas de acordo com o método de Kaplan-Meier. RESULTADOS: Este estudo englobou 102 pacientes, 74 dos quais do sexo masculino. A mediana da idade foi 64 anos e a média da fração de ejeção, 25 por cento. Não encontramos diferenças entre os nossos pacientes e os pacientes do estudo SCD-HeFT em relação a essas três variáveis. Durante o período de acompanhamento de 19,6 meses, 21 pacientes morreram (20,6 por cento), contra 28,8 por cento do estudo SCD-HeFT. Essa diferença não foi estatisticamente significante (p = 0,08). CONCLUSÃO: Não houve diferença na taxa de mortalidade dos nossos pacientes e dos pacientes do grupo de placebo do estudo SCD-HeFT. Esses resultados indicam que a população do SCD-HeFT é representativa dos nossos pacientes.

BACKGROUND: Recent MADIT II and SCD-HeFT trials have led to an expansion of indications for use of prophylactic Implantable Cardioverter Defibrillator (ICD) in patients with severe left-ventricular impairment. This therapy has not been fully adopted in our health care system, mainly due to its high cost. OBJECTIVE: To assess total mortality of SCD-HeFT-like patients from our daily practice who are under stable, optimal medical treatment and who have not received an ICD; and to compare it to that of the placebo arm of the SCD-HeFT Trial. METHODS: SCD-HeFT-like patients identified from office medical records were included in our study. Total mortality was assessed by telephone contact. Statistical analysis was performed by Student's t-Test, Mann-Whitney Test or chi2 test, depending on the type of variable. Cumulative mortality rates were calculated according to the Kaplan-Meier method. RESULTS: Our study comprised 102 patients (seventy-four of which were men) with a median age of 64 years, and an overall median ejection fraction of 25 percent. We found no differences between our patients and SCD-HeFT patients across these 3 variables. Over a 19.6-month follow-up period, 21 patients died (20.6 percent) vs. 28.8 percent of the SCD-HeFT patients. This difference was not statistically significant (p = 0.08). CONCLUSION: SCD-HeFT-like patients from our practice had no difference in mortality rate than patients enrolled in the placebo arm of the SCD-HeFT trial. These results suggest that the SCD-HeFT population is representative of our patients.

Introducción a las complicaciones graves de la quimioterapia que debe enfrentar un cardiólogo / Severe cardiac complications of chemotherapy: a review

La aplicación de diferentes esquemas farmacológicos para el tratamiento oncológico ha tenido en los últimos años un gran crecimiento, en muchos casos con efectos curativos o clara mejoría de la sobrevida y la calidad de vida. Algunos esquemas incluyen drogas que puedenprovocar efectos cardiotóxicos graves, lo que motiva la consulta a los cardiólogos que en la mayor parte de los casos no hemos tenido entrenamiento en esta complicación. En esta revisión se resumen mecanismos de acción y efectos adversos de diferentes drogas de usofrecuente en patología oncológica y se exponen casos clínicos con reacciones adversas graves, con dificultades en la toma de decisiones. Finalmente, se discuten los aspectos para tener en cuenta para la prevención, el control y el tratamiento de la cardiotoxicidad por agentes quimioterapéuticos.

In recent years, there has been an increase in the use of various pharmacological protocols for the treatment of oncological disorders, often with curative effects or a clear improvement in survival and quality of life. Some schemes include drugs that may cause severe cardiotoxic effects. Such effects prompt patients to consult the cardiologist, who generally has no previous experience in dealing with these complications. Hence, in this review, we summarize the mechanisms of action and adverse effects of various drugs that are frequently used in neoplastic diseases, and we also present clinical cases with serious adverse reactions, which complicate the decision-making process. Finally, we discuss several issues that need to be considered for the prevention, control and treatment of cardiotoxicity due to chemotherapeutic agents.

Fibrilación auricular en una paciente con megaorejuela auricular izquierda / Atrial fibrillation in a patient with a giant left atrial appendage

La FA constituye una de las arritmias sostenidas más frecuentes que motivan la consulta. El sustrato comprende diferentes mecanismos, entre los que se encuentra el agrandamiento auricular izquierdo. Presentamos el caso de una mujer de 33 años con antecedentes de palpitaciones, que ingresó en la guardia por FA de alta respuesta ventricular. En la radiografía de tórax se observó una deformación del borde izquierdo de la silueta cardíaca. Posteriormente, el ecocardiograma transesofágico y la resonancia magnética nuclear evidenciaron una megaorejuela aneurismática debida, probablemente, a un defecto pericárdico. La conducta fue anticoagulación oral y tratamiento con atenolol, con evolución favorable.

Among sustained arrhythmias, atrial fibrillation is one of the most common causes of patient consultation. Its substrate comprises various mechanisms, including left atrial enlargement. In this report, we present the case of a 33 yearold woman with a history of palpitations, who was admitted to the emergency room due to atrial fibrillation with a rapid ventricular response. In the chest X-ray, the left border of the cardiac silhouette was deformed. Subsequently, both the transesophageal echocardiogram and the magnetic resonance images showed a giant aneurysmal left atrial appendage, probably due to a pericardial defect. Treatment consisted of oral anticoagulation and atenolol, with a favorable patient outcome.