Doxorubicin cardiotoxicity and Camellia sinensis cardioprotection determined by speckle-tracking echocardiography

Abstract Doxorubicin (Dox) is a medication used in the treatment of cancerous tumors and hematologic malignancies with potentially serious side effects, including the risk of cardiotoxicity. Flavonoids are plant metabolites with antioxidant properties and can be extracted from Camellia sinensis (CS). The aim of this study is to evaluate the possible cardioprotective effect of CS against injuries induced by Dox in rats. A total of 32 animals were distributed into four groups: (1) control - intraperitoneal injection (I.P.) of 0.5 mL saline weekly and 1.0 mL water by gavage daily; (2) CS - 0.5 mL saline I.P. weekly and 200 mg/kg CS by gavage daily; (3) Dox - 5.0 mg/kg Dox I.P. weekly and 1.0 mL water by gavage daily; and (4) Dox+CS -5.0 mg/kg Dox I.P. weekly and 200 mg/kg CS by gavage daily. Clinical examinations, blood profiles, electrocardiograms, echocardiograms, and histological analyses of hearts were performed over 25 days. The animals in the Dox group showed changes in body weight and in erythrogram, leukogram, electrocardiography, and echocardiography readings. However, animals from the dox+CS group had significantly less change in body weight, improved cardiac function, and showed more preserved cardiac tissue. This study demonstrated that CS prevents dox-induced cardiotoxicity, despite enhancing the cytotoxic effect on blood cells

Cardioneuroablación como tratamiento del síncope reflejo: reporte de un caso

Resumen: El síncope mediado neuralmente es un trastorno causado por un reflejo autónomo anormalmente amplificado que involucra componentes tanto simpáticos como parasimpáticos. Es la causa más frecuente de síncope en personas jóvenes y su tratamiento sigue siendo un desafío, ya que no se ha demostrado que alguna terapia farmacológica prevenga por completo su recurrencia. En los últimos años ha surgido una técnica denominada cardioneuroablación, que consiste en la ablación por radiofrecuencia de los plexos ganglionares (PG) parasimpáticos, con buenos resultados a corto y largo plazo en la prevención de síncope recurrente, según los diferentes grupos de investigación. Presentamos el primer caso en Chile de un hombre joven con síncopes mediados neuralmente recurrentes que fue tratado con esta técnica en el Hospital Regional de Concepción.

Abstract: Cardioneuroablation is a novel method that can be used to treat reflex syncope. Although the experience with this technique is relatively limited it provides a more physiological way to treat this condition. The first case in Chile is herein reported along with a discussion of the subject.

Wearable technology for electrocardiogram and vectocardiogram using the Dower Transformation / Tecnologia vestível para exames de eletrocardiograma e vetocardiograma utilizando a transformada de Dower / Tecnología vestible para exámenes de electrocardiograma y vetocardiograma utilizando de la transformada de Dower

Objectives: Thousands of people suffer from cardiovascular diseases. Even though the electrocardiogram is an exam consolidated. The lack of methodological observation in the placement of sensors can compromise the results. This article proposes a wearable vest capable of conditioning cardiac signals from three simultaneous channels, reducing the chance of failures in the exam due to the smaller number of electrodes attached to the patient's body. Methods: It adds the vectorcardiogram technique to the electrocardiogram wearable, which consists of three orthonormal derivations Vx, Vy, and Vz, measuring dynamic components of the heart vector. Results: The display of the cardiac biopotential in the web-mobile application represents the visualization of the twelve derivations synthesized from the Dower transform and the spatial projections of the cardiac loop under a three-dimensional view. Conclusion: Feasibility of integrating the vectorcardiogram with the electrocardiogram exam.

Objetivos: Milhares de pessoas sofrem com doenças cardiovasculares, apesar do Eletrocardiograma ser um exame consolidado, a falta de observação metodológica na colocação dos sensores pode comprometer os resultados. O presente artigo propõe um colete vestível capaz de condicionar sinais cardíacos de três canais simultâneos, reduzindo a chance de falhas na execução do exame em função da menor quantidade de eletrodos fixados ao corpo do paciente. Métodos: Acrescenta a técnica do vetocardiograma ao vestível de eletrocardiograma, que consiste em três derivações ortonormais Vx, Vy e Vz, medindo componentes dinâmicos do vetor coração. Resultados: Exibição do biopotencial cardíaco na aplicação web-mobile representa de forma satisfatória a visualização das doze derivações sintetizadas a partir da transformada de Dower, bem como, as projeções espaciais do loop cardíaco sob uma visão tridimensional. Conclusão: Viabilidade de integração do vetocardiograma ao exame de eletrocardiograma.

Objetivos: Miles de personas padecen enfermedades cardiovasculares, a pesar de que el electrocardiograma es un examen consolidado, la falta de observación metodológica en la colocación de sensores puede comprometer los resultados. Este artículo propone una tecnología vestible capaz de acondicionar las señales cardíacas de tres canales simultáneos, reduciendo la posibilidad de fallas en el examen por la menor cantidad de electrodos adheridos al cuerpo del paciente. Métodos: Agrega la técnica del vetocardiograma al electrocardiograma vestible, que consta de tres derivaciones ortonormales Vx, Vy y Vz, midiendo los componentes dinámicos del vector cardíaco. Resultados: La visualización del biopotencial cardíaco en la aplicación web-móvil representa satisfactoriamente la visualización de las doce derivaciones sintetizadas a partir de la transformada de Dower, así como las proyecciones espaciales del bucle cardíaco bajo una vista tridimensional. Conclusión: Viabilidad de integrar el vetocardiograma con el examen electrocardiográfico.

Determination of the increased risk of developing atrial fibrillation in fibromyalgia syndrome

Abstract Introduction: Atrial fibrillation (AF) is the leading cause of ischemic stroke and is one of the most common arrhythmias. Previous studies have shown that impaired diastolic functions, P wave dispersion (Pd), and prolonged atrial conduction times (ACT) are associated with increased incidence of atrial fibrillation (AF). The aim of this study was to evaluate diastolic functions, Pd, and ACT in fibromyalgia syndrome (FMS) patients to determine whether there is an increase in the risk of developing AF. Methods: The study included a total of 140 female patients (70 FMS group, 70 healthy control group). Pd was evaluated using 12 lead electrocardiography (ECG), and diastolic functions and ACT with echocardiography. The ECG and echocardiographic evaluations were performed by different cardiologists blinded to the clinical information of the subjects. Results: There was no difference between the two groups in laboratory and clinical parameters. Patients with FMS had significantly higher echocardiographic parameters of ACT known as left-sided intra-atrial (13.9 ± 5.9 vs. 8.1 ± 1.8, p < 0.001), right-sided intra-atrial (21.9 ± 8.2 vs. 10.4 ± 3.5, p < 0.001) and interatrial [40 (25-64) ms vs. 23 (14-27) ms p < 0.001] electromechanical interval (EMI) compared with the control group. Pd was significantly greater in the FMS group compared with the control group [46 (29-62) ms vs. 32 (25-37) ms, p < 0.001]. In the FMS group, there was no significant relationship of the echocardiographic parameters of ACT, Pmax and Pd with age, E/A ratio and deceleration time (DT); while all these five parameters were significantly correlated with left atrial dimension, isovolumetric relaxation time (IVRT), fibromyalgia impact questionnaire (FIQ) and visual analogue scale (VAS). There was a strong correlation between FIQ and VAS and echocardiographic parameters of ACT, Pmax and Pd. Conclusions: Impaired diastolic functions, an increase in Pd, and prolongation of ACT were observed in FMS. Current disorders are thought to be associated with an increased risk of AF in FMS. The risk of developing AF increases with the severity of FMS and clinical progression.(AU)

Early T-wave inversion in anterior leads predict patency of the anterior descending artery in ST-segment elevation myocardial infarction / La onda T invertida temprana en derivaciones anteriores predice permeabilidad de la arteria descendente anterior en infarto agudo de miocardio con elevación del segmento ST

Abstract: Introduction: T-wave inversion has always been considered as a natural progression sign of the non-perfunded myocardial infarction, however it is also seen after early succesful reperfusion via fibrinolysis or primary angioplasty; its role in predicting auto-reperfusion has not been established. Objective: Assess the patency of the infarct-related artery (IRA) in patients presenting with early (< 3 hours of symptoms onset) T-wave inversion (TWI) in leads with ST-segment elevation (STE) myocardial infarction (STEMI). Methods: We retrospectively analyzed 432 patients admitted at the emergency department of the National Cardiology Institute in Mexico City with a diagnosis of STEMI who arrived within three hours of symptoms onset and underwent primary percutaneous coronary intervention (p-PCI) from October 2005 to November 2015. Clinical data, electrocardiogram (ECG) and angiographic data were reviewed. The subjects were divided in two groups: those with TWI and those with positive T waves (PTW). Results: 386 (89.3%) patients presented with PTW and 46 (10.6%) with TWI. The presence of early TWI in anterior leads predicted patency of the anterior descending artery (LAD) (18 [69.2%] vs 41 [24%]; p < 0.001) but not in other arteries. Conclusions: The presence of early TWI in anterior leads with STE is associated with patency of the LAD. This relationship was not found in other infarct-related arteries.(AU)

Resumen: Introducción: La onda T invertida siempre se ha considerado como progresión natural de un infarto de miocardio no reperfundido, sin embargo, también se puede observar posterior a fibrinólisis o angioplastia primaria exitosas, su rol en predecir autorreperfusión no ha sido establecido. Objetivo: Valorar la permeabilidad de la arteria culpable del infarto (ACI) en pacientes que se presentan con onda T invertida (OTI) temprana (menos de tres horas de inicio de síntomas) en derivaciones con elevación del segmento ST (IAMCEST). Métodos: Se analizaron 432 pacientes de forma retrospectiva que fueron admitidos al Servicio de Urgencias del Instituto Nacional de Cardiología en la Ciudad de México con diagnóstico de IAMCEST dentro de las primeras tres horas de inicio de los síntomas y que fueran llevados a angioplastia primaria de octubre de 2005 a noviembre de 2015. Se revisaron datos clínicos, electrocardiogramas y angiografías coronarias. Los sujetos fueron divididos en dos grupos: aquéllos con OTI y aquéllos con onda T positiva (OTP). Resultados: Se presentaron 386 (89.3%) pacientes con OTP y 46 (10.6%) con OTI. La presencia de OTI temprana en derivaciones anteriores predijo permeabilidad de la descendente anterior (DA) (18 [69.2%] vs 41 [24%]; p < 0.001) pero no en las otras arterias. Conclusión: La presencia de OTI tempranas en derivaciones anteriores con elevación del segmento ST se asocia a permeabilidad de la DA. Este hallazgo no fue encontrado en otras arterias culpables de infarto.(AU)

Análise da população atendida por meio de tele-eletrocardiograma em serviço móvel de urgência / Analysis of the population attended through a tele-electrocardiography in mobile emergency medical service / Análisis de la población asistida por medio de tele-electrocardiograma en el servicio de urgencia móvil

O estudo aqui apresentado teve como objetivo analisar a população atendida por meio de teleeletrocardiografia realizada por serviço público que pode ser referência para outros em matéria de atendimento pré-hospitalar móvel de urgência no município de Porto Alegre. Trata-se de estudo transversal retrospectivo. Foram analisados 1.338 eletrocardiogramas realizados de setembro 2013 a agosto 2014 pelo Samu/POA, com laudo a distância feito no Hospital do Coração (HCor) em São Paulo. Utilizou-se a metodologia embasada nas diretrizes STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Em 115 (8,6%) desses tele-eletrocardiogramas, os pacientes foram diagnosticados com supradesnivelamento do segmento ST. Esta alteração eletrocardiográfica prevaleceu no gênero masculino (p = 0,012) com idade acima de 60 anos (p = 0,014). Dor torácica típica retroesternal foi mencionada por 314 homens (54,3%) e 726 mulheres (56,3%). Síncope foi relatada por 94 homens (16,3%) e 107 mulheres (14,2%). A dispneia foi um sintoma apontado por 47 homens (8,1%) e 84 mulheres (11,1%). Os resultados do estudo revelaram que alterações eletrocardiográficas sugestivas de SCA (Síndrome coronariana aguda) predominam em homens idosos; embora as mulheres solicitem o serviço de atendimento com mais frequência, o supradesnivelamento do segmento ST mostrou-se preponderante no gênero masculino. A dor torácica ter sido mencionada como o sintoma mais referido está em concordância com a literatura atual. =O conhecimento de nossa realidade pode auxiliar a elaboração de protocolos de serviço.(AU)

The study presented now had as objective to analyze the population attended by tele-electrocardiography in a public service that is a reference for mobile emergency medical service in the city of Porto Alegre, RS, Brazil. It is a retrospective cross-sectional study. We analyzed all electrocardiograms performed by Samu Porto Alegre, from September 2013 to August 2014, and their medical reports produced remotely by the Hospital do Coração (HCor), SP, Brazil. The study was based on the STROBE (Strengthening Reporting Observational Studies Epidemiology) guidelines. From tele-electrocardiograms, 115 (8.6%) patients were diagnosed having a ST-segment elevation. This electrocardiographic alteration was more prevalent in men (p = 0.012) who were 60 years old or over (p = 0.014). Among the symptoms expressed by patients, 314 (54.3%) men and 726 (56.3%) women felt typical retrosternal chest pain. Syncope was reported by 94 (16.3%) men and 107 (14.2%) women. Dyspnea was a symptom reported by 47 (8.1) men and 84 (11.1) women. The results of the study revealed that electrocardiographic alterations suggesting ACS (Acute Coronary Syndrome) are more prevalent in elderly men. Although women request more frequently the mobile emergency medical service, the ST-segment elevation was more prevalent in men. The chest pain was the most symptom mentioned, a result in agreement with the current literature. The knowledge of our reality can help the organization of service protocols.

El estudio presentado aquí ha tenido el objetivo de analizar la población atendida a través de tele-electrocardiografía, en servicio público que es referencia en atención pre-hospitalaria móvil de emergencia, en el municipio de Porto Alegre, RS, Brasil. Consiste en un estudio transversal retrospectivo. Fueron analizados electrocardiogramas realizados entre los meses de septiembre/2013 y agosto/2014 por el Samu/POA, con laudos emitidos a distancia por el Hospital del Corazón (HCor), SP, Brasil. El estudio es basado en las directrices del STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). En 115 (8,6%) de estos tele-electrocardiogramas, los pacientes fueron diagnosticados con supra desnivel del segmento ST. Esta alteración electrocardiográfica fue más predominante en el género masculino (p = 0,012), con edad superior a 60 años (p = 0,014%). Dolor en el pecho típíco retroesternal fue mencionado por 314 hombres (54,3%) y 726 mujeres (56,3%). Síncope fue relatado por 94 hombres (16,3%) y 107 mujeres (14,2%). La disnea fue un síntoma mencionado por 47 hombres (8,1%) y 84 mujeres (11,1%). Los resultados del estudio revelaron que alteraciones sugestivas de SCA (Síndrome coronario agudo) son más predominantes en los hombres con edad superior a 60 años; las mujeres suelen recurrir a el servicio de atención con más frecuencia, entretanto, el suspradesnivel del segmento ST ha prevalecido en el género masculino. El dolor en el pecho fue el síntoma más mencionado, hecho que coincide con la literatura actual. El conocimiento de nuestra realidad puede auxiliarnos a elaborar protocolos de servicio.

Tarjeta de adquisición de datos para el sistema integrado de estetoscopio digital y ECGAR del proyecto SEDAR / Data acquisition card for integrated system of digital stethoscope and ECGAR of SEDAR Project

El artículo presenta el desarrollo de una tarjeta de adquisición de datos (TAD) para uso biomédico. Este diseño forma parte de un sistema que permite realizar un análisis comparativo entre los sonidos cardiopulmonares (SC) y el electrocardiograma de alta definición (ECGAR). La TAD reportada digitaliza simultáneamente tres señales adquiridas. Los dos primeros canales digitalizan las señales correspondientes a las derivaciones dI y dIII del ECGAR. El tercer canal digitaliza la señal captada del SC. El instrumento consta de dos partes, una etapa de hardware para adquirir la señal y un software para la manipulación de datos en la computadora. El hardware está compuesto por un microcontrolador de alto rendimiento, una interfaz de comunicación con la computadora vía USB y los circuitos de seguridad eléctrica inherentes a un equipo médico. El software permite la adquisición de las señales transmitidas desde el hardware, su visualización gráfica y el almacenamiento de la información en una base de datos. Las pruebas de funcionamiento demostraron errores inferiores al 0,1 % en las mediciones de amplitud y no se registró perdida de información en la comunicación con la computadora

The paper reports the development of a data acquisition card (TAD) for biomedical use. This design is part of a system that allows a comparative analysis between cardiopulmonary sounds (SC) and the high-definition electrocardiogram (ECGAR). The reported TAD simultaneously digitizes three acquired signals. The channels 1 and 2 digitize the ECGAR signals corresponding to leads dI and dIII. The channel 3 digitizes to SC captured signal. The instrument consists of two parts, a hardware for acquire the signal and a software for data manipulation in the computer. The hardware consists of a high performance microcontroller, a USB communication interface with the computer and the electrical safety circuits inherent to medical equipment. The software allows the signals acquisition transmitted from the hardware, its graphic visualization and the information storage in a database. The performance tests showed errors less than 0.1 % in amplitude measurements and no loss of information in the communication with the computer

Electrocardiographic analysis of V1-V4 leads in infarction by proximal right coronary artery occlusion / Análisis electrocardiográfico de derivaciones V1-V4 en infarto por oclusión de la arteria coronaria derecha proximal

Abstract: Introduction: In some cases, ST segment elevation in right precordial leads in conjunction with inferior leads can be originated by an obstruction of the right coronary artery in its proximal portion, generating an inferior myocardial infarction which involves the right ventricle. Case presentation: We present the case of a 57-year-old male, which presents symptoms of acute coronary syndrome. The electrocardiogram shows subepicardial injury in anteroseptal leads (V1-V3) and elevation of ST segment in inferior leads (DIII, AVF). A coronariography is performed finding a complete obstruction of right coronary artery in the proximal portion, left coronary artery without lesions. Analysis: In right ventricular infarction or anteroseptal infarction, the ST segment vector always has a posterior- anterior direction in horizontal plane, the direction of this vector will produce an elevation of ST segment in leads V1 to V3 (even V4). Conclusion: It is necessary to do a correct analysis of the electrocardiogram for understanding the mentioned changes and to not assume that the electrocardiographic manifestations are a consequence of multivessel disease.(AU)

Resumen: Introducción: En algunos casos, la elevación del segmento ST en derivaciones precordiales derechas en conjunción con derivaciones inferiores, puede originarse por una obstrucción de la arteria coronaria derecha en su porción proximal, generando así un infarto de miocardio inferior que involucra al ventrículo derecho. Presentación del caso: Presentamos el caso de un paciente varón de 57 años, que presenta síntomas de síndrome coronario agudo, el electrocardiograma muestra lesión subepicárdica en derivaciones anteroseptales (V1-V3) y elevación del segmento ST en derivaciones inferiores (DIII, AVF). Una coronariografía se realiza encontrando una obstrucción completa de la arteria coronaria derecha en la porción proximal, arteria coronaria izquierda sin lesiones. Análisis: En el infarto ventricular derecho o infarto anteroseptal, el vector del segmento ST siempre tiene una dirección posterior-anterior en el plano horizontal, la dirección de este vector producirá una elevación del segmento ST en las derivaciones V1 a V3 (incluso V4). Conclusión: Es necesario hacer un análisis correcto del electrocardiograma para comprender los cambios mencionados y no asumir que las manifestaciones electrocardiográficas son consecuencia de la enfermedad multivaso.(AU)

Bioamplificador multicanal para la adquisición de la señal ECGAR, del prototipo DIGICARDIAC / Multichannel bioamplifier for ECGAR signal acquisition, DIGICARDIAC prototype

El prototipo DIGICARDIAC es un instrumento de uso médico que permite la adquisición simultánea de las doce derivaciones del electrocardiograma (ECG) estándar, con características de alta resolución (ECGAR). El presente trabajo reporta el desarrollo de la etapa de amplificación multicanal implementada en el hardware de este prototipo. Esta etapa consta de 8 amplificadores diferenciales en configuraciones especiales, con un elevado rechazo al ruido en modo común (CMRR). Los filtros utilizados permiten la corrección automática de la línea de base y la eliminación de señales de ruido por encima de los 300Hz. Adicionalmente se incorporaron los circuitos de protección correspondientes a un equipo médico. En las pruebas de funcionamiento se comprobó la eficiencia del dispositivo. Los resultados demostraron la superioridad del instrumento desarrollado en comparación con los electrocardiógrafos comerciales.

The prototype DIGICARDIAC is a medical instrument that allows the simultaneous acquisition the twelve lead of standard electrocardiogram (ECG), with high resolution features (ECGAR ). This paper reports the development the multichannel amplifier implemented in the hardware of this prototype. This section consists of 8 differential amplifiers in special configurations, with a high common mode rejection ratio (CMRR). The filters used allow automatic correction of baseline and eliminating noise signals above 300Hz. Additionally were incorporated protective circuits corresponding to a medical team. In the device operation testing efficiency was checked. The results demonstrated the superiority of the instrument developed in comparison with commercial electrocardiographs.

Uso de betabloqueador no choque cardiogênico da cardiomiopatia de Takotsubo / Use of beta-blockers in cardiogenic shock due to Takotsubo cardiomyopathy

A cardiomiopatia de Takotsubo se caracteriza por alterações reversíveis na função sistólica e segmentar do ventrículo esquerdo associada à coronariografia normal. O choque associado a essa cardiomiopatia é causado por disfunção sistólica e/ou obstrução dinâmica do trato de saída do ventrículo esquerdo. A identificação da etiologia do choque tem implicações terapêuticas. Relata-se o caso de paciente feminina, 76 anos, com cardiomiopatia de Takotsubo cuja apresentação mimetizou infarto agudo do miocárdio complicado com choque cardiogênico. O choque foi revertido após administração endovenosa de propranolol.

Takotsubo cardiomyopathy is characterized by reversible changes in the systolic and segmental left ventricular function associated with normal coronariography. The shock associated with this cardiomyopathy is caused by left ventricular systolic dysfunction and/or dynamic left ventricular outflow tract obstruction. Identification of the etiology of the shock has implications for treatment. This case study reports on a 76-year-old women diagnosed with Takotsubo cardiomyopathy whose presentation mimicked an acute myocardial infarction complicated by cardiogenic shock. The shock was reversed after intravenous administration of propanolol.

Síncope vasovagal em criança com Wolff-Parkinson-White / Vasovagal syncope in child with Wolff-Parkinson-White

Relatamos o caso de uma criança de nove anos de idade, com quadro de síncope há dois anos e eletrocardiograma revelando síndrome de Wolff-Parkinson-White (WPW). História familiar de irmã com síndrome vasovagal. A paciente foi submetida a estudo eletrofisiológico (EEF), para estratificação de risco e ablação da via anômala. Após a ablação, permaneceu com os mesmos sintomas que a fizeram procurar atendimento médico na primeira consulta, sendo então solicitado teste de inclinação (tilt test), que foi positivo para síndrome vasovagal do tipo mista. Conclui-se, portanto, que a causa dos desmaios foi a síndrome vasovagal, sendo as alterações eletrocardiográficas compatíveis com Wolff-Parkinson-White apenas um achado casual. Dois anos após a primeira consulta elaapresenta aumento dos intervalos entre os episódios de síncope.

We report a case of a child nine years old, presented with syncope about two years, with electrocardiogram Wolff-Parkinson-White (WPW) and family history of a sister with vasovagal syndrome. The patient underwent electrophysiological study (EPS) for risk stratification and ablation of the anomalous pathway. After ablation remained with the same symptoms that caused her to seek medical attention at the first consultation, and then asked the tilt test, which was positive for mixed type of vasovagal syndrome. Therefore concluded to be the syncope?s cause, the vasovagal syndrome and electrocardiographic changes compatible with Wolff-Parkinson-White, being just an incidental finding. Two years after the first consultation, she finds with increase interval between episodes of syncope.

Fármacos que podem provocar Síndrome de Kounis / Drugs that may provoke Kounis Syndrome / Fármacos que pueden provocar Síndrome de Kounis

A Síndrome de Kounis (SK) corresponde ao aparecimento simultâneo de síndromes coronárias agudas (SCA) com reações alérgicas ou de hipersensibilidade. Na literatura têm sido reportados vários casos associados a fármacos, picadas de inseto, alimentos, exposições ambientais e doenças médicas. Essa síndrome é encontrada na prática médica diária mais frequentemente do que antecipada. Por isso, o desconhecimento dessa síndrome poderá contribuir para a falha no diagnóstico. Apresentamos um caso clínico de Síndrome de Kounis secundária à ingestão de diclofenaco.

Kounis Syndrome (KS) is the contemporary occurrence of Acute Coronary Syndromes (ACS) with an allergic or hypersensitivity reaction. This syndrome has been reported in association with a variety of drugs, food, insect stings, environmental exposures and medical conditions. Cases of KS seem to be more often encountered in everyday clinical practice than anticipated. It is believed that the lack of awareness of this association may lead to underreporting. We report a case of KS secondary to diclofenac intake.

El Síndrome de Kounis (SK) es el surgimiento simultáneo de síndromes coronarios agudos (SCA) con reacciones alérgicas o de hipersensibilidad. En la literatura han sido reportados varios casos asociados con fármacos, picadas de insecto, alimentos, exposiciones ambientales y enfermedades médicas. Ese síndrome se encuentra en la práctica médica diaria con más frecuencia de lo que se cree. Por eso, su descubrimiento podrá contribuir a la mejoría en los fallos de diagnóstico. Presentamos un caso clínico del Síndrome de Kounis secundario a la ingestión de diclofenaco.

Eletrocardiografia computadorizada em cães: estudo comparativo / Computerized electrocardiography in dogs: a comparative study

Computerized electrocardiography (C-EKG) has been more frequently used in Veterinary Medicine. Many equipment models are available for this purpose. Due to possible device sensitivity and reproducibility differences during examination, the main goal of this study was to compare electrocardiographic parameters of dogs using two different C-EKG systems: Wincardio Micromed® (WIN) and TEB ECGPC® (TEB). Forty two healthy male and female dogs of different breeds (Cocker Spaniel, Dachshund, Labrador, Pinscher, Pitbull Terrier, Poodle, Schnauzer, Shih Tzu, Yorkshire and mongrel dogs), with age between 4 months and 16 years old were grouped according to weight and evaluated by both systems. The electrocardiographic measurements were performed on DII lead for both systems. The study showed that the TEB system was more sensitive for measurement of P wave and QRS complex duration, while the WIN system showed more sensitivity for the measurements of amplitude of the same parameters. The larger animals (26-37kg) showed greater variance in the measurements of P wave and QRS complex amplitude and duration than the groups of medium (14-25kg) or smaller (3-13kg) dogs. These differences must be considered when using diverse computerized electrocardiography systems to perform measurements due to the possibility of erratic interpretation of the results between veterinary medicine services.

O método de eletrocardiografia computadorizada (ECG-C) vem sendo crescentemente difundido na medicina veterinária, havendo atualmente diversas marcas e modelos de eletrocardiógrafos disponíveis no mercado. Diante da possibilidade de diferenças na sensibilidade e na reprodutibilidade das medidas obtidas nos traçados, o presente estudo teve como objetivo comparar os parâmetros eletrocardiográficos de cães, obtidos por dois sistemas. Foram avaliados dois diferentes softwares computadorizados, o Wincardio Micromed® (WIN) e o modelo TEB ECGPC® (TEB). Quarenta e dois cães hígidos, de diferentes raças (Cocker Spaniel, Daschund, Labrador, Pinscher, Pit Bull Terrier Poodle, Schnauzer, Shit Tzu, Yorkshire e sem raça definida), machos e fêmeas e com idade entre 4 meses e 16 anos foram agrupados segundo o peso e examinados pelos dois sistemas. As medidas eletrocardiográficas dos diferentes traçados foram analisadas na derivação DII. Os resultados indicaram que o sistema TEB apresentou maior sensibilidade na obtenção das medidas de duração da onda P e do complexo QRS, enquanto o sistema WIN foi mais sensível para determinar as medidas de amplitude dos mesmos parâmetros. Os animais de maior porte (26-37kg) apresentaram maior variância nas medidas de duração e amplitude de onda P e duração do complexo QRS em comparação aos cães de médio (14-25kg) e pequeno (1-13kg) porte. O achado de diferenças entre os sistemas testados deve ser levado em consideração ao se empregar os diversos equipamentos para diagnóstico por meio de ECG-C na rotina clínica, de modo a evitarem-se divergências na interpretação dos exames entre diferentes prestadores de serviços veterinários.

Usefulness of an Implantable Loop Recorder in Patients with Syncope of an Unknown Cause

PURPOSE: The mechanisms underlying syncope remain unknown in about 20% of patients with recurrent syncope. The implantable loop recorder (ILR) has been shown to be a useful diagnostic tool in patients with unexplained syncope even after negative initial evaluations. Nevertheless, ILR has rarely been used in clinical practice. MATERIALS AND METHODS: This study included 18 consecutive patients who had an ILR implanted at our center because of recurrent unexplained syncope after extensive diagnostic tests between February 2006 and June 2011. RESULTS: Diagnosis was confirmed in 10 (55.6%) of the 18 enrolled patients (13 males, 61+/-15 years). The confirmed diagnoses included sick sinus syndrome (n=6, 60%), advanced atrioventricular block (n=2, 20%) and ventricular tachyarrhythmia (n=2, 20%). The mean follow-up durations of the total study subjects and the diagnosed patients were 11.3+/-10.6 months and 5.6+/-9.2 months, respectively. Of the 10 diagnosed patients, 8 (80%) were diagnosed within 6 months of loop recorder implantation. CONCLUSION: ILR may be a valuable and effective diagnostic tool for patients with unexplained syncope.

Desarrollo del prototipo de un sistema de adquisición de datos para la digitalización de la señal electrocardiográfica de alta resolución / Prototype development of a data acquisition system for ECG signal digitalization high resolution

Resumen - El presente trabajo reporta el desarrollo de una tarjeta de adquisición de datos para uso biomédico. El proyecto consta de una etapa de hardware y una de software. La etapa de hardware permite la digitalización multicanal de 8 señales, con una velocidad de adquisición de 2000 muestras por segundo (mps) en cada canal y 12 bits de resolución por muestra. El software de aplicación se diseñó con la finalidad de visualizar en tiempo real y almacenar en el computador las señales adquiridas. Este proyecto se realizó buscando desarrollar tecnología propia, que permita la adquisición simultánea de los doce canales del electrocardiograma (ECG) superficial estándar, con características de alta resolución (ECGAR). La tarjeta de adquisición de datos reportada se diseña como parte de un proyecto, que tiene como propósito obtener la representación digital de la señal ECG multicanal, con las características adecuadas para aplicar técnicas de análisis especializadas que permitan estudiar enfermedades cardiovasculares de metabolismo retardado, como el mal de Chagas. En las pruebas realizadas se constató que el sistema presenta errores inferiores al 0,15 % en las mediciones de amplitud y no presenta perdida de información en la comunicación del hardware con la computadora. También se constató que la representación gráfica de las señales adquiridas es de muy buena calidad para su implementación por médicos especialistas.

Abstract - This paper reports the development of a data acquisition card for biomedical use. The project involves development of hardware and software. The hardware enables acquisition of 10 analog signals, at a rate of 2000 samples per channel per second (mps) and 12-bit resolution per sample. The application software was designed for visualizing and storing, in real time, the acquired signals. This project was performed aiming at developing proprietary technology, for simultaneous acquisition of 12 leads of the standard electrocardiogram (ECG) including high resolution (ECGAR) features. The acquisition card was designed as part of a larger project aiming at developing a high resolution electrocardiograph, incorporating advanced digital processing techniques for research about cardiovascular diseases such as the Chagas disease. The tests performed for this acquisition card show amplitude errors lower than 0.15 % and no loss of information during the communication with the computer. It was also found that the graphical representation of the acquired signals is of high quality for interpretation by cardiologists.

Alteraciones electrocardiográficas en pacientes con enfermedad de chagas. Hospital José Rangel de Villa de Cura. 1998 - 2008 / Electrocardiographic abnormalities in patients with. chagas disease. Hospital José Rangel of Villa de Cura. 1998 - 2008

Objetivo: Analizar las principales alteraciones electrocardiográficas en pacientes con Enfermedad de Chagas que asistieron al Hospital José Rangel de Villa de Cura Edo. Aragua, entre los años 1998 -2008. Se realizó una revisión de historias clínicas y electrocardiogramas de la Unidad de Archivos del Hospital José Rangel de Villa de Cura. La población estuvo conformada por 85 pacientes con enfermedad de Chagas que asistieron al Hospital José Rangel de Villa de Cura entre los años 1998 - 2008. De ellos, 64 % de los pacientes tuvo edades comprendidas entre los 60 a 84 años, a predominio del sexo masculino en 55%. El trastorno de conducción más frecuente fue el bloqueo de rama (52,9%), principalmente bloqueo de rama derecha; El trastorno del ritmo más frecuente fue fibrilación auricular (55.3%), principalmente fibrilación auricular con respuesta ventricular rápida. También se observó extrasístole ventricular, bradicardia sinusal, arritmia ventricular, y otras alteraciones electrocardiográficas, principalmente alteraciones del segmento ST, alteraciones de la onda P y bajo voltaje. Las principales patologías cardiovasculares fueron: hipertensión arterial (49,4 %), insuficiencia cardíaca (57,6) enfermedad cerebrovascular (22,4%). Los medicamentos más utilizados fueron Ácido acetilsalicílico (60%), (55,3%), Digoxina (35,6%), Amiodarona (29,4%), Furosemida (57,3%), Espironolactona (31,8%), Captopril (44,7%), Enalapril (22,4%) y Clonidina (20%). solo 4,7% ameritó el uso de marcapasos. Metodología: La investigación se enmarca como un estudio epidemiológico descriptivo de corte transversal. Conclusiones: Se concluye que en estos pacientes la presencia de fibrilación auricular fue levemente más frecuente que el bloqueo de rama, con alta frecuencia de hipertensión arterial e insuficiencia cardíaca, indicando grave compromiso cardíaco y mal pronóstico.

Objective: To analyze the electrocardiographic changes in patients with Chagas disease who attended the Hospital José Rangel de Villa de Cura Edo. Aragua, between the years 1998 -2008. Clinical records and electrocardiograms in the archives unit were reviewed. The population consisted of 85 patients with Chagas disease who attended the Hospital José Rangel of Villa de Cura between the years 1998 to 2008. Of these, 64% of patients were aged 60-84 years, 55% of patients were male. Branch block disorder was the most frequent (52,9%), with predominance of right bundle branch block (31,7%), Atrial fibrillation was the most common rhythm disorder (55,3%), with predominance of atrial fibrillation with rapid ventricular response. (3,7%) was also observed ventricular extrasystole, sinus bradycardia, ventricular arrhythmia and other ECG abnormalities, particularly ST-segment abnormalities, alterations in the P wave and low voltage. The major cardiovascular diseases were: hypertension (49,4%), heart failure (57,6) cerebrovascular disease (22,4%). Acetylsalicylic acid was the drug most used (60%), and also Isosorbide (55,3%), Digoxin (35.6%), Amiodarone (29,4%), Furosemide (57,3%), Spironolactone (31,8%), Captopril (44,7%), Enalapril (22,4%) and Clonidine (20%). just 4,7% required the use of pacemakers. Methodology: The research was framed as cross sectional a descriptive epidemiological study. Conclusions: We conclude that in these patients the presence of atrial fibrillation was slightly more common than bundle branch block, with a high frequency of hypertension and heart failure, indicating severe heart failure and poor prognosis.

Terremoto 2010: Impacto en la incidencia de lesiones subepicárdicas. experiencia en telemedicina / Impact of the 2010 earthquake and tsunami in Chile: a telemdicine evaluation of suepicardial lesions

Background: The association of stress and acute coronary events has been extensively explored. An increased output of catecholamines leading to high blood pressure and alteration of hemostasis may be responsible for this effect. A severe earthquake and tsunami is a major stress. Methods and Results. 280,592 electrocardiograms (ECG) obtained via a telemedicine system in the years 2009 and 2010 were analyzed. The frequency of subepicardial lesions recorded during the weekend in which the earthquake took place (27/2/2010 - 28/2/2010) was compared to that observed in all other weekends throughout the period. 7 subjects had a blood pressure Holter monitoring on that weekend. A subepicardial lesion was diagnosed in 0.64% of ECGs recorded throughout the period, increasing significantly in the earthquake's weekend (p<0.05). The age distribution of subepicardial lesions was similar in all weekends. However, the higher proportion of males with sub epicardial lesions throughout the study period changed to a higher proportion of females in the earthquake's weekend. Significant increases in blood pressure and heart rate were observed in coincidence with the earthquake in patients undergoing blood pressure monitoring. Conclusion: a statistically significant increase in subepicardial lesions demonstrated by telemedicine ECG recordings was associated to the stressful situation of the 2010 earthquake in Chile.

La asociación de estrés y eventos coronarios agudos ha sido extensamente estudiada. En relación a un evento estresante existiría un aumento en la liberación de ca-tecolaminas que incide en un incremento en la presión arterial y alteraciones de hemostasia, como sería el caso de un terremoto. En el presente trabajo se describe la relación contemporánea observada entre el terremoto del 27 de febrero del 2010 y el diagnóstico de lesión subepicárdica, en electrocardiogramas recibidos en ITMS, Telemedicina de Chile. Se analizaron 280.592 electrocardiogramas (ECGs) provenientes de todo el territorio nacional, que corresponden a un periodo de 12 meses de los años 2009 y 2010. Se realizó una comparación estadística entre el porcentaje de lesiones subepicárdicas registradas en el fin de semana del terremoto (27/02/2010 y 28/02/2010) versus los fines de semana de los meses estudiados. Se obtuvieron los datos correspondientes a siete pacientes que se encontraban con monitoreo ambulatorio de presión arterial (MAPA) el día 27/02. El diagnóstico de lesión subepicárdica se hizo en 1.795 trazados, correspondientes a un 0.64% del total de ECGs recibidos. Hubo un aumento estadísticamente significativo de las lesiones subepicárdicas (p<0,05) en el fin de semana del terremoto, la distribución por edad se mantuvo similar al resto de los períodos analizados. Sin embargo se invirtió la distribución por género durante dicho fin de semana siendo mayor en mujeres que en hombres, como es en el resto de los períodos analizados. En los registros MAPA se documentó un aumento de la presión arterial y frecuencia cardíaca en relación al evento estresante. Se confirmó entonces un aumento estadísticamente significativo del diagnóstico electrocardiográfico de lesiones subepicárdicas en relación al estrés producido por el terremoto del 27 de febrero de 2010.

Unveiling the uncertainty principle in the QRS complex offset detection on high resolution electrocardiography

The accuracy of high resolution electrocardiographic (HRECG) methods for stratifying the risk of malignant ventricular arrhythmia depends on the fidelity of QRS fiducial points detection. This study aims at examining the effect of acquisition and processing variables in HRECG on the variability of QRS complex offset (QRS offset) detection in simulated and biological signals, as well as investigating the factors related to the so called uncertainty principle applied to HRECG. Successive QRS offset locations were calculated in different signals configurations including HRECG data from patients with and without ventricular late potentials and simulated data using linear and exponential functions. The expected error in QRS offset detection was assessed as a function of: i)   signal characteristics (Simulated or Biological); ii) Sampling Frequency (SF); iii) Residual Noise Level (RNL); iv) QRS maximum amplitudes. The uncertainty principle was related to HRECG and a given exponential signals, and increasing RNL up to  0.5  μV. SF and RNL are outstanding factors influencing QRS offset variability. Thus, HRECG related uncertainty principle is a deterministic phenomenon associated with both HRECG signal and mathematical formulation of the terminal decay of the QRS complex to the fusion with the ST segment.

A precisão dos resultados dos exames de eletrocardiografia de alta resolução (ECGAR) para estratificação do desenvolvimento de arritmias ventriculares malignas depende da fidelidade na detecção dos pontos fiduciais do complexo QRS. O presente estudo tem o objetivo de avaliar o efeito das variáveis de aquisição e processamento do ECGAR sobre a variabilidade da detecção do ponto final do complexo QRS (QRS-fim) em sinais biológicos simulados e reais, bem como investigar o efeito de condições relacionadas ao assim formulado “princípio da incerteza da eletrocardiografia de alta resolução”. Detecções sucessivas do QRS-fim foram realizadas usando diferentes configurações de sinais simulados e de pacientes com e sem potenciais tardios ventriculares. Os sinais simulados empregaram funções lineares e exponenciais para mimetização da porção final do complexo QRS. O erro de detecção do QRS-fim esperado foi avaliado em função de: i) procedência dos sinais (simulado ou biológico); ii) frequência de amostragem (FA); iii) nível de ruído residual (NRR); iv) amplitude máxima do complexo QRS. A presença do princípio da incerteza relacionou-se ao padrão de decaimento exponencial e ao aumento progressivo da NRR, até  0,5  μV. FA e NRR têm impacto significativo na variabilidade do QRS-fim. Assim, o principio da incerteza da ECGAR é um fenômeno determinístico dependente da forma de onda relativa ao decaimento da região terminal do complexo QRS até a sua fusão com o segmento ST.

Bloqueio atrioventricular adquirido por uso de amiodarona: relato de caso / Atrioventricular block induced by amiodarone therapy: case report

JUSTIFICATIVA E OBJETIVOS: A amiodarona é um antiarrítmicoda classe III, amplamente utilizado nas mais diversas arritmias. Entretanto, a despeito de seus benefícios hemodinâmicos e eletrofisiológicos, ela produz efeitos colaterais relevantes, como coloração azulada da pele, fotossensibilidade,disfunção tireoidiana, depósito corneal, neuropatia periférica, supressão da medula óssea, hepatite, bloqueios cardíacos, pneumonites e outros. Os principais efeitos colaterais cardíacos, após terapia prolongada com amiodarona são: bradicardia sinusal, observada mais frequentemente e,menos comumente, bloqueio atrioventricular (BAV). O objetivo deste estudo foi relatar um caso de BAV por uso de amiodarona.RELATO DO CASO: Paciente do sexo masculino, 73 anos, negro,portador de insuficiência renal crônica dialítica, encaminhado para internação com história de inapetência, vômitos, emagrecimento e dor abdominal, além de bradicardia assintomática. No eletrocardiograma (ECG) observou-se bloqueio atrioventricular total (BAVT). Após a suspensão dos fármacos utilizados, os sintomas desapareceram em seis dias. CONCLUSÃO: Pacientes em uso inadvertido e prolongado de alguns fármacos devem ser com frequência reavaliados, clinica e laboratorialmente, pois níveis acima da janela terapêutica só serão descobertos desta forma, na ausência de sintomatologia.(AU)

BACKGROUND AND OBJECTIVES: Amiodarone is a class III antiarrhythmic, widely used in a variety of arrhythmias. However, despite its hemodynamic and electrophysiological benefits,amiodarone produces serious collateral effects such as blue skin coloration, photosensitivity, thyroid dysfunction, corneal deposits,peripheral neuropathy, bone marrow suppression, hepatitis,heart blocks, pneumonitis and other. The main cardiac side effects after prolonged therapy with amiodarone are bradycardia,observed more frequently and less commonly, atrioventricular block. The objective of this study is to report a case of atrioventricular block due to use of amiodarone.CASE REPORT: Male, year 73, a black patient with chronic renal failure, referred to internation, with history of innapetency,vomiting, weight loss and abdominal pain and also asymptomatic bradycardia. On EKG there was an atrioventricular block. After discontinuation of the drug, the symptoms disappeared in 6 days.CONCLUSION: Patients on inappropriate use of some drugs,mainly long-term, should be frequently reassessed, so clinical and laboratory, because levels above the therapeutic window only this way will be discovered, in absence of symptoms.(AU)