Evaluation of New Potential Inflammatory Markers in Patients with Nonvalvular Atrial Fibrillation.

Atrial fibrillation (AF), the most common arrhythmia in clinical practice, is associated with an increase in mortality and morbidity due to its high potential to cause stroke and systemic thromboembolism. Inflammatory mechanisms may play a role in the pathogenesis of AF and its maintenance. We aimed to evaluate a range of inflammatory markers as potentially involved in the pathophysiology of individuals with nonvalvular AF (NVAF). A total of 105 subjects were enrolled and divided into two groups: patients with NVAF (n = 55, mean age 72 ± 8 years) and a control group of individuals in sinus rhythm (n = 50, mean age 71 ± 8 years). Inflammatory-related mediators were quantified in plasma samples by using Cytometric Bead Array and Multiplex immunoassay. Subjects with NVAF presented significantly elevated values of interleukin (IL)-2, IL-4, IL-6, IL-10, tumor necrosis factor (TNF), interferon-gamma, growth differentiation factor-15, myeloperoxidase, as well as IL-4, interferon-gamma-induced protein (IP-10), monokine induced by interferon-gamma, neutrophil gelatinase-associated lipocalin, and serum amyloid A in comparison with controls. However, after multivariate regression analysis adjusting for confounding factors, only IL-6, IL-10, TNF, and IP-10 remained significantly associated with AF. We provided a basis for the study of inflammatory markers whose association with AF has not been addressed before, such as IP-10, in addition to supporting evidence about molecules that had previously been associated with the disease. We expect to contribute to the discovery of markers that can be implemented in clinical practice hereafter.

Thrombin Generation and other hemostatic parameters in patients with atrial fibrillation in use of warfarin or rivaroxaban.

Patients with atrial fibrillation (AF) present hyperactivation of both platelets and coagulation leading to a hypercoagulable state which contributes to an increased risk of thromboembolism. Therefore, one of the main strategies for treatment of AF is prevention of these events through the use of oral anticoagulants (OAC). The aim of this study was to evaluate hemostasis as a whole in patients with non-valvular AF undergoing warfarin or rivaroxaban by thrombin generation test (TGT), in addition to monocyte-platelet aggregates (MPA), glycoprotein IIb/IIIa (GPIIb/IIIa), and platelet (PMP) and endothelium (EMP) microparticles, compared to age and sex matched controls. PT/INR for OAC use was also determined. In patients taking OAC, compared to control group, a decrease in TGT (p = 0.000 for all parameters) were observed. Patients taking warfarin showed to be more hypocoagulable, presenting lower levels of ETP (p = 0.000) and peak (p = 0.002) than patients using rivaroxaban. Patients on warfarin use with INR > 3 had also lower levels of ETP (p = 0.01) and peak (p = 0.006). A decrease in ETP (p = 0.03) and peak (p = 0.02) values was also observed in patients using rivaroxaban with PT > 21.4 s. Patients using warfarin (p = 0.000) and rivaroxaban (p = 0.000) presented lower levels of MPA in relation to control group. It was also observed in patients using warfarin, lower GPIIb/IIIa levels in relation to control group (p = 0.011). Patients taking rivaroxaban (p = 0.003) and warfarin (p = 0.001) had higher PMP levels compared to control group. There was no difference in levels of EMP between the groups (p = 0.0536). The present study reinforces the usefulness of OAC in AF, which decisively contribute to a better management of the disease preventing possible complications.

Comparison of Inflammatory Mediators in Patients With Atrial Fibrillation Using Warfarin or Rivaroxaban.

Background: Atrial fibrillation (AF) is the most common arrhythmia associated with high risk of venous thromboembolism. Inflammatory mechanisms may be involved in the pathophysiology of AF and in the AF-related thrombogenesis, and patients with AF might benefit from the use of anticoagulants with anti-inflammatory properties. However, the evidence is still scarce, and it points out the need of trials seeking to investigate the levels of inflammatory mediators in patients with AF under different anticoagulant therapies. Therefore, this study was designed to define whether patients with AF treated either with an activated coagulation factor X (FXa) inhibitor (rivaroxaban) or with a vitamin K inhibitor (warfarin) present changes in peripheral levels of inflammatory mediators, mainly cytokines and chemokines. Methods: A total of 127 subjects were included in this study, divided into three groups: patients with non-valvular atrial fibrillation (NVAF) using warfarin (N = 42), patients with NVAF using rivaroxaban (N = 29), and controls (N = 56). Plasma levels of inflammatory mediators were quantified by immunoassays. Results: Patients with AF (both warfarin and rivaroxaban groups) presented increased levels of inflammatory cytokines in comparison with controls. The use of rivaroxaban was associated with decreased levels of inflammatory cytokines in comparison with warfarin. On the other hand, patients with AF using rivaroxaban presented increased levels of the chemokines (MCP-1 in comparison with warfarin users; MIG and IP-10 in comparison with controls). Conclusions: AF is associated with an inflammatory profile that was less pronounced in patients on rivaroxaban in comparison with warfarin users. Further studies are necessary to assess the clinical implications of our results and whether patients with AF would benefit from rivaroxaban anti-inflammatory effects.

Bloqueio atrioventricular avançado: uma manifestação incomum da endomiocardiofibrose / Advanced atrioventricular block: an unusual manifestation od endomyocardial fibrosis

A endomiocardiofibrose é uma causa importante de cardiopatia restritiva na zona tropical, ocasionalmente verificada no Brasil. Caracteriza-se pelo espessamento fibroso do endocárdio e do miocárdio subjacente, com progressão tardia para insuficiência cardíaca grave e prognóstico reservado. Relata-se aqui uma apresentação infrequente da doença: a insuficiência cardíaca de baixo débito, secundária a bloqueio atrioventricular avançado. O paciente foi tratado com sucesso por meio de implante de marcapasso DDD/R e encontra-se em classe funcional I (NYHA) há dois anos.

Endomyocardial fibrosis is an important cause of restrictive cardiomyopathy observed in tropical areas and has been occasionally found in Brazil. It is characterized by fibrous thickening of the endocardium and underlying myocardium with late progression to severe heart failure and poor prognosis. We report an unusual presentation of the disease: low output heart failure secondary to advanced atrioventricular block. The patient was successfully treated by implanting a DDD/R pacemaker and has been in functional class I (NYHA) for 2 years.

Síncope vasovagal e teste de inclinaçäo ("Tilt-Test"): Revisäo para padronizaçäo / Vasovagal syncope and head-up tilt test: literature review for standardization

A síncope é um sintoma comum e até recentemente sua etiologia näo era estabelecida em cerca de 45 "por cento" dos casos. Acredita-se que cerca de 55 "por cento" dos casos de síncope sejam decorrentes de reflexos mediados pelo sistema nervoso, do tipo vasovagal. Difundiu-se recentemente a aplicaçäo do teste de inclinaçäo ("tilt-test") para confirmaçäo diagnóstica. Entretanto, protocolos distintos têm sido utilizados e os resultados encontrados classificados de diversas formas, o que tem dificultado a comparaçäo dos achados de diferentes serviços. A presente revisäo da literatura tem por objetivo discutir a fisiopatologia da síncope vasovagal, os vários protocolos de teste de inclinaçäo utilizados para o seu diagnóstico, assim como a posiçäo ideal deste método complementar dentro de um algoritmo racional de avaliaçäo de síncope.