Arrhythmias, Cardiac – ABC CARDIOL

IJCS

Original Article

Frequent Cardiovascular Manifestations Associated With SARS Cov-2 Infection: Experience at a Tertiary Hospital In Cali, Colombia

Duvan Arley Galindes-Casanova et al. Edith Norela Benitez-Escobar Luis Álvaro Melo-Burbano Nelson Eduardo Murillo-Benitez … Juan Carlos Avila-Valencia Jorge Enrique Daza-Arana

Abstract

Background:

Coronavirus disease 2019 (COVID-19) mainly affects the respiratory system, while the most common extrapulmonary complication of COVID-19 is cardiovascular involvement.

Objective:

To identify the frequency of electrocardiographic changes and cardiac arrhythmias in patients hospitalized with COVID-19 infection.

Methods:

This was a cross-sectional study, including patients aged >18 years with diagnosis of severe acute respiratory syndrome coronavirus 2 infection in a high-complexity hospital in Santiago de Cali, Colombia, from March to September 2020. A descriptive analysis with an analytical component and multiple logistic regression analysis were performed; all estimates were established with a 95% confidence level (CI) and a 5% significance level.

Results:

This study included 183 individuals; of whom 160 were considered for electrocardiographic analysis, 63% of which evidenced significant findings, the most frequent being sinus tachycardia (29.4%). The frequency of myocardial injury was 21.9% and was more common among non-survivors than among survivors (41.7% vs. 12.2%, p < 0.001). Myocardial injury was also significantly more common in patients who presented electrocardiographic findings than those who did not (26.5% vs. 12.1%, p = 0.032) and in those who required intensive care admission (31.8% vs 10.5%, p < 0.001). The strongest mortality-associated factor was the need for mechanical ventilation — odds ratio (OR), 9.14; 95% confidence interval, 3.4–24.5.

Conclusions:

Electrocardiographic findings in patients with COVID 19 are frequent, including newly diagnosed arrhythmias, justifying the use of cost-effective tools for the initial approach and follow-up of this affected population. Worse outcomes depend on factors such as invasive mechanical ventilation, comorbidities, age, and superinfection.

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Editorial

Hyperthyroidism and Cardiac Contractility

Dhiãnah Santini de Oliveira Chachamovitz

Much information is lacking on hyperthyroidism and cardiac function, especially in isolated muscles. Certainly, the time the heart muscle is exposed to elevated thyroid hormones (TH) influences the magnitude of their effects. The primary changes seem to be related to increases in the heart mass/body mass ratio and in relaxation kinetics.

These cardiac changes may also be related not only to the time of exposure to excess thyroid hormones, but to the level or intensity of hyperthyroidism, as well as the underlying cardiac condition, which may reflect exercise conditioning and overload. In this sense, the cellular mechanisms of muscle adaptation, energy and oxygen consumption, certainly make differences. As well as muscle strength and sarcoplasmic/endoplasmic reticulum calcium (SRCa) activity, they may also have different individual adaptive characteristics.

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Viewpoint

COVID-19 and the Beat-To-Beat Heart

Diego Santos Souza et al. Aimée O Durço Camila Souza Gama Rocha Lino Sérgio Rocha Conceição

Introduction

Since December 2019, the coronavirus disease (COVID-19) has caused an exponential increase in acute respiratory syndrome cases and has rapidly spread to more than 210 regions, countries and territories, resulting in considerable morbidity and mortality in more than 100 countries worldwide.

Over this period, several studies describing the clinical and epidemiological characteristics of COVID-19 have been published, allowing rapid dissemination of knowledge and helping health care professionals and policy makers to help patients with the disease.

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Original Article

The Association between Tp-e interval, Tp-e/QT , and Tp-e/QTc Ratios and Coronary Artery Disease Spectrum and Syntax Score

Serkan Kahraman et al. Ali Dogan Gokhan Demirci Arda Guler … Ali Kemal Kalkan Fatih Uzun Nuri Kurtoglu Mehmet Erturk Mehmet Emin Kalkan

Abstract

Background

Coronary artery disease (CAD) causes electrical heterogeneity on ventricular myocardium and ventricular arrhythmia due to myocardial ischemia linked to ventricular repolarization abnormalities.

Objective

Our aim is to investigate the impact of increased level of CAD spectrum and severity on ventricular repolarization via Tp-e interval, Tp-e/QT and Tp-e/QTc ratios.

Methods

127 patients with normal coronary artery (group 1), 129 patients with stable CAD (group 2) and 121 patients with acute coronary syndrome (group 3) were enrolled. Tp-e interval, Tp-e/QT and Tp-e/QTc ratios were evaluated as well as baseline demographic and clinical parameters. Kruskal-Wallis one-way ANOVA test was used for comparing quantitative variables with abnormal distribution while One-Way ANOVA test was used for comparing the means between groups with normal distribution. Tukey HSD and Welch tests were used for subgroups analyses with normal distribution. Spearman analysis was used to evaluate the correlation between clinical variables and repolarization markers. A p-value < 0.05 was considered statistically significant.

Results

Tp-e interval [66(50-83), 71(59-82) and 76(64-86); group 1,2 and 3 respectively, p<0.001], Tp-e/QT (0.170.02, 0.180.01 and 0,190.01; group 1,2 and 3 respectively, p<0.001) and Tp-e/QTc (0.150.02, 0.160.02 and 0.170.02; group 1,2 and 3 respectively, p<0.001) ratios were found to be associated with increased level of CAD spectrum. Syntax score was positively correlated with Tp-e interval (r=0.514, p<0.001), Tp-e/QT (r=0.407, p<0.001), and Tp-e/QTc ratios (r=0.240, p<0.001).

Conclusion

Prolonged Tp-e interval and increased Tp-e/QT and Tp-e/QTc ratios were detected in the presence of CAD and especially in patients with acute ischemic syndromes. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Viewpoint

Dysautonomic Arrhythmogenesis: A Working Hypothesis in Chronic Chagas Cardiomyopathy

Roberto Coury Pedrosa

Abstract

Sudden cardiac arrest (SCA) represents the most dramatic course of chronic Chagas cardiomyopathy (CCC) and is closely related to the presence of ventricular arrhythmias and heart disease. Although several aspects of ventricular arrhythmias in CCC have been elucidated in the last decades, such as the role of impaired cardiac autonomic modulation reported in pre-clinical studies, important questions remain unresolved regarding these cardiac problems and SCA. The aim of this article is to discuss recent developments in the understanding of the role played by the autonomic nervous system on arrhythmic events in CCC. We draw attention to the neurogenic theory of CCC (“catecholamine-induced cardiomyopathy”) and its autoimmune regulation. Finally, we contextualize treatment strategies for Chagas disease considering the prevention of malignant ventricular arrhythmias. The most clinically relevant message from this article may be the high negative predictive value of dysautonomia for SCA in CCC. Nevertheless, there is a long journey from the identification of a potential marker for SCA to its actual use, which will require a common effort by the entire Chagas community.

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Original Article

Evaluation of the Autonomic Nervous System in Chronic Chagasic Cardiopathy: A Systematic Review of the Literature

Lorena dos Santos Marreto Rimolo et al. Roberto Magalhães Saraiva Ademir Batista da Cunha

Abstract

Background

The importance of regional sympathetic denervation in the pathophysiology and prognosis of Chagas disease has been recognized.

Objective

To conduct a review of studies that have assessed dysautonomia in chronic Chagas heart disease.

Methods

The search was performed on the Medline, Pubmed, Lilacs and SciELO databases. The inclusion criteria were: original articles published in full; studies on individuals with Chagas disease, that used diagnostic methods for chagasic cardiomyopathy, and had clear inclusion and exclusion criteria. Duplicate studies, studies including children (0 to 10 years old), studies involving animals, in vitro experiments, case reports, editorials, theses, and dissertations were excluded.

Results

A total of 281 articles were retrieved, and 10 met the inclusion criteria and were analyzed. There was great heterogeneity as to the technique for assessing dysautonomia, groups of patients studied and classification of Chagas disease. The methods used for studying the autonomic system was immunohistochemistry (n=1), Valsalva and tilt-test (n=1), scintigraphy (n=6) and Holter monitoring (n=2). The results indicated dysautonomia in the indeterminate, digestive and cardiac forms of Chagas disease, and sympathetic denervation in the indeterminate and cardiac forms of the disease. There was agreement between areas of denervation, hypoperfusion and fibrosis, but areas of denervation were larger than those of hypoperfusion. The frequency of denervation and its extension increased from the indeterminate to the cardiac form. There was an association between extension of denervation and previous history of malignant ventricular arrhythmia.

Conclusions

The evidence presented in this review supports that an early diagnosis of autonomic denervation in chronic Chagas’ disease allows the identification of patients with an increased risk of sudden death. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Viewpoint

Severe Cardiovascular Complications of COVID-19: a Challenge for the Physician

Nathalie Cristina Crivelari et al. Gisele Queiroz de Oliveira Clarice Hyesuk Lee Park Gregorio da Cruz Riemma … Isabela Bispo Santos da Silva Costa Marcus Vinícius Guimarães de Lacerda Glaucia Maria Moraes de Oliveira Francisco Carlos da Costa Darrieux Luciana Sacilotto Ludhmila Abrahão Hajjar

Introduction

Since December 31, 2019, when China reported the appearance of cases of acute respiratory failure caused by a new species of coronavirus, SARS-CoV-2, which causes the disease called COVID-19, almost 20 million cases were confirmed, causing 726 thousand deaths worldwide. In Brazil, on August 8^th, 2020, there was approximately 3 million cases and 100 thousand death by the disease.

Its rapid spread, its high potential for hospitalization, and its high lethality, especially in the most fragile groups such as geriatric patients and those with comorbidities, particularly cardiovascular ones, make this pandemic a challenge never faced by modern medicine. To date, we have no specific medication that has effective and safe results for the treatment of COVID-19. The scientific community has sought to research drugs with therapeutic plausibility, and controlled and randomized studies are underway. Many therapeutic proposals are based on in vitro experiments. The medications used are described in case records, with no solid scientific evidence for their use, and with a high probability of causing damage due to their adverse effects alone or in combination.

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Original Article

Analysis of Conduction Intervals in Normal Electrophysiological Studies: Establishment of Reference Values the Brazilian Population

Tiago Luiz Luz Leiria et al. Catarine Benta Lopes dos Santos Roberto Tofani Sant'anna Julia Santana Trombetta … Gabriela Osterkamp Marcelo Lapa Kruse Leonardo Martins Pires Gustavo Glotz Lima

Abstract

Background

In the investigation of cardiac rhythm disorders, a normal electrophysiological (EPS) study is associated with a favorable prognosis. One of the normality criteria is established by conduction intervals within expected range.

Objective

To establish reference values in EPS for the intracavitary conduction intervals (PA, AH and HV) in a Brazilian population.

Methods

A retrospective cohort study of the first 1,500 patients submitted to EPS ablation was performed at Instituto de Cardiologia do Rio Grande do Sul, Brazil. The EPS was considered normal if the test was performed for diagnostic purpose; absence of induced arrhythmias; and conduction intervals within the expected range. The REDCap software was used for data collection and management, and the SPSS Statistics 22.0 used for data analysis. Continuous variables were compared with Student’s t-test for independent samples and categorical variables with the chi-square test (X ² ). Values of p ≤ 0.05 were considered significant.

Results

A total of 124 (8.3%) with EPS considered normal were included; mean age was 52 ± 21 years, and 63 were male. The mean values in milliseconds of PA, AH and HV were 23 ± 9, 88 ± 25 and 44 ± 7, respectively. The PA, AH, and HV percentile ranges were 13 – 25, 81-107 and 40 – 52, respectively. When the patients were divided into three age groups (1 to 18 years, 19 to 64 years and 65 or more), we observed that the group of older patients had significantly higher values of PA, AH and HV compared with younger patients.

Conclusion

This study showed that intracavitary conduction intervals in a sample of the Brazilian population were similar to previously published studies. Elderly patients tend to have higher values of intracavitary conduction intervals in EPS. Future studies including broader age ranges could enable the acquisition of more reliable and reproducible reference values. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Case Report

Sudden Cardiac Arrest in Athletes: Do not Miss Suspicious Details

Marta Luísa Braga et al. Paula Dias Mariana Vasconcelos Rui Almeida … Paulo Araújo Maria Maciel

Introduction

Sudden cardiac death (SCD) related to sports activities is an unexpected and rare event, usually occurring in young and apparently healthy athletes. The main cause of SCD in young athletes (< 35 years old) is ventricular arrhythmia (VA) associated with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy – ARVC, channelopathies). Some of these conditions can be suspected by routine pre-participation clinical evaluation, while others remain undetectable even after careful screening.^– This paper presents the case of a professional athlete with undiagnosed ARVC, whose first manifestation was malignant VA and biventricular dysfunction.

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Original Article

Cardiopulmonary Exercise Testing in Patients with Implantable Cardioverter-Defibrillator: A Retrospective Study

Carolina Mizzaci et al. Thiago Fagundes Felipe Malafaia Sandro Felicioni … Susimeire Buglia Carlos Alberto Hossri Almir Ferraz Rica Buchler Romeu Meneghelo Luiz Mastrocolla

Abstract

Background:

Cardiopulmonary exercise testing is widely used in the evaluation of patients with left ventricular dysfunction, and some of these patients have an implantable cardioverter-defibrillator (ICD). However, this test presents specific challenges because of the susceptibility to ventricular arrhythmias during maximal levels of exercise.

Objective:

To evaluate the safety of cardiopulmonary exercise testing in patients with ICD.

Methods:

The study included patients with ICD who underwent cardiopulmonary exercise testing between 2007 and 2015. The tests were completed once the electronic devices were programmed. The maximum allowed heart rate reached during exercise was 10 beats below the first therapy zone programmed.

Results:

The study included 69 patients with mean age 53.7 ± 10.8 years, including 68% men. Exercise time was 8.7±2.3 minutes, with peak oxygen consumption of 13.3 ± 4.3 ml.kg^-1.min^-1. Peak heart rate was 62.9 ± 13.4% of the maximum rate predicted, with all patients taking specific medication. Ventricular arrhythmia was observed in 29% of the patients, and paired ventricular extrasystoles, ventricular bigeminism or non-sustained ventricular tachycardia were observed in only 14.5% of the patients. There was no sustained ventricular arrhythmia resulting in ICD therapy or other complications, such as inappropriate therapies. The frequency of severe events was 0%, 95% CI (0 – 5.2%).

Conclusion:

In the sample of patients evaluated, the cardiopulmonary exercise testing was shown to be safe during its performance in a hospital setting, following the safety standards.

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Case Report

Isolated Non-Compacted Myocardium: Should We Consider the Presence of Extrasystoles as the Initial Manifestation?

Erivelton Alessandro do Nascimento et al. Raphaella Nagib Carvalho Santos Fernanda Fraga Tolomelli Dutra Maria Gabriela Inocente Vitório

Abstract

Ventricular non-compaction occurs due to failure in myocardial morphogenesis during the fetal period. Patients can have heart failure, as well as systemic complications due to thromboembolism and cardiac arrhythmias. Early diagnosis is essential. We present the case of an asymptomatic 49-year-old woman who initially manifested ventricular extrasystoles and heart failure with reduced ejection fraction and a myocardial noncompaction diagnosis.

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Original Article

Evaluation of Galectin-3 and Myocardial Fibrosis in Patients with Hypertrophic Cardiomyopathy

Murillo de Oliveira Antunes et al. Edmundo Arteaga-Fernández Fabio Fernandes Carla David Soffiatti … Paula de Cássia Buck Ester Cerdeira Sabino Carlos Henrique Valente Moreira Charles Mady

Abstract

Background:

Galectin-3 is the designation given to the protein that binds to ß-galactosides, expressed by activated macrophages and described as a cardiac fibrosis mediator. In hypertrophic cardiomyopathy (HCM), myocardial fibrosis is an independent predictor of adverse outcome; however, the association between Galectin-3 and myocardial fibrosis has not been studied in this cardiopathy.

Objective:

To evaluate the association of Galectin-3 and the presence of myocardial fibrosis in a patient with hypertrophic cardiomyopathy.

Methods:

Galectin-3 was measured in automated equipment using the Elisa technique in 100 participants divided into two groups: 50 patients with hypertrophic cardiomyopathy and 50 healthy control subjects. All patients with hypertrophic cardiomyopathy underwent magnetic nuclear resonance with the late enhancement technique to investigate myocardial fibrosis. For the statistical analysis, p values < 0.05 were considered statistically significant.

Results:

Galectin-3 levels were low and did not show significant differences between patients with hypertrophic cardiomyopathy and the control group, 10.3 ± 3.1 ng/dL and 11.3 ± 2.6 ng/dL (p = 0.12) respectively. Myocardial fibrosis was a common finding and was identified in 84% (42/50) of patients with HCM, but no differences were observed between Galectin-3 levels when comparing patients with and without fibrosis, 10.3 ± 2.4 ng/dL and 10.1 ± 2.1 ng/dL (p = 0.59).

Conclusion:

The results did not show an association between Galectin-3 and myocardial fibrosis in patients with hypertrophic cardiomyopathy, suggesting that non-inflammatory mechanisms of myocardial fibrosis formation and cardiac remodeling are involved in this cardiopathy.

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Case Report

Brugada Pattern, Brugada Phenocopy, What to Think?

José Luis Martins et al. Raquel Ferreira Jesus Viana José Santos

Introduction

Propafenone is a class 1 anti-arrhythmic medication with beta-adrenergic and calcium channel blocker properties.

Brugada syndrome (BrS) has a typical electrocardiographic pattern characterized by increased propensity for malignant ventricular arrhythmias and sudden death in patients with no structural heart disease.

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Case Report

Acute Heart Failure Exacerbation in the Setting of Electrical Storm: Total Artificial Heart vs. Ventricle Assist Device

Juan Simon Rico et al. Daniela Arango-Isaza Megha Prasad Clara Saldarriaga

Introduction

Total artificial heart (TAH) is a novel device with over a thousand implantations worldwide, being a suitable option for patients as a bridge to transplantation (BTT). The following case was the second implantation of a TAH at our institution.

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Case Report

Biventricular Arrhythmogenic Cardiomyopathy: A New Paradigm?

João Augusto et al. João Abecasis Victor Gil

Abstract

Arrhythmogenic right ventricular dysplasia is a classic form of chronic myocardial disease with a broad phenotypical spectrum. We report an atypical case of a patient with biventricular arrhythmogenic cardiomyopathy. Although the current diagnosis criteria are the most widely accepted ones, they focus solely on the right ventricular phenotype. The use of late gadolinium enhancement in cardiac magnetic resonance in this patient was essential for the diagnosis and assessment of the left ventricular involvement extent. This tool allows a broader use of current diagnosis criteria for this disease.

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Case Report

Monomorphic Ventricular Tachycardia as the First Manifestation in a Patient with Anomalous Coronary Artery

Júlio César Vieira de Sousa et al. Raiana Maciel Miranda Gabriela Melchuna Madruga Domitila Costa de Farias … Paula de Medeiros Nacácio e Silva Nastassja Morgana de Sousa Figueiredo

Introduction

Coronary artery anomalies comprise a heterogeneous group of rare congenital heart defects, being classified according to their origin, course and distal bed, with an incidence ranging between 0.3% and 1.5% in the overall population. Dodge-Khatami et al. subdivided them into seven categories, according to their clinical complexity: coronary arteries originating from the pulmonary artery, coronary arteries with anomalous aortic origin, congenital atresia of the left main coronary artery, coronary arteriovenous fistulas, coronary arteries forming myocardial bridges, coronary artery aneurysms and coronary stenosis. The Texas Children’s Hospital classification uses angiotomography with virtual angioscopy and divides the classification into three topics: origin of the anomalous coronary artery, coronary artery course and ostium morphology. From the viewpoint of anatomical risk, the anomalous left coronary artery with an interarterial course, presence of intramurality and a slit-like ostium are the main predictive factors of severity.^–

A specific type is the anomalous origin of the left coronary artery from the right coronary sinus with an interarterial course, which is associated with hard outcomes in approximately 60% of the cases. Clinically, patients may present with nonspecific symptoms, ranging from palpitations, chest pain, post-exertion syncope or remain asymptomatic throughout life, with sudden death being the first and only manifestation of this condition.

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