2019;32(5) – ABC CARDIOL

IJCS

ABC Family | IJCS

Editorial

The Truth is that Doctors do not Prescribe Physical Activities

Lorena Christine A. Albuquerque et al. Nabil Ghorayeb

Considering the well-established health benefits of regular physical activity, doctors have a primary role in counseling, encouragement, and education. In fact, they should be proactive in promoting health. Multiple published manuscripts attempted to link the doctors’ level of physical activity to the encouragement of their patients’ physical activity. Sufficient evidence has been provided that medical advice alone does not lead to sustained changes in the behavior of their patients.

There was statistical significance in the manuscript that we analyzed, by Meira DT, et al.: “Talk the Talk and Walk the Walk! Association between Weekly Exercise Load and Knowledge about Recommendations for Fighting Inactivity”, demonstrating a linear association between the amount of physical exercise recommended per week and the knowledge of the WHO recommendations against a sedentary lifestyle among the health professionals attending the Conference of the Society of Cardiology of Rio de Janeiro in 2017.

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Editorial

Neuromuscular Electrical Stimulation: A Promising Modality of Exercise Training in Cardiovascular Rehabilitation Phase I?

Sergio Chermont et al. Mônica Quintão

There are currently few indications for the use of neuromuscular electrical stimulation (NMES) in cardiac patients that are based on systematic reviews or even meta-analyses from the perspective of evidence-based practice. Therefore, the therapeutic potential of NMES is probably still poorly explored. Previous studies have shown benefits of NMES in patients with stable chronic heart failure (CHF). However, we wonder whether the application of this technique in cardiac patients has been extensively explored. We are certainly dealing with a new therapeutic possibility so far rarely recommended and employed in patients with cardiovascular diseases, especially in intrahospital cardiovascular rehabilitation. In this scenario, what could be added to the current knowledge and its main indications?

In the absence of well-defined protocols, feasibility and safety studies may be considered as a starting point for further studies and for paving the way clinical trials and to determine whether or not the conduct is favorable for a patient`s specific clinical condition. So, what would be the role of NMES in heart surgery?

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Editorial

Anxiety, Depression, Stress and the Heart: When Measurement Matters

Cristiano Tschiedel Belem da Silva et al. Rafaela Doebber Escobar

The interplay between cardiovascular symptoms and stress has been a matter of concern for centuries. The first known scientific description of panic disorder, for example, which would nowadays be considered a mixture of panic disorder itself, post-traumatic-stress disorder, cardiac arrhythmia and congestive heart failure, took place in a cohort of three hundred patients of a military hospital in Philadelphia (USA). The name of the new diagnostic entity that followed (“irritable heart syndrome” or simply “Da Costa Syndrome,” named after the author of the original description) is rather an indicator of the historical overlap between cardiovascular diseases (CVD) and psychosocial conditions than properly an example of scientific rigor in describing the discovery of a new medical syndrome.

About sixteen years after the description of the irritable heart syndrome, Augustus Waller, a British physiologist, published the first human electrocardiogram (EKG) applying a capillary electrometer and placing electrodes in the chest and back of an individual. More than half a century after Waller’s publication, the 12-Lead EKG – as we know it now – was standardized by the American Heart Association. Since then, EKG is the most important test for the interpretation of cardiac rhythm and for the detection of myocardial ischemia. In sharp contrast with diagnostic developments in Cardiology and despite a whole new era in neuroimaging, no single physiological marker has emerged to help detecting anxiety disorders or depression in Psychiatry. Nonetheless, the degree to which mental disorders are realized within the brain or in the rest of the body is still unclear.

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Editorial

Conduction Abnormalities after Transcatheter Aortic Valve Replacement: Pretty Common, Fairly Predictable, Barely Avoidable

Mohammad Abdelghani

The cardiac conduction system is commonly diseased in patients with aortic valve disease, and the site of conduction defect in those with severe calcific aortic valve stenosis is most commonly the His bundle or infra-Hisian.^, The bundle of His traverses the membranous septum towards the left ventricular outflow tract (LVOT) running superficially over the crest of the ventricular septum, originating the left bundle branch. This anatomical course makes the His bundle and its left branch susceptible to mechanical injury during transcatheter aortic valve replacement (TAVR), which involves multiple mechanical manipulations with wires, catheters, balloons, and the transcatheter heart valve (THV) inflow within that vicinity. Atrioventricular and intra-ventricular conduction abnormalities are indeed a common finding in patients with severe aortic valve stenosis referred to TAVR and new onset persistent conduction abnormalities (NOPCAs) are a common complication arising during/after TAVR.

Unlike other periprocedural complications of TAVR, whose incidence has decreased over time, a regression in the incidence of NOPCAs after TAVR was neither seen with the introduction of new TAVR technologies/techniques nor it is foreseeable in the near future.

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Editorial

Risk Scores for Stroke Prevention in Patients with Non-Valvular Atrial Prevention: Is it Time to Put Parameters of Left Atrial Appendage Morphology and Function Into Clinical Practice?

Angelo A. V. de Paola

Overall, one-third of thromboembolic events originated from the heart. Left atrial appendage (LAA) and its anatomic complexity has been implicated in 90% of cases of thrombus formation and cardioembolic events in patients with non-valvular atrial fibrillation (AF). Risk scores to predict thromboembolism from AF, such as CHADS₂ and CHA₂DS₂VASc are widely used to guide anticoagulation therapy and varies in relation to comorbidities associated with the thrombogenic substrate; however, because of its clinical conception, they did not include atrial anatomy (atrial enlargement), function (flow velocities) and electrophysiology (atrial fibrillation burden). Patients with CHA₂DS₂VASc score ≥ 2 are at intermediate or higher risk (event rate ≥ 2-3%/year) and anticoagulation is recommended. Left atrial variables such as LAA function and morphology, routinely studied by transesophageal echocardiography (TEE), were not considered in these scores.

In 2012, Di Biase et al.; published a retrospective study of 932 patients with AF and computed tomography (CT)/magnetic resonance imaging (MRI) classification of four different types of LAA morphologies: chicken wing, cactus, windsock and cauliflower. Non-chicken wing categories were 4 to 8 times more likely to have had stroke/TIA. Eight additional cross-sectional studies utilizing this classification for LAA morphology in 2,210 patients (6 with CT and 2 with TEE), found a significant association with non-chicken-wing morphology and stroke in 5 series^– and no significant difference in 3 other studies.^–

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Editorial

Antiplatelet Therapy for Elderly Patients: When Less May Be More

Roberto Esporcatte et al. Fernando Oswaldo Dias Rangel

In the last two decades, double antiplatelet therapy, together with percutaneous coronary intervention (PCI), has become a cornerstone of acute coronary syndrome (ACS) treatment and its use is recommended as early as possible, although there are many unanswered questions about the efficacy and safety of loading dose (LD), best moment of administration, clinical scenarios and, especially, its use in elderly patients. Despite the fact that elderly patients represent approximately 30% of the population admitted for ACS, they are virtually excluded from large clinical trials, receive fewer diagnostic and therapeutic approaches and have more ischemic and hemorrhagic complications.

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Editorial

Rheumatic Heart Disease – How are We in 2019, Have We Evolved?

Andressa Mussi Soares

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with the sole member of the group A Streptococcus (GAS), Streptococcus pyogenes. ARF leads to a condition characterized by various combinations of joint pain and swelling, cardiac-valve regurgitation with the potential for secondary heart failure, chorea, skin and subcutaneous manifestations, and fever.

Rheumatic heart disease (RHD) is a disease of poverty that affects children and working-age adults. The global economic impact of early death from RHD is still very high. In Brazil, the average cost of RHD-related damage is around 89 million Brazilian reals (close to US$ 28 million) a year. Information from the Brazilian Unified National Health System database (DATASUS) indicates a cardiac mortality rate of about 7.9% from chronic rheumatic fever (RF).

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Original Article

Increased Left Atrial Volume and Its Relationship to Vitamin D in Primary Care

Erica de Abreu Macedo et al. Maria Luiza Garcia Rosa Antônio José Lagoeiro Jorge Adson Renato Leite … Leivys Henrique Silva Santos Juliana Salge Vieira

Abstract

Background:

The study is based on the fact that left atrial (LA) volume measurement is a marker of the presence of diastolic dysfunction and that Vitamin D deficiency may be associated with ventricular remodeling, worsening of left ventricular (LV) diastolic and systolic function, and activation of the renin-angiotensin-aldosterone system.

Objective:

To evaluate whether LAV changes are related to vitamin D deficiency.

Method:

A cross-sectional, population-based, unicentric study in which 640 patients over 45 years of age enrolled in the Niterói’s Médico de Família program, RJ, were evaluated. Patients were submitted to tissue Doppler echocardiography to evaluate the parameters of diastolic and systolic function and vitamin D dosage. The presence or absence of hypovitaminosis D associated with structural and functional cardiac changes was compared between each group. A p < 0.05 value was considered as an indicator of statistical significance.

Results:

Of the 640 individuals analyzed, hypovitaminosis D was confirmed in 39.2% of the patients, of whom 34.8% had diastolic dysfunction. The most relevant echocardiographic parameters that were statistically significant were non-indexed AEDs and LAV, E’/A’ and E wave deceleration time, which were associated with the presence of hypovitaminosis D (P < 0.01).

Conclusion:

The study of the association of hypovitaminosis D and the appearance of structural and functional cardiac abnormalities may contribute to the discussion of the adoption of one more criterion to select individuals at risk of developing clinical cardiac insufficiency in primary care since, with the use of echocardiography, the subclinical condition of cardiac involvement, with prognostic and treatment implications for the referred patients with hypovitaminosis D, can be identified early.

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Original Article

Validation of the Brazilian Version of the Screening Tool for Psychosocial Distress (Stop-D) for Cardiac Patients

Isabella Barros Rabelo Gontijo et al. Juciléia Rezende Souza Daniel Fernandes Barbosa Salvador Rassi

Abstract

Background:

Distress has a potentiating effect on complications of heart disease. Early identification of distress and psychosocial management could help patients to deal with the disease and improve their quality of life. However, in Brazil, there is no specific instrument for evaluation of distress in cardiac patients.

Objectives:

To describe the validation process of the Screening Tool for Psychosocial Distress (STOP-D) for the Brazilian population.

Methods:

Cross-sectional, observational study with a quantitative approach. A total of 144 patients (including outpatients and inpatients) were interviewed at the waiting room of the outpatient cardiology clinic or in cardiology wards. Sociodemographic and clinical data were collected, and distress was assessed using two instruments – the Brazilian version of the STOP-D and the Hospital Anxiety and Depression Scale (HADS). First, we performed an exploratory factor analysis and analysis of the accuracy of the STOP-D score by the receiver operating characteristic (ROC) curvet.

Results:

The factorability analysis of the correlation matrix did not detect any factor that made the factorial solution unfeasible. The instrument showed a single-factor nature, confirmed by the criterion of eigenvalues, with an 85% accuracy in predicting distress. A cut-off point of 15.5 was chosen for distress using the ROC curve.

Conclusions:

The Brazilian version of the STOP-D is an adequate instrument for the screening of heart disease patient for distress. It can be easily used by any health professional and would contribute to the promotion of a comprehensive support to cardiac patients.

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Viewpoint

Performance of the Rapid Response Systems in Health Care Improvement: Benefits and Perspectives

Viviane Cordeiro Veiga et al. Salomón Soriano Ordinola Rojas

Introduction

In the last two decades, the rapid response systems (RRS) have been explored as initiatives to increase the safety of hospitalized patients. The main function is to identify and treat patients at risk, or who are presenting signs of clinical instability, and to prevent adverse events during hospital stay, with a consequent reduction in in-hospital mortality. Every year in the United States, more than 200,000 intrahospital cardiac arrests (CAs) occur, most of which could be avoided. RRS are formed by two health care components called the afferent limb and the efferent limb. The afferent limb is represented by the health care team in the admission units, responsible for the care of hospitalized patients and trained to activate the afferent limb, when physiological changes that predict adverse events are detected, especially cardiac arrests. The efferent limb is represented by a team of health care professionals, who respond to codes, and may be headed by a physician, a nurse or a physiotherapist. The efferent limb is better known as the rapid response team (RRT). In addition to these health care components, the rapid response systems must also have two other components, namely the administrative arm, which provides the necessary documentation and is responsible for the systems daily activities and the quality and governance arm, which contributes to continuous improvement and reassessment of the system. These systems have been implemented around the globe, but still in a non-uniform way in institutions and health systems with different characteristics. However, in Brazil, there are few reports on this issue.^,

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Original Article

Association between Morphodynamic Variables by Transesophageal Echocardiography and CHA2DS2-Vasc Values

Renata Rejane Linhares et al. Dalmo Antonio Ribeiro Moreira Luciana Braz Peixoto Andresa Paes da Cruz … Luara Piovam Garcia Rodrigo Bellio de Mattos Barretto David Costa de Souza Le Bihan Carlos Eduardo Suaide Silva

Abstract

Background:

In atrial fibrillation (AF), the CHA₂DS₂-VASc score calculates the risk for stroke. Di Biase classified the left atrial appendage (LAA), using magnetic resonance imaging, into 4 morphological types and correlated it with cerebrovascular events. Transesophageal echocardiography (TEE) also evaluates LAA and is a more widespread technique.

Objective:

To evaluate, using TEE, the possibility of characterizing LAA and to analyze its morphological aspects using the CHA₂DS₂VASc score.

Methodology:

A total of 247 patients were divided into three groups considering the CHA₂DS₂-VASc score: Group 1: 0 and 1; Group 2: 2 and 3 and, Group 3: ≥ 4 points. TEE produced the echocardiographic data. LAA was classified into thrombogenic and non-thrombogenic morphologies. In the analysis of statistical tests, a significance level of 5% was adopted.

Results:

The average age was 50 and 16.2% presented AF. In Group 1, we observed normal variables with a lower prevalence of AF (8.7%, p < 0.001). In group 2, spontaneous contrast was detected in 26.7%, (p < 0.001), thrombus in 6.7% (p = 0.079) and flow velocity in LAA < 0.4 m/s in 22.7% (p < 0.001) of the cases. Group 3 presented the highest percentages of AF (31.8%, p < 0.001), stroke/TIA (77.3%, p < 0.001), EF < 55% (18.2%, p = 0.010) and higher prevalence of thrombogenic type LAA (72.7%, p = 0.014). A higher occurrence of stroke/TIA was observed in patients with thrombogenic LAA (25.2%) compared to the non-thrombogenic group (11.2%), (p = 0.005).

Conclusions:

The thrombogenic morphology of LAA identified in TEE presented a higher risk of stroke regardless of the CHA₂DS₂VASc score. Patients with higher scores had greater abnormalities in echocardiographic variables.

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Original Article

Is There Safety in the Use of Clopidogrel Loading Dose in Patients Over 75 Years of Age with Acute Coronary Syndrome?

Alexandre de Matos Soeiro et al. Guilherme Casale Maria Antonieta Albanez Albuquerque de Medeiros Lopes Lucas Colombo Godoy … Aline Siqueira Bossa Bruno Biselli Tatiana de Carvalho Andreucci Torres Leal Maria Carolina Feres de Almeida Soeiro Carlos V Serrano Jr. Múcio Tavares Oliveira Jr.

Abstract

Background:

There is limited evidence in the literature regarding the administration of clopidogrel to acute coronary syndrome (ACS) in patients over 75 years of age. Most studies excluded this age group, making the subject controversial due to the increased risk of bleeding in this population.

Objective:

This is a retrospective, unicentric, and observational study aimed at assessing whether the administration of clopidogrel loading dose increases bleeding rates in patients over 75 years of age.

Methods:

Patients were divided into two groups: group I: 75 mg of clopidogrel; group II: 300-to 600-mg loading dose of clopidogrel. A total of 174 patients (129 in group I and 45 in group II) were included between May 2010 and May 2015. Statistical analysis: The primary outcome was bleeding (major and/or minor). The secondary outcome was combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed through Q-square and T-test. The multivariate analysis was performed by logistic regression, being considered significant p < 0.05.

Results:

Comparisons between groups I and II showed differences in the prevalence of diabetes (46.5% vs. 24.4%, p = 0.01), arterial hypertension (90.7% vs. 75, p = 0.01), dyslipidemia (62% vs. 42.2%, p = 0.021), ST segment elevation (11.6% vs. 26.6%, p = 0.016) and coronary intervention percutaneous (16.5% vs. 62.2%, p < 0.0001), respectively. In the multivariate analysis, significant differences were observed between groups I and II in relation to the occurrence of bleeding (8.5% vs. 20%, OR = 0.173, 95% CI: 0.049 – 0.614, p = 0.007).

Conclusion:

A loading dose of 300 mg or more of clopidogrel.

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Original Article

Talk the talk and walk the walk! Association between Weekly Exercise Load and Knowledge about Recommendations for Fighting Innactivity

Diogo Thadeu Meira et al. Leonardo Giglio Gonçalves Luiz Henrique Araújo Matheus Gasparini … Bernardo Souza Cunha Amanda Monteiro Michele Heringer Christiane Prado Andre Volschan Fabrício Braga da Silva

Abstract

Background:

The World Health Organization (WHO) recommends as a weekly “target dose” of exercise 150 minutes of moderate exercise or 75 minutes of intense exercise. Public health policies have prioritized the practice of exercise as a strategy for disease prevention and health promotion, with health professionals as their main promoters.

Objective:

To assess the interaction between the amount of exercise per week and the knowledge about recommendations for fighting a sedentary lifestyle among health care professionals attending a congress of cardiology.

Methods:

Participants of the 2017 Rio de Janeiro Society of Cardiology Congress were interviewed. Knowledge about the World Health Organization (WHO) recommendations for fighting a sedentary lifestyle was assessed by asking participants the question: “How much weekly exercise is recommended by the WHO?” Responders were stratified by the weekly exercise load reported. A multivariate logistic model was created to determine independent predictors of knowledge.

Results:

A total of 426 participants were interviewed (45.5% men, median age 31 years, 37.8% physicians, 65.8% of the physicians were cardiologists). The overall knowledge level was 44.6%; 38.1%, 52.7% and 56.6% among non-physicians, non-cardiologists and cardiologists, respectively (p = 0.002). Of all participants, 21.8% were inactive, 15% were lightly active, 34.7% moderately active and 28.4% highly active, and the percentage of individuals who gave a correct answer to the question on exercise recommendations was 30.1%, 42%, 48% and 52.9% respectively (p < 0.0001). In the multivariate analysis, being highly active (OR = 2.25, IC95%, 1.238 – 4.089), moderately active (OR = 1.93, IC 95% 1.105 – 3.39) and being a cardiologist (OR = 2.01, IC 95% 1.243 – 3,267) were predictors of knowledge.

Conclusions:

There was a linear association between exercise level and knowledge about the WHO recommendations on exercise. Policies to stimulate the practice of exercise among health professionals can positively impact campaigns for reducing sedentary lifestyle in the general population.

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Original Article

Neuromuscular Electrical Stimulation on Hemodynamic and Respiratory Response in Patients Submitted to Cardiac Surgery: Pilot Randomized Clinical Trial

Telma Cristina Fontes Cerqueira et al. Manoel Luiz de Cerqueira Neto Auristela Julia Guilhermino Carvalho Géssica Uruga Oliveira … Amaro Afrânio de Araújo Filho Vitor Oliveira Carvalho Lucas de Assis Pereira Cacau Walderi Monteiro da Silva Júnior José Teles de Mendonça Valter Joviniano de Santana Filho

Abstract

Background:

Neuromuscular electrical stimulation seems to be a promising option to intensify the rehabilitation and improve the exercise capacity of patients in the immediate postoperative period of cardiac surgery.

Objective:

This study aimed to evaluate the hemodynamic (heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure) and respiratory (respiratory rate and oxygen saturation) responses to neuromuscular electrical stimulation in the immediate postoperative period in patients submitted to cardiac surgery and to verify its feasibility and safety.

Methods:

This is a pilot randomized controlled trial, wherein critical patients in the immediate postoperative period of cardiac surgery were randomly assigned to a control group, using sham neuromuscular electrical stimulation, or an experimental group, submitted to neuromuscular electrical stimulation sessions (FES), for 60 min, with a 50-Hz frequency, 200-µs pulse duration, time on: 3 s, and time off: 9 s. Data distribution was evaluated by the Shapiro-Wilk test. The analysis of variance was used and a p-value < 0.05 was considered significant.

Results:

Thirty patients were included in the study. The neuromuscular electrical stimulation was applied within the first 23.13 ± 5.24 h after cardiac surgery, and no changes were found regarding the hemodynamic and respiratory variables between the patients who underwent neuromuscular electrical stimulation, and those in the control group.

Conclusions:

In the present study, neuromuscular electrical stimulation did not promote changes in hemodynamic and respiratory responses of patients in the immediate postoperative period of cardiac surgery.

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Original Article

Cardiovascular Risk and Metabolic Syndrome in Individuals with Mental Disorders

Sarah de Melo Rocha Cabral et al. Marize Melo dos Santos

Abstract

Background:

Patients with mental disorders are more susceptible to cardiovascular diseases and metabolic disorders compared to the general population.

Objective:

To evaluate cardiovascular risk and metabolic syndrome in individuals with mental disorders.

Materials and methods:

A cross-sectional study, conducted at the Psychosocial Care Centers. Socioeconomic, clinical, biochemical and anthropometric data were collected using a standard form. Cardiovascular risk was assessed by the Framingham risk score. Metabolic syndrome (MS) was determined by the World Health- Organization (WHO), the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) criteria. Data were analyzed by descriptive statistics, and associations were evaluated by the chi-square test and Fisher’s exact test, as well as Odds Ratio. The significance level adopted for all statistical tests was 5%.

Results:

The chance of individuals diagnosed with MS be at intermediate-to-high cardiovascular risk was greater (12.22, 8.01 and 6.23 times higher according to WHO, NCEP and IDF criteria, respectively) than those without MS.

Conclusion:

A high percentage of patients with mental disorders were at intermediate / high cardiovascular risk, and this was significantly associated with MS.

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Original Article

Incidence of Conduction Disorders and Requirements for Permanent Pacemaker After Transcatheter Aortic Valve Implantation

Marcela Cedenilla dos Santos et al. Cristiane da Cruz Lamas Fabiula Schwartz de Azevedo Alexandre Siciliano Colafranceschi … Clara Weksler Leandro Cordeiro Dias Rodrigues Gustavo de Castro Lacerda

Abstract

Background:

Transcatheter aortic valve implantation (TAVI) has become a therapeutic option for high-risk or non-operable patients with severe symptomatic aortic stenosis. Atrioventricular conduction disturbances requiring permanent pacemaker (PPM) are a common and clinically important complication.

Objectives:

To evaluate the incidence of conduction disorders (CDs) after TAVI and the need for subsequent PPM implantation. To identify the predictors of postoperative PPM implantation.

Methods:

Retrospective study. All patients who underwent TAVI in a public hospital from December/2011 to June/2016 were included. Multivariate analysis was conducted to establish the predictor of permanent pacemaker implantation. Survival curves were constructed by the Kaplan-Meyer method. Statistically significant variables were those with p value < 0.05.

Results:

64 patients with AS underwent TAVI. Eleven patients were excluded. TAVI induced a new CD in 40 (77%) of the remaining 53 patients. The most common new CDs were 3rd degree AV block (32%) and left bundle branch block (30%). Sixteen patients (30,2%) underwent PPM implantation during the index hospitalization. On univariate analysis the risk factors for PPM implantation were CoreValve® use (OR: 1,76; P = 0,005), larger prosthesis implantation (P = 0,015), presence of a QRS ≥ 120 ms (OR: 5,62; P = 0,012), and 1st degree AV block (OR: 13; P = 0.008). On multivariate analysis the presence of 1st degree AV block predicted the need for PPM.

Conclusion:

TAVI induced CDs requiring PPM in 30% of the patients. The presence of 1st degree AV block predicted the need for PPM.

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Case Report

Complete Resolution of Electrocardiographic Changes Induced by Acute Chagas Myocarditis

Joseane Elza Tonussi Mendes Rossette do Valle et al. Luiz Carlos de Abreu Raimundo Barbosa Barros Rodrigo Daminello Raimundo … Andrés Ricardo Pérez Riera Isabel Sorpreso

Abstract

We present a case of a female adolescent with severe acute Chagas myocarditis, acquired by oral transmission in an endemic area in the Brazilian western Amazon, who had electrocardiographic changes normalized after empirical treatment with the antiparasitic drug benznidazole combined with conventional treatment for severe heart failure.

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Case Report

Left Ventricular Dyssynchrony in a Patient with Normal Perfusion and Stress-Induced Left Bundle Branch Block

Maria Gazzilli et al. Rexhep Durmo Claudio Tinoco Mesquita Raffaele Giubbini

Introduction

Left bundle branch block (LBBB) is an electrocardiographic abnormality that occurs in approximately 0.5-1.1% of all patients who undergo exercise testing. The diagnosis of complete LBBB is made with the 12-lead electrocardiogram (ECG) if all the following criteria are met: conduction originating above the atrioventricular node; a QRS duration of 120 milliseconds or more; predominantly upright complexes with broad-slurred R waves in leads I, V5, and V6; and a QS or RS pattern in V1 with a normal intrinsicoid deflection of 35 milliseconds.

The precise mechanism and the prognostic significance of Exercise Induced-LBBB (EI-LBBB) remains unclear. EI-LBBB can be associated with coronary artery disease (CAD). However, in a group of patients, coronary arteries are normal. Several authors have attributed EI-LBBB to functional alterations of the conduction system mediated by autonomic influences in non-ischemic cases. We report a case of a 72-year-old female patient who developed LBBB during exercise stress testing and showed reversible abnormalities in cardiac contraction.

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Review Article

Impact of Obesity and Bariatric Surgery in the Outcome of Patients with Heart Failure

Ricardo Mourilhe-Rocha et al. Nathália Felix Araujo Salvino

Abstract

Currently, the association between obesity and heart failure (HF) is increasingly known. Patients with advanced obesity who suffer from HF without an identifiable cause can be diagnosed as having obesity-associated cardiomyopathy. Although data suggest that obesity may reduce mortality in HF, weight loss, especially in the presence of morbid obesity, reduces symptoms and improves the quality of life of those patients.

Bariatric surgery is the major treatment available for sustained weight loss in morbid obesity. Observational studies have demonstrated an improvement in ventricular structure and function of morbidly obese patients with HF who underwent that procedure.

Thus, despite the risks, bariatric surgery should be considered for patients with HF, because of its potential for reducing associated comorbidities and improving quality of life and functional capacity, in addition to making eligible for heart transplantation those excluded due to high body mass index.

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