Carina Arantes’s research while affiliated with Hospital Braga and other places

Background: The potential benefit of implantable cardioverter-defibrillator (ICD) therapy in individuals with inherited arrhythmia syndromes is well known. However, it is not deprived of morbidity, in the form of inappropriate therapies and other ICD-related complications. Objective: The aim of this systematic review is to estimate the rate of appropriate and inappropriate therapy, as well as other ICD-related complications, in individuals with inherited arrhythmia syndromes. Methods: A systematic review was performed, regarding appropriate and inappropriate therapy, and other ICD-related complications, in individuals with inherited arrhythmia syndromes (Brugada Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia, Early Repolarization Syndrome, Long QT Syndrome and Short QT syndrome). Studies were identified by searching published papers in PubMed and Embase up to August 23rd, 2022. Results: From data gathered of 36 studies, with a total of 2750 individuals, during a mean follow-up time of 69 months, appropriate therapies occurred in 21% of the individuals and inappropriate therapies in 20% of the individuals. Concerning the other ICD-related complications, 456 complications were observed, amongst 2084 individuals (22%), with the most frequent being lead malfunction (46%), followed by infectious complications (13%). Conclusions: ICD-related complications are not uncommon, especially when one considers the exposure time of young individuals. The incidence of inappropriate therapies was 20%, although lower rates were reported in recent publications. S-ICD is an effective alternative to transvenous ICD for sudden death prevention. The decision to implant an ICD should be individualized, taking into account the risk profile of each patient, as well as the possibility of complications.

Introduction Infective endocarditis (IE) is associated with high morbidity and mortality, despite advances in diagnosis and treatment. Objective To assess changes in the epidemiological profile of IE, to perform a time-trend analysis and to define short-term and long-term prognostic predictors of IE. Methods Retrospective analysis of 173 patients admitted with a diagnosis of IE to a Portuguese level II Hospital between January 1998 and December 2013. The patients were divided into two groups according to the period of occurrence of the IE episode (1998-2007 vs. 2008-2013). The clinical event studied was the occurrence of death or the need for urgent surgery during hospitalization, and death in the follow-up period. Independent predictors of short-term and long-term prognosis were identified. Results In the first portion of the study, IE occurred in younger individuals, often drug addicts, users of intravenous drugs and with gastrointestinal disease, human immunodeficiency virus and hepatitis B infection. In the second portion of the study, IE occurred more frequently in individuals of an older age with concomitant cardiovascular disease; enterococcus was isolated more frequently. The independent predictors of in-hospital death or need for urgent valve surgery were septic shock and the occurrence of peri-annular complications. The independent predictors of long-term mortality were age, chronic kidney disease and IE due to multidrug-resistant microorganisms. Conclusion Differences were found in the epidemiological profile of IE during the study period. Referral for valve surgery increased slightly, but mortality remained high.

Background Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with worse prognosis. Data in literature are scarce on the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study. Methods Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n=298) or absence of IDef (n=519) on admission. The clinical event under study was the occurrence of death or severe HF in the long term. Independent predictors of prognosis were determined with logistic regression analysis. Results Thirty-six percent of patients had IDef. There was higher mortality (p=0.004), higher incidence of HF (p=0.011) during follow-up and a higher rate of hospital readmissions (p=0.048) in this group. IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death. Conclusion IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

Funding Acknowledgements Type of funding sources: None. Background Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas. Purpose To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope. Methods Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation. Results In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications. Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department. Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance). Conclusions Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Resumo Introdução O défice de ferro (DeF) é uma condição prevalente em doentes com patologia cardíaca. Naqueles com insuficiência cardíaca (IC) demonstrou‐se que esse défice se associa a pior prognóstico. Existem poucos dados na literatura relativamente ao impacto prognóstico do DeF nas síndromes coronárias agudas (SCA), sendo este o principal objetivo deste estudo. Métodos Estudo observacional retrospetivo que incluiu 817 doentes admitidos por SCA. Definiram‐se dois grupos de acordo com a presença (n = 298) ou ausência de DeF (n = 519) à admissão. O evento clínico estudado foi a ocorrência de morte ou IC grave em longo prazo. Calcularam‐se os preditores independentes de prognóstico com base na análise de regressão logística. Resultados Verificou‐se que 36% dos doentes tinham DeF. Estes doentes apresentaram maior taxa de mortalidade (p = 0,004) e de IC (p = 0,011) durante o follow‐up, bem como maior taxa de readmissões hospitalares (p = 0,048). O DeF foi preditor independente de morte ou IC grave no follow‐up, a par da anemia, da disfunção do ventrículo esquerdo, da disfunção renal e da ausência de revascularização. Além disso, o DeF permitiu estratificar adicionalmente o prognóstico dos doentes sem anemia em termos de ocorrência de morte ou IC grave e aqueles com classes de Killip mais baixas (≤ 2) em termos da ocorrência de morte. Conclusão O DeF foi um fator preditor independente de morte ou IC grave nos doentes admitidos com SCA e permitiu estratificar adicionalmente aqueles sem anemia ou com classes de Killip ≤ 2 à admissão.

Funding Acknowledgements Type of funding sources: None. INTRODUCTION Symptoms like syncope and palpitations are frequent and represent a diagnostic challenge. The implantable loop recorder (LR) is an important diagnostic tool, in selected cases. AIM To describe the main implantation indications of LR and to evaluate the diagnostic findings and therapeutic interventions. METHODS A retrospective study of patients (pts) that underwent LR implantation in our hospital from 2014 to 2019. For each pt the indication for implantation, baseline characteristics, previous study, recorded tracing and interventions were evaluated. RESULTS A total of 52 pts were included, 56% women, with a mean age of 60 years old. The implantation indications were recurrent syncope/ presyncope in 47 pts (90%) and palpitations in 5 pts (10%). All pts had a baseline echocardiogram and electrocardiogram, with 90% in sinus rhythm. QRS complex and atrial-ventricular conduction was normal in 50% of the pts. Previous to LR implantation, 46 pts (89%) had performed Holter, 19 (37%) carotid sinus massage, 14 (27%) Tilt table test, 29 (56%) stress test, 11(21%) ambulatory blood pressure monitoring and 9 (17%) electrophysiological study. During the monitoring period, 27 pts (52%) had recurrence of the symptoms. In this subgroup, we observed that 67% had a rhythmic cause capable of justified the symptoms, with a median of 5 months since implantation until diagnosis. In addition, the LR was useful in ruling out a rhythmic cause for symptoms in 33% of the cases. In the 47 pts with syncope/presyncope: 6(13%) had sinus node dysfunction, 4 (9%) had atrioventricular conduction disturbance, 1(2%) had atrial fibrillation (AF) and 3 (6%) had ventricular dysrhythmias. In the 5 pts with palpitations: 1(20%) had AF ad 3 (60%) had paroxysmal supraventricular tachycardia. LR results led to cardiac device implantation in 13 pts (pacemaker-9, implantable cardioverter desfibrillator-4). In addition, 2 pts are waiting for electrophysiological study and eventual ablation and 3 pts initiated antiarrhythmic therapy, and those with new diagnosis of AF also initiated oral anticoagulants. CONCLUSION In this study, the implantation of LR was useful to clarify the cause of the symptomology in 52% of the pts. In 35% of pts with symptom-rhythm correlation it ensured timely introduction of therapeutic approach with a positive impact on life quality.

Funding Acknowledgements Type of funding sources: None. INTRODUCTION Takotsubo syndrome (TS) is characterized by transient wall motion abnormality of the left ventricle, which may happen in response to different triggers. AIM To characterize the population with confirmed diagnosis of TS. METHODS We analysed retrospectively 129 patients (pts) admitted in our center from 2010 to 2018 with this presumptive diagnosis. 29pts were excluded because TS wasn´t confirmed. For each pt we evaluate clinical characteristics, exams results, inhospital complications and long-term outcomes (minimum FUP of 1 year). RESULTS The average age was 66 years and 89% were females. Regarding the cardiovascular (Cv) risk factors, 78% had hypertension, 53% dyslipidemia and 19% Diabetes mellitus. In relation to noncardiovascular comorbidities it’s important to point out that 32% had psychiatric disorders. The trigger was emotional in 37%, physical in 18%, and unidentifiable in 45%. Concerning the clinical presentation 72% had Killip(K) 1 and 13% K≥3 at admission. The initial electrocardiogram had ST-elevation in 37%, T wave inversion in 64% and a mean QTc interval of 470ms. The mean ejection fraction (EF) by echocardiogram was 37%, with apical ballooning in 83% and at least moderate mitral regurgitation (MR) in 11%. Only 16% had intraventricular pressure gradient. Coronarography revealed absence of obstructive coronary disease in 71% of pts. In addition, 51% of pts underwent cardiac magnetic resonance (CMR), which had an increase usage since 2013. The mean time until the CMR was 14 days, which may explain why only 14% had segmental kinetic changes. It’s noteworthy that the mean peak NTproBNP/troponin I ratio was 1,4 ± 2,9. We compared the ratio in TS with EF < 40% with the one obtained in a cohort of ST-elevation myocardial infarction (MI) with EF < 40% and found statistically difference (1,7 ± 3,8vs0,01 ± 0,03; p < 0,001). Considering inhospital complications, 6% had intracardiac thrombus, 2% acute severe MR, 2% ventricular dysrhythmia and 2% died. During the FUP, 2% had recurrence, 4% had acute heart failure hospitalizations an 17% died. CONCLUSION Despite increased awareness TS is still poorly recognized. Lack of non-invasive tools for reliable diagnosis obliged the use of coronarography. It’s noteworthy that the peak NTproBNP/troponin I ratio may help to differentiate TS from MI and the use of CMR should be encouraged to exclude other causes. Although considered a benign condition, significant in-hospital mobility and 2% mortality was observed.

Takotsubo syndrome (TTS) is an acute, reversible cardiomyopathy. The central autonomic nervous system (ANS) is believed to play a role in this disease. The aim of the present study was to investigate the patterns of brain functional connectivity in a sample of patients who had experienced a previous episode of TTS. Brain functional connectivity, both at rest and in response to the stressful stimulus of topical cold stimulation, was explored using functional magnetic resonance imaging (fMRI), network-based statistics (NBS) and graph theory analysis (GTA) in a population consisting of eight patients with a previous episode of TTS and eight sex- and age-matched controls. At rest, a network characterized by increased connectivity in the TTS group compared to controls and comprising elements of the central ANS was identified. GTA revealed increased local efficiency, clustering and strength in regions of the bilateral hippocampus in subjects with a previous episode of TTS. When stressed by local exposure to cold, the TTS group differed significantly from both a pre-stress baseline interval and from the control group, showing increased connectivity in a network that included the left amygdala and the right insula. Based on the results, patients with TTS display a reorganization of cortical and subcortical networks, including areas associated with the emotional response and autonomic regulation. The findings tend to support the hypothesis that a deregulation of autonomic control at the central level plays a significant role in this syndrome.