P Medeiros’s research while affiliated with Hospital Braga and other places

Sr. Editor: La lesión miocárdica aguda en adultos jóvenes es un hallazgo que puede ser todo un desafío. Aunque la enfermedad coronaria asociada a factores de riesgo cardiovascular tradicionales es posible, otras etiologías tales como el uso de drogas recreativas, la miocarditis, la embolia coronaria, la disección espontánea de la arteria coronaria o el vasoespasmo coronario también han de tenerse en cuenta1. Las técnicas de imagen intracoronaria proporcionan información diagnóstica sobre las características de las lesiones coronarias, que se suma a la de la coronariografía invasiva. También sirven para guiar las intervenciones coronarias percutáneas2. Presentamos el caso de un varón de 29 años con antecedentes de tabaquismo. Los antecedentes familiares incluían enfermedad coronaria, pero no a una edad tan joven. El paciente acudió a urgencias con signos de dolor torácico agudo irradiado a brazo izquierdo la mañana siguiente a una noche con una enorme ingesta de alcohol y cannabis. El electrocardiograma de 12 derivaciones confirmó la presencia de ritmo sinusal, una frecuencia cardiaca de 60 pulsaciones por minuto y elevación del segmento ST leve y difusa (figura 1A). El análisis bioquímico reveló la presencia de niveles elevados de troponina I (37,6 ng/ml; valores normales < 0,045 ng/ml). El ecocardiograma transtorácico mostró una función...

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 Heart failure with reduced ejection fraction (HFrEF) patients are prone to developing ventricular arrhythmias. In the PARADIGM-HF trial, sacubitril-valsartan (SV) showed a reduction in the composite endpoint of death and HF hospitalization in HFrEF patients; subgroup analysis of this trial revealed a reduction in both sudden death and deaths from worsening HF. The mechanism by which SV may affect the incidence of ventricular arrhythmias is currently under debate, and the literature provides conflicting results. The aim of our study was to evaluate the potential antiarrhythmic effect of this drug in patients with HFrEF carrying an implantable cardiac defibrillator (ICD) or a cardiac resynchronization therapy with a defibrillator (CRT-D). Methods This was a single-center, observational and retrospective study. Inclusion criteria were implantation of an ICD or CRT-D device between 2009 and 2019, age ≥18 years, left ventricle ejection fraction (LVEF) ≤40%, New York Heart Association (NYHA) functional class ≥II, and treatment with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker for at least 12 months, followed by replacement with SV. Exclusion criteria were NYHA class IV, frequent alterations in chronic medication for HFrEF, and implantation of an ICD or CRT-D after the introduction of SV. The primary outcome was the occurrence of ventricular arrhythmias in the form of appropriate device shocks, ventricular fibrillation, or ventricular tachycardia. The comparisons were performed between two periods of time (12 months before and 12 months after SV) in the same group of patients. Results Fifty-four patients met the inclusion criteria. The mean age was 69.5 ± 1.65 years, and 74.1% of patients were male. The number of patients experiencing appropriate shocks was significantly lower after SV initiation (2% vs. 18%; p=0.016). The percentage of VT (13 vs. 20%; p=0.549) and VF episodes (4% vs. 13% for VF; p=0.289) were also lower, but these differences were not statistically significant. There were no significant differences in the value of NT-proBNP (1128 vs. 775 pg/mL; p=0.858), LVEF (28.4 vs. 29.6%; p=0.315), and left ventricular end-diastolic diameter (65.0 vs. 66.0 mm; p=0.5492). Conclusion SV seems to reduce the risk of arrhythmic events requiring appropriate shock therapy.

Introduction: Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI. Methods: Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography. Results: A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013). Conclusion: In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.

To the Editor, Acute myocardial injury in young adults may be a challenging finding. Although coronary artery disease associated with traditional cardiovascular risk factors is possible, other etiologies like the use of recreational drugs, myocarditis, coronary embolism, spontaneous coronary artery dissection or coronary vasospasm should be considered as well.1 Intracoronary imaging modalities provide diagnostic information added to invasive coronary angiography on coronary lesion features, and are useful to guide percutaneous coronary interventions.2 This is the case of a 29-year-old male patient with a history of smoking. His family history included coronary artery disease, but not at a young age. The patient presented to the emergency room with signs of acute chest pain radiating down his left arm the morning following a night of heavy alcohol and cannabis consumption. The 12-lead electrocardiogram revealed sinus rhythm, heart rate of 60 beats per minute, and slight and diffuse ST-segment elevation (figure 1A). Blood biochemistry analysis revealed elevated troponin I levels (37.6 ng/mL; normal values < 0.045 ng/mL). The transthoracic echocardiogram revealed the presence of preserved left ventricular systolic function with normal heart wall motion kinetics, and no evidence of structural heart disease. Figure 1. A: first 12-lead electrocardiogram. B: invasive coronary angiography of left main coronary artery...

Presentation A 59-year-old woman, with multiple cardiovascular risk factors, a history of CABG (left internal mammary artery—obtuse marginal artery; right internal mammary artery—left anterior descending artery) and PAD; presented to the emergency department with prolonged thoracic pain (3 hours) associated with dyspnea. She was hypertense at admission, but the remaining physical exam was unremarkable. Initial electrocardiogram showed descendent segment ST depression in the lateral leads (DI, aVL and V4-V6). Blood test showed a rise in troponin I 0.6 → 8.3 ng/mL). Cardiac catheterization demonstrated patency of both bypasses. However, a calcified stenosis (70–80%) of the left subclavian artery proximal to the emergence of the left internal mammary artery was observed. Diagnosis The findings suggested a possible coronary subclavian steal syndrome (CSSS). Management The patient was reevaluated and was found to have a systolic blood pressure differential of 18mmHg between the two arms. Despite anti-anginal therapeutic optimization, episodes of angina upon minimal exertion continued. Consequently, she was submitted to percutaneous subclavian artery angioplasty with symptom resolution and was discharged under dual antiplatelet therapy and high-intensity statin. Learning points CSSS complicates 0.2–6.8% of the patients who have undergone CABG with a left internal mammary graft. Peripheral artery disease is its strongest predictor and atherosclerosis is the main pathogenic mechanism. In patients with suspected CSSS, physical examination is paramount, often showing a systolic blood pressure differential. Subclavian artery angiography should be performed, whenever it is relevant, during the coronary angiography. First-line therapy includes percutaneous angioplasty and optimal medical therapy.