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Introduction: The COVID-19 pandemic has imposed an unprecedented burden on healthcare systems worldwide, changing the profile of interventional cardiology activity., Objectives: To quantify and compare the number of percutaneous coronary interventions (PCIs) performed for acute and chronic coronary syndromes during the first COVID-19 outbreak with the corresponding period in previous years., Methods: Data on PCI from the prospective multicenter Portuguese Registry on Interventional Cardiology (RNCI) were used to analyze changes in PCI for ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndromes (NSTE-ACS) and chronic coronary syndromes (CCS). The number of PCIs performed during the initial period of the COVID-19 outbreak in Portugal, from March 1 to May 2, 2020, was compared with the mean frequency of PCIs performed during the corresponding period in the previous three years (2017-2019)., Results: The total number of PCIs procedures was significantly decreased during the initial COVID-19 outbreak in Portugal (-36%, p<0.001). The reduction in PCI procedures for STEMI, NSTE-ACS and CCS was, respectively, -25% (p<0.019), -20% (p<0.068) and -59% (p<0.001)., Conclusions: Compared with the corresponding period in the previous three years, the number of PCI procedures performed for STEMI and CCS decreased markedly during the first wave of the COVID-19 pandemic in Portugal., (Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The standard of care for acute ST-elevation myocardial infarction (STEMI) includes the activation of a STEMI care network, the administration of adjuvant medical therapy, and reperfusion through primary percutaneous coronary intervention (PCI). While primary PCI is nowadays the first option for the treatment of patients with STEMI, antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize their clinical outcomes., Objective: The aim of this study was to describe contemporaneous real-world patterns of use of antithrombotic treatments in Portugal for STEMI patients undergoing primary PCI., Methods: An observational, retrospective cross-sectional study was performed for the year 2016, based on data from two national registries: the Portuguese Registry on Acute Coronary Syndromes (ProACS) and the Portuguese Registry on Interventional Cardiology (PRIC). Data on oral antiplatelet and procedural intravenous antithrombotic drugs were retrieved., Results: In 2016, the ProACS enrolled 534 STEMI patients treated with primary PCI, while the PRIC registry reported data on 2625 STEMI patients. Of these, 99.6% were treated with aspirin and 75.6% with dual antiplatelet therapy (mostly clopidogrel). GP IIb/IIIa inhibitors (mostly abciximab) were used in 11.6% of cases. Heparins were used in 80% of cases (78% unfractionated heparin [UFH] and 2% low molecular weight heparin). None of the patients included in the registry were treated with cangrelor, prasugrel or bivalirudin. Missing data are one of the main limitations of the registries., Conclusions: In 2016, according to data from these national registries, almost all patients with STEMI were treated with aspirin and 76% with dual antiplatelet agents, mostly clopidogrel. GP IIb/IIIa inhibitors were used in few patients, and UFH was the most prevalent parenteral anticoagulant drug., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Coronary intravascular ultrasound (IVUS) is increasingly important in catheterization laboratories due to its positive prognostic impact. This study aims to characterize the use of IVUS in percutaneous coronary intervention (PCI) in Portugal., Methods: A retrospective observational study was performed based on the Portuguese Registry on Interventional Cardiology of the Portuguese Society of Cardiology. The clinical and angiographic profiles of patients who underwent PCI between 2002 and 2016, the percentage of IVUS use, and the coronary arteries assessed were characterized., Results: A total of 118 706 PCIs were included, in which IVUS was used in 2266 (1.9%). Over time, use of IVUS changed from none in 2002 to generally increasing use from 2003 (0.1%) to 2016 (2.4%). The age of patients in whom coronary IVUS was used was similar to that of patients in whom IVUS was not used, but in the former group there were fewer male patients, and a higher prevalence of cardiovascular risk factors (hypertension, hypercholesterolemia and diabetes), previous myocardial infarction, previous PCI, multivessel coronary disease, C-type or bifurcated coronary lesions, and in-stent restenosis. IVUS was used in 54.8% of elective PCIs and in 19.15% of PCIs of the left main coronary artery., Conclusion: Coronary IVUS has been increasingly used in Portugal since 2003. It is used preferentially in elective PCIs, and in patients with higher cardiovascular risk, with more complex coronary lesions and lesions of the left main coronary artery., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: In iatrogenic or potentially reversible bradyarrhythmia, drug discontinuation or metabolic correction is recommended before permanent cardiac pacemaker (PM) implantation. These patients often have conduction system disease and there are few data on recurrence or the need for a permanent PM., Objective: To analyze the need for PM implantation in patients with iatrogenic bradyarrhythmia or bradyarrhythmia associated with other potentially reversible causes., Methods: We assessed consecutive symptomatic patients admitted to the emergency department with a primary diagnosis of bradyarrhythmia (atrioventricular [AV] node disease - complete or second-degree AV block (AVB) [CAVB: 2nd-degree AVB - 2:1], sinus bradycardia [SB] and atrial fibrillation [AF] with slow ventricular response [SVR]) in the context of iatrogenic causes or metabolic abnormalities. We determined the percentage of patients who required PM implantation., Results: We studied 153 patients (47% male) admitted for iatrogenic or potentially reversible bradyarrhythmia. Diagnoses were SB 16%, CAVB 63%, second-degree AVB 12%, and AF with SVR 10%. Eighty-five percent of patients were under negative chronotropic therapy, 3% had hyperkalemia and 12% had a combined etiology. After correction of the cause, 55% of patients (n=84) needed a PM. In these patients the most common type of bradyarrhythmia was CAVB, in 77% (n=65) patients., Conclusion: In a high percentage of patients with bradyarrhythmia associated with a potentially reversible cause, the arrhythmia recurs or does not resolve during follow-up. Patients with AV node disease constitute a subgroup with a higher risk of recurrence who require greater vigilance during follow-up and should be considered for PM implantation after the first episode., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Iron metabolism disorders have been associated with an increased risk of cardiovascular events. However, the prognostic impact on patients (pts) with acute coronary syndrome (ACS) has yet to be clarified., Objective: To determine the prognostic value of serum iron and ferritin levels in pts with ACS in the short and long-term., Methods: Consecutive pts admitted to a coronary care unit with a diagnosis of ACS, for a period of 2 years, were evaluated. The population was divided into tertiles of serum iron and ferritin distribution. The primary adverse events were the occurrence of in-hospital death or heart failure (HF) and death or HF at 1 year of follow-up., Results: We studied 280 pts (73% males; mean age 68 ± 13 years). The mean levels of serum iron and ferritin were 59 ± 34 mcg/dL and 205 ± 185 ng/mL, respectively. Patients included in the 1st tertile of serum iron (≤ 40 mcg/dL) had a higher rate of adverse events, in-hospital and after 1 year. Lower and higher levels of ferritin (1st and 3rd tertiles, ≤ 110; >219 ng/ml, respectively) were associated with a higher incidence of HF during hospitalization and death at 1 year. A ferritin value >316 ng /mL was an independent risk factor for death at 1 year (adjusted OR: 14; 95%CI: 2.6 to 75.9)., Conclusion: In this population, iron metabolism alterations were associated with a higher rate of adverse events and higher ferritin levels constituted an independent mortality predictor in the long-term.

Introduction: Non-dipper and extreme dipper blood pressure (BP) profiles are associated with a worse cardiovascular prognosis. The relationship between nocturnal BP profile and hypertensive retinopathy (HR) is not fully established., Aim: To assess the association between the prevalence and severity of HR and nocturnal BP., Methods: We prospectively studied hypertensive patients who underwent 24-hour ambulatory BP monitoring. The population was divided into two groups according to the presence or absence of lesions and compared according to baseline characteristics, nocturnal BP profile (dippers, non-dippers, inverted dippers/risers and extreme dippers) and mean nocturnal systolic (SBP) and diastolic (DBP) BP values. The presence and severity of HR were assessed using the Scheie classification. The relationship between nocturnal SBP and DBP values (and nocturnal BP profile) and the prevalence and severity of HR was determined., Results: Forty-six patients (46% male, aged 63±12 years) were analyzed, of whom 91% (n=42) were under antihypertensive treatment. Seventy percent (n=33) had uncontrolled BP. HR was diagnosed in 83% (n=38). Patients with HR had higher mean systolic nocturnal BP (151±23 vs. 130±13 mmHg), p=0.008). Patients with greater HR severity (Scheie stage ≥2) had higher nocturnal BP (153±25 vs. 140±16 mmHg, p=0.04). There was no statistically significant association between DBP and nocturnal BP patterns and HR., Conclusions: The prevalence and severity of HR were associated with higher nocturnal SBP. No relationship was observed between nocturnal BP profile and the presence of HR., (Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

The aim of the present paper is to report trends in Portuguese interventional cardiology from 2010 to 2015. We studied data from the prospective multicentre Portuguese National Registry of Interventional Cardiology (RNCI) to analyse percutaneous coronary intervention (PCI) procedures and structural heart interventions from 2010 to 2015. A total of 73,977 PCIs and 780 transcatheter aortic valve implants were performed during the study period. Since 2010 there has been a 60% increase in PCI procedures and a twofold increase in primary angioplasty rates reaching 316 per million population. Significant PCI trends were observed, notably the increase of radial access, a reduction in restenosis indications, as well as an increase in stent use, including DES, in imaging and in functional techniques. Importantly, there was a fourfold increase in the TAVI rates reaching 29 per million population.

Kounis syndrome (KS) is the coincidental occurrence of acute coronary syndrome (ACS) and anaphylactic or allergic insult. It results from mast cell degranulation with subsequent release of numerous inflammatory mediators, leading to coronary vasospasm or atheromatous plaque rupture. Diagnosis is clinical and based on the temporal relationship between the two events. Despite the growing number of reported cases, especially in southern Europe, the lack of awareness of this association may lead to under-reporting in Portugal. Recognition of KS, even if retrospective, has clinical implications since individual atopy must be investigated and desensitization measures should be employed, if possible, to prevent future events. We report the case of a 70-year-old man who was admitted to hospital because of generalized exanthema and itching and onset of chest pain while under observation. Coronary angiography confirmed coronary artery disease and ACS and he was diagnosed as having type II KS., (Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs are common and five types of reactions have been defined. The prevalence of such reactions in patients with myocardial infarction is unclear, and so antiplatelet therapy in this population is a challenge. Various desensitization protocols have been developed but there are no specific guidelines for their use. The authors present the case of a patient with acute coronary syndrome and aspirin hypersensitivity referred for urgent coronary angiography. Aspirin desensitization therapy is safe and successful in many patients, but more randomized trials are needed to confirm its benefits in coronary artery disease patients., (Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

The length of hospital stay (LOS) is an important measure of efficiency in the use of hospital resources. Acute Myocardial Infarction (AMI), as one of the diseases with higher mortality and LOS variability in the OECD countries, has been studied with predominant use of administrative data, particularly on mortality risk adjustment, failing investigation in the resource planning and specifically in LOS. This paper presents results of a predictive model for extended LOS (LOSE - above 75th percentile of LOS) using both administrative and clinical data, namely laboratory data, in order to develop a decision support system. Laboratory and administrative data of a Portuguese hospital were included, using logistic regression to develop this predictive model. A model with three laboratory data and seven administrative data variables (six comorbidities and age ≥ 69 years), with excellent discriminative ability and a good calibration, was obtained. The model validation shows also good results. Comorbidities were relevant predictors, mainly diabetes with complications, showing the highest odds of LOSE (OR = 37,83; p = 0,001). AMI patients with comorbidities (diabetes with complications, cerebrovascular disease, shock, respiratory infections, pulmonary oedema), with pO2 above level, aged 69 years or older, with cardiac dysrhythmia, neutrophils above level, pO2 below level, and prothrombin time above level, showed increased risk of extended LOS. Our findings are consistent with studies that refer these variables as predictors of increased risk.

Although a transradial approach (TRA) is considered feasible in many clinical situations, no data are available in patients undergoing orthotopic heart transplantation (OHT). Our goal was to randomly compare TRA versus a transfemoral approach (TFA) in this clinical setting. This single-center, prospective, randomized trial was conducted from January to November 2006, and all OHT patients scheduled for a control coronary angiography were randomized to receive TRA or TFA. The primary endpoint was the amount of contrast used during the procedure. The participating interventional cardiologists were intermediate-volume radial operators, and this was their initial experience of TRA in OHT patients. The analysis was performed according to the intention-to-treat principle. Overall, 49 patients (mean age, 55 ± 13 years; 74% male) were included in the trial: 26 patients were assigned to TRA, and 23 were assigned to TFA. A higher amount of contrast (147 mL [range, 113-175 mL] vs 105 mL [range, 86-127 mL]; P = .009), a longer fluoroscopy time (9.2 minutes [range, 6-12 minutes] vs 3.5 minutes [range, 3-5 minutes]; P < .001), a trend toward increased number of catheters used for left ostium cannulation, and a higher crossover rate (19% vs 0%; P = .03) were associated with TRA compared with TFA. Furthermore, patients treated with TRA exhibit a shorter hospital stay (6 [range 4-8]) compared with the other group (26 [range 24-28]) (P < .001). There were no significant differences between the 2 groups regarding total procedural time, and no vascular complications were reported in either group. For these operators with their first experience of TRA in OHT patients, TFA seemed to be more efficient., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Antiphospholipid syndrome (APS) is an autoimmune coagulation disorder that manifests clinically as venous and arterial thrombosis, and may affect any tissue or organ. Coronary artery involvement, however, is very rare. Case reports in the literature describing patients with coronary acute syndrome and APS treated with coronary angioplasty show conflicting results. We report an adult male patient with APS who presented with an acute myocardial infarction. Given the high risk of thrombosis in these patients, he was treated percutaneously with thrombectomy and abciximab. We review the few cases of coronary angioplasty in patients with APS reported to date. To our knowledge, this is the first case in which acute myocardial infarction due to thrombotic coronary occlusion was treated with thrombectomy and abciximab without stenting the artery., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Background: Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization., Population and Methods: All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points., Results: The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality., Conclusions: In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.

The authors report the case of a 52-year-old woman with depressive syndrome, treated with lamotrigine for about five months, who went to the emergency department for atypical precordial pain. The electrocardiogram (ECG) revealed a 2-mm downsloping ST-segment elevation and negative T waves in V1 and V2. Due to suspicion of ST-elevation acute coronary syndrome, cardiac catheterization was performed, which revealed normal coronary arteries. The initial ECG was suggestive of type 1 Brugada pattern, but subsequent serial ECGs were less typical. A flecainide test showed the same pattern. After discontinuation of lamotrigine reversal of the typical Brugada ECG pattern was observed. Although not currently contraindicated in Brugada syndrome, the antidepressant lamotrigine blocks sodium channels, which are usually inactivated in heart cell membranes in Brugada syndrome, and may be responsible for the expression of type 1 Brugada pattern., (Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Introduction: Higher values of red blood cell distribution width (RDW) have recently been associated with worse outcome in patients with cardiovascular disease. However, its relation to bleeding events in patients with non-ST elevation acute coronary syndromes has not been established., Aim: To determine the prognostic value of RDW in patients with non-ST segment elevation acute coronary syndromes, particularly regarding the risk of major bleeding., Methods: We analyzed 513 consecutive patients admitted with non-ST elevation acute coronary syndromes. The population was divided into tertiles of baseline RDW and clinical, laboratory characteristics and adverse events were analyzed for each group. The primary outcome was defined as the occurrence of major bleeding (according to the Crusade bleeding score). The predictive value of RDW for risk of major bleeding was determined., Results: The mean RDW was 15.13%±1.62%. Patients in the third tertile were older and more frequently had renal dysfunction or previous coronary revascularization. Higher values of RDW were associated with greater risk of major bleeding and in-hospital death. RDW >15.7% was an independent predictor of bleeding events (odds ratio 3.1, 95% CI 1.4-6.9)., Conclusions: In a population of patients with non-ST elevation acute coronary syndromes, RDW was associated with higher in-hospital mortality and was an independent predictor of in-hospital major bleeding., (Copyright © 2011 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Introduction: Carcinoid tumors are rare, most commonly originating from the neuroendocrine cells in the gastrointestinal tract. Carcinoid syndrome is characterized by flushing, diarrhea, and bronchospasm. Half of these patients have carcinoid heart disease, affecting the right side of the heart, causing tricuspid and pulmonary regurgitation and stenosis and subsequently right heart failure., Case Report: 73-year-old female was admitted with heart failure associated with episodes of diarrhea and flushing. The echocardiogram showed typical characteristics of carcinoid heart diasease. The CT scan of abdomen showed a small bowel mass. The 24-hour urine 5-hydroxyindoleacetic acid (5HIAA) and indium-111-pentetreotide scintigraphy confirmed the diagnosis. The patient was treated with furosemide, warfarine, digoxin and octreotide and there was clinical improvement., Conclusion: The echocardiogram was very useful, establishing the provisory diagnosis of a rare disease based on pathognomonic echocardiographic features.

Objectives: Compare the discriminatory performance of two validated ischemic risk scores and a bleeding risk score for in-hospital adverse events across the spectrum of non-ST elevation acute coronary syndromes (NSTE-ACS)., Material and Methods: Single center, 516 consecutive patients admitted with the diagnosis of NSTE-ACS. The following risk scores were calculated for each patient: TIMI, GRACE and CRUSADE. The following in-hospital endpoints were used: major bleeding (as defined by the CRUSADE criteria); recurrent ischemia (re-infarction or recurrent angina); and death. Discriminatory performance was measured by the c-statistic and compared., Results: There were 36 major bleeding events, 34 recurrent ischemic events and 10 deaths. TIMI RS, GRACE RS, and CRUSADE RS demonstrated fair discriminatory accuracy for major bleeding (c-statistic = 0.64, 0.58, and 0.61, respectively). GRACE and CRUSADE risk scores demonstrated a better performance than TIMI RS for predicting in-hospital death (c-statistic = 0.92 and 0.86, respectively versus c-statistic = 0.63, P < 0.001). For the combined endpoint of in-hospital death or recurrent ischemia there was no statistically significant difference between CRUSADE RS, GRACE RS, and TIMI RS (c-statistic = 0.58, 0.57, and 0.62, respectively)., Conclusion: Both ischemic and bleeding risk scores are able to predict in-hospital bleeding, ischemic and fatal events.

Introduction: The use of drug-eluting stents (DES) is beneficial in patients undergoing percutaneous coronary intervention (PCI) and there is particular interest in long-term follow-up., Objective: We aimed to assess and characterize early DES use in Portugal during 2003 and patient follow-up over a 5-year period. We developed a web-based database to collect and organize patient and procedural data from PCI performed in ten cardiovascular interventional centers sharing the same database., Methods: This was a multicenter retrospective study that included 1833 consecutive angiographically successful coronary angioplasties in which a DES was implanted in 2003. A subgroup of patients with 5-year clinical follow-up after the initial procedure was selected for which there was at least a 90% follow-up rate during one quarter of 2003. Demographic, clinical and angiographic characteristics of the entire population were assessed. In the clinical follow-up cohort, the incidence of major adverse cardiac events (MACE)--death, myocardial infarction and surgical or percutaneous target lesion revascularization--was analyzed by survival curves and logistic regression analysis., Results: Of the total population, 23% were female, and mean age was 62 +/- 11 years (25-92). The main risk factors were hypertension (60.5%), dyslipidemia (42.9%), smoking (45.1%) and diabetes (23.9%, of whom 13.2% were on insulin therapy). There was a history of myocardial infarction, PCI or bypass surgery respectively in 23.1%, 25.1%, and 9.7% of the patients. Multivessel disease was present in 59.9% of patients (mean of 1.86 +/- 0.81 vessels). PCI was performed on average in 1.24 +/- 0.48 lesions, and complete revascularization in 58.8%. A total of 2058 stents were used (mean of 1.62 +/- 0.84) in 1271 patients. The longitudinal substudy included only 320 PCIs, for which follow-up was achieved in 319 (99%; median: 1875 days, P25: 1457 days, P75: 2045 days). Thirty-seven deaths (11.6%) and 61 MACE (19.1%) occurred in this group, with no differences between insulin-treated and other diabetic patients., Conclusion: This is the first study to analyze the early Portuguese experience with drug-eluting stents. The clinical results compare favorably with the first published international registries. The on-line platform used was successful in collecting data in a standardized format on the clinical experience of multiple centers.

Background: Patients with acute coronary syndrome (ACS) frequently present chronic noncardiovascular medical comorbidities that can influence treatment and prognosis. Compliance with therapeutic guidelines in ACS is crucial to event reduction and the presence of these comorbidities may be a determining factor in guideline adherence., Objective: To assess the prevalence of chronic noncardiovascular medical comorbidities in patients with ACS and their impact on guideline adherence., Methods: We studied consecutive patients admitted to the coronary care unit of our institution with a diagnosis of ACS. We identified patients with noncardiovascular comorbidities, divided into five groups: chronic renal failure, pulmonary disease, gastrointestinal disease, blood disease or cancer). We assessed complete adherence to pharmacological therapy plus reperfusion (mechanical or pharmacological) in ST-segment elevation myocardial infarction, and use of coronary angiography in non-ST segment elevation myocardial infarction. We compared guideline adherence according to the presence or absence of comorbidities and their impact on in-hospital mortality., Results: The study sample consisted of 146 patients, mean age 64 +/- 13 years and 71% male. In 53% of the patients at least one comorbidity was identified: chronic renal failure in 23%, pulmonary disease in 14%, gastrointestinal disease in 20%, blood disease in 7% and cancer in 9%. Patients with comorbidities were older, and more frequently had a history of ACS, heart failure and peripheral arterial disease. Complete adherence to guidelines was worse in the group with comorbidities (56% vs. 74%; p = 0.025). The presence of noncardiovascular comorbidities was associated with higher in-hospital mortality (9% vs. 0%, p = 0.011)., Conclusion: Noncardiovascular medical comorbidities are frequently found in patients with ACS. Adherence to therapeutic guidelines for ACS is suboptimal, particularly in patients with chronic noncardiovascular comorbidities. Moreover, the presence of such comorbidities influences short-term prognosis in ACS patients.

Background: Supraventricular tachycardias (SVTs) are the most common arrhythmias in children, with Wolff-Parkinson-White (WPW) syndrome the most prevalent entity. Percutaneous catheter ablation is now the standard of care for SVT in pediatric patients, although specific techniques are required due to their age., Objective: To evaluate the results of percutaneous catheter ablation of arrhythmias in children at our institution., Methods: This was a retrospective study of the clinical records of patients aged 18 years who underwent electrophysiologic study and ablation between January 2002 and December 2006. The following variables were evaluated: demographic data, type of arrhythmia, associated structural heart disease, type of energy used, immediate and late success rate and incidence of complications., Results: During this period, 101 procedures were performed in 97 patients aged < or = 18 years. The mean age of the patients was 15.9 +/- 2.5 years (range: 7.7-18 years), and fifty-five (56.7%) were male. The arrhythmias treated were, in decreasing order of frequency: WPW syndrome (58.4%), atrioventricular reentrant tachycardia (25.7%), atrial tachycardia (5.9%), right ventricular outflow tract (RVOT) tachycardia (5%), ventricular tachycardia (2%), atrial fibrillation (2%) and frequent extrasystoles originating in the left atrium (1%). There was associated structural heart disease in six patients. Cryoablation was performed in four cases (parahisian accessory pathways in three and anterolateral accessory pathway in one). The immediate success rate was 94.1%. The six unsuccessful cases corresponded to five with parahisian accessory pathways (the procedure was not completed due to very high risk of inducing complete atrioventricular block [AVB]) and one case of RVOT tachycardia associated with arrhythmogenic right ventricular dysplasia. There were complications in two procedures (2%): one case of right bundle branch block and one of ventricular tachycardia requiring electrical cardioversion. The mean follow-up was 17.6 months. In 87.1% of cases there was clinical and ECG success on long-term followup. Three patients (3%) required repeat procedures, and were asymptomatic in later follow-up., Conclusion: Percutaneous catheter ablation of arrhythmias in children proved to be a safe and effective treatment.

Purulent pericarditis is a rare disease associated with high mortality, even with appropriate antibiotic therapy. The authors report the case of a patient with purulent pericarditis with no identifiable primary source that presented clinically as cardiac tamponade. The patient required emergency pericardiocentesis and surgical pericardiectomy due to persisting signs of tamponade. Microbiology cultures isolated anaerobic agents of Fusobacterium spp., Corynebacterium spp. and Peptostreptococcus. The authors review the etiology and treatment of this entity and its main complication, the development of constrictive pericarditis.

Acute heart failure (AHF) is a serious clinical condition associated with high morbidity and mortality. The authors present the case of a 61-year-old man, with a past history of idiopathic dilated cardiomyopathy with heart failure, who came to the emergency room due to acute decompensation. During hospital stay he developed cardiogenic shock and inotropic support was initiated, followed by mechanical circulatory assistance with intra-aortic balloon counterpulsation, as a bridge to heart transplantation. The authors discuss theoretical considerations concerning subtypes and etiology of AHF, and indications for the use of mechanical support and heart transplantation.

Background: Cardiac resynchronization therapy (CRT) is currently used in selected patients with dilated cardiomyopathy and heart failure. However, 30% of patients do not respond to CRT when selection is based on clinical and electrocardiographic criteria. Left ventricular dyssynchrony can be evaluated by tissue Doppler imaging and it has been described as a useful precdictor of response to CRT., Objective: To evaluate whether left ventricular dyssynchrony, as measured by tissue Doppler imaging, can be used to predict response to CRT., Methods: 23 consecutive patients (age 67 +/- 10 years, 13 male) with heart failure refractory to medical therapy and who underwent CRT were studied. Before and six months after the procedure, various characteristics - clinical (including NYHA functional class), electrocardiographic (QRS interval) and echocardiographic (left ventricular ejection fraction [EF] and respective volumes)--were evaluated. In addition, pulsed wave tissue Doppler imaging was used to assess the time interval (QS) between the beginning of the QRS complex and the beginning of the systolic wave on the Doppler signal, in the basal segments of the septal, lateral, anterior and inferior walls. Left ventricular dyssynchrony was quantified as the difference between the maximum and minimum QS interval (QS(max-min)). The patients were divide into two groups: responders, if functional class improved by at least one and EF increased by more than 10%, and non-responders for the remainder. Differences between groups were assessed and predictors of response to CRT were determined., Results: CRT improved functional class by at least one in 87% of patients and EF improved from 21 +/- 6 to 33 +/- 9% (p < 0.001). QS(max-min) was reduced from 80 +/- 38 to 38 +/- 14 ms (p < 0.001). In 15 patients (65%), classified as responders, there was an improvement in functional class and an increase in EF of more than 10%. There were no differences between groups, except for QS(max-min). Patients in the responder group had greater left ventricular dyssynchrony (QS(max-min) 94 +/- 39 vs. 54 +/- 16 ms, p = 0.002). QSmix-min was an independent predictor of response to CRT and a cut-off of 60 ms identified responders with a sensitivity of 87% and specificity of 75%., Conclusion: Despite the good results achieved with CRT, about one third of patients do not benefit from it. Left ventricular dyssynchrony can be quantified by tissue Doppler imaging using QS(max-min) and values greater than 60 ms can identify responders to CRT.

Background: Cardiac resynchronization therapy (CRT) improves left ventricular synchrony as evaluated by tissue Doppler imaging (TDI), leading to improved left ventricular performance and reverse remodeling. New CRT devices enable programming of left and right VV delay. The aim of this study was to determine whether sequential biventricular (BiV) pacing by echo-guided programming of VV delay would enhance the response to CRT., Methods: 15 consecutive patients with severe heart failure and left bundle branch block underwent CRT by BiV device implantation. They were studied with conventional and TDI echo the day before implantation. Left ventricular ejection fraction (LVEF) was determined, and the electromechanical delay (QS), defined as the time interval from the beginning of the QRS to the S wave in pulsed TDI, was assessed in each of the four left ventricular basal segments. The dyssynchrony index was calculated as the difference between the longest and shortest electromechanical delay (QS(max-min)). The parameters were re-evaluated the day after implantation during simultaneous BiV pacing and with seven different VV delays. The optimal VV delay was determined by finding the VV interval corresponding to the maximum aortic velocity time interval (VTI)., Results: QS(max-min) decreased from 85.3 +/- 27.0 msec to 46.7 +/- 23.0 msec (p = 0.0002), LVEF increased from 21.7 +/- 7.3% to 30.0 +/- 7.7% (p = 0.0001) and aortic VTI increased from 12.7 +/- 3.6 cm to 15.2 +/- 4.0 cm (p < 0.0001), with simultaneous BiV pacing. The VV intervals were programmed as follows: LV pre-excitation by 10 msec in five patients, 20 msec in three, 30 msec in two, and 40 msec in three; and RV pre-excitation by 10 msec in one and by 20 msec in one. The maximal aortic VTI obtained with VV delay programming increased from 15.2 +/- 4.0 cm to 17.7 +/- 4.0 cm (p = 0.0005). During optimized sequential BiV pacing, QS(max-min) further decreased from 46.7 +/- 23.0 msec to 30.6 +/- 21.0 msec (p = 0.02) and LVEF further increased from 30.0 +/- 7.7% to 35.0 +/- 7.7% (p = 0.0003)., Conclusions: Sequential BiV pacing with VV delay optimized by evaluation of aortic VTI enhanced the response to CRT with additional improvements in left ventricular synchrony and left ventricular function compared to simultaneous CRT.

Introduction: Coronary artery disease (CAD) becomes an important cause of morbidity and mortality after the age of 45 years., Objective: To evaluate the epidemiology and clinical features of all patients under 45 years old admitted with myocardial infarction., Methods: We studied 595 patients admitted with myocardial infarction between January 2000 and December 2002. We analyzed risk factors for CAD, clinical profile, therapeutics and complications (arrhythmic, mechanical and ischemic). The patients were divided into two groups: A--under 45 years old and B-- aged 45 or over., Results: Group A--56 patients (9.4%); group B--539 patients (90.6 %). There was a higher prevalence of smoking in group A (57% vs. 23.6%; p < 0.01). Hypertension, diabetes and history of CAD were significantly more common in group B. There were no differences in hyperlipidemia (group A: 43% vs. group B: 43.5%). Fibrinolysis was performed in 28 patients (70%) from group A compared to 40 patients (45.9%; p < 0.01) from group B. Use of digitalis and inotropic agents was greater in group B. No differences were found in other pharmacological therapeutics. We found more complications in group B (24% vs. 11%)., Conclusions: There was a higher prevalence of smoking in patients under 45 years old and of hypertension, diabetes and CAD in patients aged over 45. The high rate of hyperlipidemia in both groups highlights the importance of primary prevention. Fibrinolysis was performed more frequently in younger patients. There were more complications in older patients.

Introduction: In patients (pts) with atrial fibrillation (AF) of more than 48 hours' duration, electrical cardioversion (ECV) should only be performed after 3 weeks of effective anticoagulation. Transesophageal echocardiography (TEE) allows earlier ECV; however, despite exclusion of thrombi in the atrium and left atrial appendage (LAA), cases of thromboembolism related to ECV have been documented in AF. To define a low-risk group for cardioversion without previous anticoagulation, pts were selected for immediate ECV if no thrombi or dynamic spontaneous echo contrast (auto-contrast) were found after TEE and if LAA velocity was more than 0.25 m/sec., Methods and Results: We performed TEE in 31 consecutive pts referred for ECV for AF of more than 48 hours' duration and without previous anticoagulation. After TEE the pts eligible for immediate ECV began anticoagulation with low molecular weight heparin (enoxaparin), subcutaneously in therapeutic doses, together with warfarin immediately before cardioversion. Enoxaparin was continued until an INR of over 2 was reached. Based on the TEE findings, the pts were divided in 2 groups: immediate ECV, group A, 20 pts with a mean age of 62 +/- 13 years, 6 female; and conventional therapy with warfarin before ECV, group B, 11 pts, mean age of 67 +/- 10 years (p < 0.05), 2 female. None of the pts in either group had mitral stenosis or previous episodes of thromboembolism. The mean transverse diameter of the left atrium in the 31 pts was 47 +/- 4.5 mm, without statistically significant differences between the 2 groups. Of the 11 pts in group B, 3 had a thrombus in the LAA, 6 dynamic spontaneous echo contrast and the remainder LAA velocities of less than 0.25 m/sec. ECV was achieved in all the pts, with no complications. Oral anticoagulation was maintained for at least a month. At one month, sinus rhythm was maintained in 75% of group A and 45% of group B (p < 0.01)., Conclusion: In pts with AF of more than 48 hours' duration and no previous history of thromboembolism, the use of our exclusion criteria during TEE enabled stratification of a low-risk population for immediate ECV, which was accomplished effectively and safely in 2/3 of the pts. This strategy is associated with early symptomatic improvement, and may contribute to maintenance of sinus rhythm after one month, which was significantly better than in the pts who had prolonged therapy with warfarin before ECV, despite the differences found in age and left ventricular function.