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Introduction: Conduction disturbances requiring permanent pacemaker (PM) implantation occur in 3–12% of patients after aortic valve replacement (AVR). Our aim was to assess long-term PM dependency and its predictors in these patients. Methods: We conducted a retrospective study of all consecutive patients undergoing permanent PM implantation after AVR between January 2004 and December 2010. Absence of sinus rhythm or atrial fibrillation with appropriate ventricular response at a pacing rate of 30 bpm for 10 s was defined as pacemaker dependency. Results: Ninety-one patients underwent permanent PM implantation and during follow-up (1026.6±732.0 days) 64% of them did not recover rhythm. Age, conduction disorders on the preoperative ECG, negative chronotropic medication before surgery, cardiopulmonary bypass and aortic cross-clamp times did not influence rhythm recovery. In multivariate analysis, valvular disease etiology related to endocarditis, prosthetic dysfunction and bicuspid valve were associated with long-term PM dependency (OR 5.05; CI: 1.43–17.75). Conclusions: The majority of patients undergoing permanent PM implantation after AVR did not recover from conduction disorders during follow-up. The etiology of valvular disease was an independent predictor of late PM dependence. Resumo: Introdução: Distúrbios da condução que requerem implantação de pacemaker (PM) permanente após a substituição da valva aórtica (SVA) ocorrem em 3-12% dos doentes. O objetivo do estudo foi avaliar a dependência do PM a longo prazo e os seus preditores neste grupo de doentes. Métodos: Foi realizado um estudo retrospetivo de todos os doentes submetidos a implantação de PM definitivo após SVA entre janeiro de 2004 e dezembro de 2010. A ausência de ritmo sinusal ou fibrilação auricular com frequência ventricular adequada sob PM a 30 batimentos/min durante um curto período de 10 segundos foi definido como dependência de PM. Resultados: Noventa e um pacientes foram submetidos a implantação de PM permanente e durante o período de follow-up (1026,6 ± 732,0 dias) 64% deles não recuperaram o ritmo. A idade, os distúrbios de condução no ECG pré-operatório, uso de medicação cronotrópica negativa antes da cirurgia, o tempo de circulação extracorporal e o tempo de clampagem da aorta não influenciaram a recuperação do ritmo. Na análise multivariada, a etiologia da doença valvular (endocardite, disfunção de prótese ou válvula bicúspide) esteve associada à dependência de PM a longo prazo (OR 5,05; IC: 1,43-17,75). Conclusões: A maioria dos doentes submetidos a implantação de PM permanente após SVA não recupera dos distúrbios de condução durante o follow-up. A etiologia da doença valvular foi um preditor independente da dependência de PM a longo prazo. Keywords: Aortic valve replacement, Permanent pacemaker, Conduction disorder, Palavras-chave: Substituição valvular aórtica, Pacemaker permanente, Distúrbios da condução

HIGHLIGHTS: Anti-diabetic drugs used at admission in myocardial infarction patients were studied. 195 admissions corresponding to different patients were under analysis. No difference in survival was seen in patients using or not using DPP-4 inhibitors. INTRODUCTION: Diabetes mellitus is frequently associated to cardiovascular disease. We aimed at studying the relations between anti-diabetic drugs in use at admission by diabetic patients with acute myocardial infarction and survival after a period of at least 36 and up to 52 months after admission. METHODS: Retrospective study based on electronic records. Data from a total number of 195 admissions corresponding to different patients were under analysis. RESULTS: Kaplan–Meier analysis, as well as Cox analysis, failed to show a difference in survival associated to the use of DPP-4 inhibitors (n = 35 patients). A non-significant trend toward increased survival was seen with metformin (n = 92 patients), and in the opposite direction with both insulin (n = 51 patients) and sulfonylureas (n = 51 patients). CONCLUSIONS: The use of DPP-4 inhibitors at admission, in patients with Diabetes mellitus admitted for acute myocardial infarction, was not associated to a different survival after no less than 36 months and up to 52 months after admission.

Fundamento: A cardiomiopatia de estresse/Takotsubo (CT) é uma entidade diagnóstica cada vez mais reconhecida. Objetivo: Este estudo teve como objetivo avaliar a prevalência e os preditores clínicos de complicações de curto e longo prazo de pacientes (pts) com CT. Métodos: Foram incluídos todos os pts consecutivamente admitidos no nosso centro, entre novembro de 2006 e agosto de 2011, que preenchiam os critérios diagnósticos da Clínica Mayo. Resultados: Analisaram-se 37 pts (35 mulheres), com idade média de 63 ± 13 anos. A CT foi precipitada na maioria dos casos por eventos de estresse emocional (57%) e dor torácica foi o sintoma de apresentação mais frequente (89%). O electrocardiograma na admissão mostrou supradesnivelamento do segmento ST em 12 pts (32%) e inversão da onda T em 15 casos (41%). Verificou-se disfunção sistólica ventricular esquerda (VE) grave em 16 pts (45%) e a elevação média de troponina I foi de 2,6 ± 1,8 ng/mL. A taxa de complicações intra-hospitalares foi de 30%, sendo o choque cardiogênico a situação mais comum. O estresse físico, a disfunção sistólica grave do VE e o valor de pico do peptídeo natriurético cerebral (BNP) foram preditores de complicações agudas. Não foi encontrada associação entre o pico de troponina I e a apresentação eletrocardiográfica. Trinta e cinco pacientes foram acompanhados por um tempo médio de 482 ± 512 dias, sem recorrência clínica. Conclusão: Na nossa série de pacientes, a CT foi associada a uma alta taxa de complicações intra-hospitalares. O estresse físico, a disfunção sistólica do VE e o valor de pico do BNP foram preditores de desfechos adversos agudos. Background: Stress-induced/Takotsubo cardiomyopathy (TC) is an increasingly recognized diagnostic entity. Objective: This study was aimed to assess the prevalence and clinical predictors of short and long-term outcome of patients (pts) diagnosed with TC. Methods: We included all consecutive pts admitted in our department, from November 2006 to August 2011, who met the Mayo Clinic criteria for TC diagnosis. Results: We evaluated 37 pts (35 women) with a mean age of 63 ±13 years. TC was precipitated by a stressful emotional event in the majority (57%) and chest pain was the most common symptom (89%). Twelve pts (32%) had ST-segment elevation and 15 pts (41%) had T-wave inversion on the electrocardiogram at admission. Severe left ventricular (LV) dysfunction was found in 16 pts (43%) and the mean troponin I level was 2.6±1.8 ng/mL. The in-hospital complication rate was 30%, with cardiogenic shock being the most common situation. Physical stress, severe LV systolic dysfunction and peak brain natriuretic peptide (BNP) were predictors of acute complications. On the other hand, we found no association between peak troponin I and electrocardiographic presentation. Thirty-five pts were followed for a mean time of 482 ± 512 days, without clinic recurrence. Conclusion: In our cohort of pts, TC was associated with a high in-hospital complications rate. Physical stress, LV dysfunction and peak BNP could predict acute adverse outcomes.

Objectives Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS. Design Data were collected within a prospective cohort study (EPIHeart). Setting Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014. Participants Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview. Outcome measures: Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex. Results Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P

The authors present a case report of successful treatment of pulmonary artery perforation by endovascular stent graft implantation. Resumo: Os autores descrevem um caso de sucesso do tratamento da rotura da artéria pulmonar com a implantação de um stent endovascular. Keywords: Swan-Ganz catheterization, Hemoptysis, Palavras-chave: Cateterização Swan-Ganz, Hemoptises

Heart transplantation is the treatment of choice in severe heart failure despite maximal medical therapy, which has no other surgical alternatives and exhibiting no contraindications. The aim of this study was to analyze the prevalence of late complications and survival of patients undergoing cardiac transplantation at our Hospital Center.We evaluated 78 patients (mean age 43 ± 15 years) transplanted at our center between February 1987 and December 2011, with a mean follow-up of 6 years.Of late complications after heart transplantation, allograft vascular disease was detected in 10 patients ( 12.8%), was the one with impact on mortality, being responsible for four deaths. The most frequent complication was hypertension in 54.6% of cases, followed by dyslipidemia (47.4%), renal failure (47.4%), diabetes mellitus (21.8%) and neoplasms (11.5%). Atrial tachyarrhythmias was observed in eight patients (10.3%). The overall survival of our population at first and tenth year after heart transplantation was 81% and 69%, respectively. The mean survival of patients was 15.6 years (Cl 95%: [12,6-18,7]).. There were 23 deaths (29.5%), nine (11.5%) of which occurred within the first 30 days after transplantation.Cardiac transplantation remains a valid therapeutic option for patients with end-stage heart disease. Our center had a heart transplant survival rate and incidence of late complications similar to those seen in international registries.

Hypoxia due to an Atrial Septal Defect (ASD), without Eisenmenger physiology, is reported rarely and may be underestimated due to difficulty in its diagnosis. We report the case of a 67-year-old woman with chronic cyanosis and hypoxia, in whom a large ASD was diagnosed by cardiac catheterization after an extensive workup to clarify the aetiology of the hypoxia. The right-to-left shunt at the ASD occurred probably due to a well-developed Eustachian valve, partly directing the right atrial flow into the left atrium, in the absence of pulmonary arterial hypertension.

Stress-induced cardiomyopathy, also known as ‘broken heart syndrome’ or Takotsubo cardiomyopathy, is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle, in the absence of significant coronary artery disease. We report the case of a 56-year-old male patient with chronic obstructive pulmonary disease (COPD), with stress-induced cardiomyopathy associated with the use of ipratropium bromide, administered in the context of an acute exacerbation of COPD. Resumo: A cardiomiopatia associada ao stress, também conhecida por cardiomiopatia de Takotsubo, é caracterizada por uma disfunção sistólica transitória dos segmentos apicais e/ou médios do ventrículo esquerdo, na ausência de doença coronária significativa. Apresentamos um caso clínico de um doente do sexo masculino, com 56 anos de idade, com doença pulmonar obstrutiva crónica (DPOC), com cardiomiopatia associada ao stress que surgiu após uso de brometo de ipratrópio, administrado no contexto de uma exacerbação de DPOC. Keywords: Stress cardiomyopathy, Takotsubo cardiomyopathy, Ipratropium bromide, Palavras-chave: Cardiomiopatia de stress, Cardiomiopatia de Takotsubo, Brometo de ipratrópio

Background: Interpretation of the symptoms of acute coronary syndrome (ACS) can influence the time of hospital admission and negatively affect patients’ prognosis. We decided to explore illness perception and its predictors among patients with ACS. Methods: We conducted a retrospective analysis of all consecutive patients with ACS admitted to the cardiology department of a tertiary hospital between January and September 2011. Data were obtained from patients’ medical records and telephone interviews. Results: One hundred and eighty-six patients with ACS (mean age 64±12 years; 70% male) were included. The majority (62.6%) had no perception of ACS until informed by their doctor. Only 26% of patients with ST-segment elevation myocardial infarction had perception of cardiac disease. Among those who had perception, 82.6% were men and 58% had a previous diagnosis of ischemic heart disease (IHD). Gender and previous diagnosis of IHD were independent predictors of ACS perception, with male gender and patients with previous IHD having greater illness perception. No association was found between ACS perception and age or residence area (rural vs. urban). Conclusions: The illness perception of ACS patients needs to be improved, independently of sociodemographic factors. An educational program for the general population, but particularly for women and individuals without a past history of IHD, focusing on the alert signs for ACS, may help to improve illness perception in this setting. Resumo: Introdução: A interpretação dos sintomas da síndrome coronária aguda (SCA) pode influenciar o tempo da admissão hospitalar e afetar negativamente o prognóstico. Decidimos explorar a perceção da doença e os seus preditores em doentes com SCA. Métodos: Efetuamos uma análise retrospetiva de todos os doentes consecutivamente admitidos no departamento de cardiologia de um hospital terciário com SCA, entre janeiro e setembro de 2011. A informação foi obtida através dos registos clínicos e entrevista telefónica. Resultados: Cento e oitenta e seis doentes (idade média de 64 ± 12 anos; 70% homens) com SCA foram incluídos. A maioria (62,6%) dos doentes não tinha perceção da SCA atéàinformação médica. Apenas 26% dos doentes com enfarte agudo do miocárdio com supradesnivelamento do segmento ST tiveram perceção da doença cardíaca. Entre aqueles que tiveram perceção, 82,6% eram homens e 58% tinha um diagnóstico prévio de doença cardíaca isquémica (DCI). O sexo e o diagnóstico prévio de DCI foram preditores independentes da perceção da SCA, tendo o sexo masculino e os doentes com DCI prévia uma perceção superior. Nenhuma associação foi encontrada relativamente à idade e área de residência (rural versus urbana). Conclusões: A perceção de doença dos pacientes com SCA precisa de ser melhorada, independentemente de fatores sociodemográficos. Um programa educacional que abranja a população geral, particularmente as mulheres e aqueles sem antecedentes de DCI, e que foque os sinais de alerta para a SCA poderá ser útil para melhorar a perceção dos sintomas neste contexto. Keywords: Acute coronary syndrome, Illness perception, Education, Palavras-chave: Síndroma coronária aguda, Perceção de doença, Educação

Background: Alkaline phosphatase (ALP) removes phosphate groups from many types of molecules. The aim of the present research was to study the relation between plasma ALP and survival in diabetic patients with myocardial infarction. Methods: Retrospective study: from 954 admissions (15 months period) in a coronary care unit, we selected 200 admissions corresponding to 195 patients with myocardial infarction and diabetes mellitus. Survival after no less than 48 months, and up to 61 months, after the myocardial infarction episode, was under study, in association with ALP levels. Results: A relatively weak but significant correlation was seen between the peak plasma cardiac troponin I and ALP levels (r: 0.21, significance level: 0.003). Using the median value for ALP as cut-off (74 IU/L), plasma creatinine was significantly higher in patients with higher values for ALP. Patients with elevated ALP had decreased survival in Kaplan-Meier analysis (significance level in log-rank test: 0.032). This finding was noted for male patients (significance level in log-rank test: 0.035), but not for female patients (significance level in log-rank test: 0.497). Conclusions: Elevated ALP acts as a prognostic indicator of decreased survival in diabetic patients with acute myocardial infarction, possibly in association to decreased renal function. This finding is limited to male patients, pointing to a possible different role for phosphatase activity in cardiovascular disease in male and female diabetic patients.

Background: Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) associated with increased morbidity and mortality. This association is less well defined across the spectrum of acute coronary syndromes. We sought to study the incidence, predictors and prognosis of new-onset AF complicating ST-segment elevation AMI (STEMI) and non-ST-segment elevation AMI (NSTEMI). Methods: We studied 977 episodes of STEMI and 1357 of NSTEMI, within a sample of acute coronary syndrome cases from 10 Portuguese hospitals, consecutively discharged within each hospital, in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors. Patients with unstable angina or AMI that could not be classified as STEMI vs NSTEMI (either due to left bundle branch block of unknown age or subacute presentation) were excluded from this analysis. We fitted logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (95% CI). Results: A total of 208 patients (8.9%) with AMI developed new-onset AF during the index hospitalization, with no difference between STEMI and NSTEMI (8.8% vs 9.0%, p=0.87). The incidence of AF increased with age in both STEMI (

Introduction: Octogenarians with Acute Coronary Syndrome (ACS) are at risk of developing Heart Failure (HF). Our purpose was to identify clinical conditions that could predict HF development during hospitalization, and to evaluate its impact on in-hospital mortality. Methods: We studied a sample of 3009 cases of ACS from 10 Portuguese public hospitals, consecutively discharged within each hospital in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors according to a standard protocol. For the present analysis patients were stratified according to age (< or ≥ 80 years) and compared regarding HF incidence (Killip2) as well as its predictors. Logistic regression analysis was performed to identify independent predictors of HF and, additionally, in-hospital death. Results: The very old group comprised 21.4% (n=645) of all ACS patients and 56.3% were women (versus 27.2% in the younger group; p

Introduction: There is evidence that cardiac rehabilitation programs (CRP) exert significant benefits in patients with coronary artery disease (CAD). However, safety and influence of residual significant coronary stenosis on CRP outcomes remain unclear. Methods: We retrospectively analyzed clinical, angiographic and functional data of a total of 287 patients referenced to a CRP after an acute coronary syndrome (ACS), between September 2008 and December 2011. Incomplete revascularization (IR) was defined by the presence of residual structural stenosis in any major epicardial vessels (>70%), consequent to unfavorable anatomy to angioplasty (PCI). Pre and post CRP functional capacity was assessed using exercise stress testing metabolic equivalents (METS). A composite outcome of overall mortality and nonfatal cardiovascular events was evaluated. Furthermore, functional capacity at follow-up evaluation was estimated using the patient-reported Duke Activity Status Index (DASI). Results: We analyzed 280 patients, mostly male (88%), aged 54±10 years. Incomplete revascularization (IR) was found in 61 (23%) patients. IR patients more frequently presented previous diagnosis of coronary heart disease (CHD) (25% vs 12%, p=0.009). They and also tended to be more often women (36% vs 22%, p=0.082) and diabetic (21% vs 14%, p=0.155), although these differences were not statistically significant. Physical training in pts with IR was safe and well tolerated. Exercise capacity increased significantly in both groups (peak MET level: + 0.7±1.7, p=0.013, in IR vs 1,0±1.7, p 0.05). The mean follow-up time was 30±13 months. Both groups showed a similar perceived physical performance, using DASI estimated peak METs (8.0±1.6 [IR] vs 8.3±1.6 [CR], p>0.05). Composite endpoints were found in 36 (10%) patients and occurred more in IR patients (19% vs 13%); however, the difference was not statistically significant (p>0.05). Kaplan Meyer showed no difference in the likelihood of a cardiovascular event, between IR and CR patients (p>0.05). Conclusion: IR patients take similar advantage from a CRP and maintain an equivalent long-term functional capacity. Although signficant residual stenosis is frequently regarded as a relative exclusion criteria for cardiac rehabilitation, these patients derive similar benefits both in short and long-term functional capacity, cardiovascular morbidity and mortality.

Background: Acute coronary syndrome (ACS) is less common in young adults than older individuals. However, the potential for long-term consequences is of particular concern because of the expected longer lifetime remaining. Our purpose was to evaluate the particularities of this age group in comparison to the more commonly affected older adults. Methods: We studied a sample of 3009 cases of ACS from 10 Portuguese public hospitals, consecutively discharged within each hospital in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors according to a standard protocol. We divided patients into two categories (≤ 45 years and > 45 years) and compared clinical data and intra-hospital outcomes. Results: Young patients comprised 6.3% (n=191) of all ACS patients and 80% were male (versus 66% in the older group, p

Introduction: Advanced age is an important risk factor for acute coronary syndrome (ACS). Our purpose was to evaluate the particularities of ACS in octogenarians in comparison with the younger group. Methods: We studied a sample of 3009 cases of ACS from 10 Portuguese public hospitals, consecutively discharged within each hospital in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors according to a standard protocol. We divided patients into two categories (

Introduction: The assessment of prognosis following acute myocarditis is still a difficult task. Novel echocardiographic modalities, such as strain measurement added new parameters in evaluating left ventricular (LV) function. The aim of our study was to assess left ventricle (LV) function by longitudinal (L) strain (S) at midterm follow-up in patients after acute myocarditis. Methods: We included 31 subjects, among which 18 patients (pts) admitted consecutively in a tertiary center after an episode of acute myocarditis and 13 healthy controls. Definition of myocarditis was based on clinical, biochemical and cardiac magnetic resonance imaging information. At 12±7 months follow-up pts were revaluated using strain analysis by speckle tracking imaging. At this stage LV function was compared with the control group. Results: Among the patients with acute myocarditis 15 (83%) were men, 4 (22%) pts presented NYHA class III-IV at baseline and at the acute setting LV ejection fraction (EF) was 52±9%. Moderate LV dysfunction (EF