Abstract Introduction: It is challenging to diagnose syncope in patients with pacemakers. Because these patients have increased morbidity and mortality risks, they require immediate attention to determine the causes in order to provide appropriate treatment. This study aimed to investigate the causes and predictive factors of syncope as well as the methods used to diagnose syncope in cardiac pacemaker patients. Methods: Patients with pacemakers implanted owing to sinus node disease or atrioventricular block were evaluated with standardized questionnaires, endocavitary electrograms, and other tests based on the suspected causes of syncope. Mann-Whitney U tests were used to analyze continuous variables and Chi-squared or Fisher’s exact tests were used for categorical variables. Logistic regression was used for multivariate analyses. Statistical significance was P<0.05. Results: The study included 95 patients with pacemakers: 47 experienced syncope in the last 12 months and 48 did not. Of the 100 documented episodes of syncope, 48.9% were vasovagal syncopes, 17% had cardiac-related causes, 10.6% had unknown causes, and 8.5% had pacemaker failure. The multivariate analysis showed that a New York Heart Association (NYHA) Functional Class II was a significant factor for developing syncope (P<0.01). Conclusion: While the most common type of syncope in pacemaker patients was neurally mediated, it is important to perform detailed evaluations in this population as the causes of syncope can be life-threatening. The best diagnostic methods were stored electrogram analysis and the tilt table test. NYHA Functional Class II patients were found to have a higher risk for syncope.

Resumo Fundamento: A evolução do paciente chagásico após implante de cardiodesfibrilador implantável (CDI) é tema ainda controverso. Objetivo: Comparar a evolução clínica pós-implante do CDI em pacientes com cardiopatia chagásica crônica (CCC) e cardiopatia isquêmica (CI). Métodos: Trata-se de um estudo prospectivo histórico de uma população de 153 pacientes portadores de CDI, sendo 65 com CCC e 88 com CI. Os dispositivos foram implantados entre janeiro de 2003 e novembro de 2011, tendo-se comparado a taxa de sobrevida e a sobrevida livre de eventos entre essas populações. Resultados: Os grupos foram similares na predominância do sexo masculino, classe funcional e fração de ejeção. Os pacientes isquêmicos são em média 10 anos mais velhos que os chagásicos (p < 0,05). Os pacientes chagásicos apresentavam escolaridade e renda mensal mais baixa do que os isquêmicos (p < 0,05). Foi demonstrado que o número de terapias apropriadas nos pacientes com CCC é 2,07 vezes maior do que naqueles com CI. A incidência de choque apropriado é maior na CCC (p < 0,05). As taxas de mortalidade anual nos dois grupos foram similares, assim como a incidência de tempestade elétrica. Não houve nenhuma morte súbita nos pacientes com CCC e apenas uma nos pacientes com CI. Não houve diferença estatisticamente significativa no tempo de sobrevida entre os dois grupos (p = 0,720) nem na sobrevida livre de eventos (p = 0,143). Conclusão: A CCC duplica o risco de receber terapias apropriadas em relação à CI, mostrando assim maior complexidade das arritmias nos pacientes chagásicos.

Abstract Background: The outcome of Chagas disease patients after receiving implantable cardioverter defibrillator (ICD) is still controversial. Objective: To compare clinical outcomes after ICD implantation in patients with chronic Chagas cardiomyopathy (CCC) and ischemic heart disease (IHD). Methods: Prospective study of a population of 153 patients receiving ICD (65 with CCC and 88 with IHD). The devices were implanted between 2003 and 2011. Survival rates and event-free survival were compared. Results: The groups were similar regarding sex, functional class and ejection fraction. Ischemic patients were, on average, 10 years older than CCC patients (p < 0.05). Patients with CCC had lower schooling and monthly income than IHD patients (p < 0.05). The number of appropriate therapies was 2.07 higher in CCC patients, who had a greater incidence of appropriate shock (p < 0.05). Annual mortality rate and electrical storm incidence were similar in both groups. There was no sudden death in CCC patients, and only one in IHD patients. Neither survival time (p = 0.720) nor event-free survival (p = 0.143) significantly differed between the groups. Conclusion: CCC doubles the risk of receiving appropriate therapies as compared to IHD, showing the greater complexity of arrhythmias in Chagas patients.

Resumo Fundamento: A terapia de ressincronização cardíaca (TRC) é um tratamento recomendado pelas principais diretrizes mundiais. Entretanto, 30%-40% dos pacientes selecionados não respondem ao tratamento. Objetivo: Elaborar um modelo ecocardiográfico preditor de risco de óbito cardíaco ou transplante (Tx) após 1 ano da TRC. Método: Estudo observacional, prospectivo, com inclusão de 116 pacientes, sendo 69,8% do sexo masculino, com idade de 64,89 ± 11,18 anos, CF III (68,1%) e IV ambulatorial (31,9%), bloqueio de ramo esquerdo em 71,55%, e mediana da fração de ejeção (FE) de 29%. Avaliações foram feitas no período pré-implante e 6-12 meses após, e correlacionadas com mortalidade cardíaca/Tx no final do seguimento. Foram realizadas análises de regressão de Cox e logística, com a curva ROC e de sobrevida de Kaplan-Meier. O modelo foi validado internamente pelo “bootstrapping”. Resultados: Ocorreram 29 (25%) óbitos/Tx durante o seguimento de 34,09 ± 17,9 meses. A mortalidade cardíaca/Tx foi de 16,3 %. No modelo multivariado de Cox, as variáveis FE < 30%, disfunção diastólica grau III/IV e regurgitação mitral grau III, aferidas com 6-12 meses, relacionaram-se independentemente a aumento de mortalidade cardíaca ou Tx, com razões de risco de 3,1, 4,63 e 7,11, respectivamente. A área sob a curva ROC foi de 0,78. Conclusão: FE menor que 30%, disfunção diastólica grave e regurgitação mitral severa indicam pior prognóstico após 1 ano da TRC, devendo ser consideradas outras opções terapêuticas na presença da combinação de duas dessas variáveis.

Abstract Background: Cardiac resynchronization therapy (CRT) is the recommended treatment by leading global guidelines. However, 30%-40% of selected patients are non-responders. Objective: To develop an echocardiographic model to predict cardiac death or transplantation (Tx) 1 year after CRT. Method: Observational, prospective study, with the inclusion of 116 patients, aged 64.89 ± 11.18 years, 69.8% male, 68,1% in NYHA FC III and 31,9% in FC IV, 71.55% with left bundle-branch block, and median ejection fraction (EF) of 29%. Evaluations were made in the pre‑implantation period and 6-12 months after that, and correlated with cardiac mortality/Tx at the end of follow-up. Cox and logistic regression analyses were performed with ROC and Kaplan-Meier curves. The model was internally validated by bootstrapping. Results: There were 29 (25%) deaths/Tx during follow-up of 34.09 ± 17.9 months. Cardiac mortality/Tx was 16.3%. In the multivariate Cox model, EF < 30%, grade III/IV diastolic dysfunction and grade III mitral regurgitation at 6‑12 months were independently related to increased cardiac mortality or Tx, with hazard ratios of 3.1, 4.63 and 7.11, respectively. The area under the ROC curve was 0.78. Conclusion: EF lower than 30%, severe diastolic dysfunction and severe mitral regurgitation indicate poor prognosis 1 year after CRT. The combination of two of those variables indicate the need for other treatment options.

ResumoFundamento:A terapia de ressincronização cardíaca pode demonstrar resultados desfavoráveis em 30-40% dos casos.Objetivo:Este estudo teve por objetivo desenvolver modelos preditores para o desfecho combinado de morte cardíaca ou transplante (Tx) em diferentes estágios da terapia de ressincronização cardíaca (TRC).Métodos:Estudo prospectivo observacional de 116 pacientes com idade média de 64,8 ± 11,1 anos, dos quais 68,1% estavam em classe funcional (CF) III e 31,9% em classe IV ambulatorial. Variáveis clínicas, eletrocardiográficas e ecocardiográficas foram avaliadas com regressão de Cox e curvas de Kaplan-Meier.Resultados:O desfecho mortalidade/Tx cardíacos foi de 16,3% durante seguimento de 34,0 ± 17,9 meses. No período pré-implante, disfunção ventricular direita (DVD), fração de ejeção < 25% e uso de altas doses de diuréticos (ADD) aumentaram o risco de morte e Tx cardíacos em 3,9, 4,8 e 5,9 vezes, respectivamente. No primeiro ano após TRC, DVD, AHDD e hospitalização por insuficiência cardíaca congestiva elevaram o risco de morte (razões de risco de 3,5, 5,3 e 12,5, respectivamente). No segundo ano após TRC, DVD e CF III/IV foram fatores de risco significativos de mortalidade no modelo multivariado de Cox. As acurácias dos modelos foram 84,6% na pré-implante, 93% no primeiro ano após TRC e 90,5% no segundo ano após TRC. Os modelos foram validados por bootstrapping.Conclusão:Desenvolvemos modelos preditores de morte e Tx cardíacos em diferentes estágios de TRC com base na análise de variáveis clínicas e ecocardiográficas simples e de fácil obtenção. Os modelos mostraram boa acurácia e ajuste, foram validados internamente e são úteis para a seleção, o monitoramento e a orientação de pacientes indicados para TRC.

AbstractBackground:30-40% of cardiac resynchronization therapy cases do not achieve favorable outcomes.Objective:This study aimed to develop predictive models for the combined endpoint of cardiac death and transplantation (Tx) at different stages of cardiac resynchronization therapy (CRT).Methods:Prospective observational study of 116 patients aged 64.8 ± 11.1 years, 68.1% of whom had functional class (FC) III and 31.9% had ambulatory class IV. Clinical, electrocardiographic and echocardiographic variables were assessed by using Cox regression and Kaplan-Meier curves.Results:The cardiac mortality/Tx rate was 16.3% during the follow-up period of 34.0 ± 17.9 months. Prior to implantation, right ventricular dysfunction (RVD), ejection fraction < 25% and use of high doses of diuretics (HDD) increased the risk of cardiac death and Tx by 3.9-, 4.8-, and 5.9-fold, respectively. In the first year after CRT, RVD, HDD and hospitalization due to congestive heart failure increased the risk of death at hazard ratios of 3.5, 5.3, and 12.5, respectively. In the second year after CRT, RVD and FC III/IV were significant risk factors of mortality in the multivariate Cox model. The accuracy rates of the models were 84.6% at preimplantation, 93% in the first year after CRT, and 90.5% in the second year after CRT. The models were validated by bootstrapping.Conclusion:We developed predictive models of cardiac death and Tx at different stages of CRT based on the analysis of simple and easily obtainable clinical and echocardiographic variables. The models showed good accuracy and adjustment, were validated internally, and are useful in the selection, monitoring and counseling of patients indicated for CRT.

Parada cardiorrespiratória é a principal causa de morte no mundo. Observa-se falta de capacitação adequada da população para agir de forma eficaz diante dessa situação e, assim, aumentar as chances de sobrevivência das vítimas. Tendo em vista esse fato, foi criado, em 1996, o Programa de Educação em Reanimação Cardiorrespiratória (Perc), que tem como objetivo difundir conhecimentos acerca da reanimação cardiorrespiratória mediante a capacitação de leigos, acadêmicos e profissionais de saúde no Estado do Ceará. Ao longo de 16 anos, aproximadamente 8 mil pessoas foram capacitadas diretamente pelo Perc. Entretanto, é difícil mensurar o benefício total pela difusão em cadeia do conhecimento pessoa a pessoa. Graças à experiência adquirida pelo Perc em reanimação, confirmamos a deficiência do tema no Ceará para os mais diversos públicos. Contudo, seguindo as diretrizes lançadas pela American Heart Association (AHA) a cada cinco anos, o projeto vem conseguindo conscientizar leigos, acadêmicos e profissionais da saúde sobre a importância da reanimação e capacitá-los para agir satisfatoriamente diante de uma vítima de PCR.

Cardiac arrest is the biggest cause of death in the world. There is a lack of adequate training of the public in how to act effectively in these situations and thus increase the victim's chances of survival. Therefore, the Cardiopulmonary Resuscitation Education Program (PERC) was created in 1996 with the principal aim of promoting knowledge about CPR by training laymen, health students and professionals in the Brazilian state of Ceará. Over the course of sixteen years, roughly 8,000 people have been trained directly by the PERC. However, it is hard to gauge the full extent of the benefits of this program due to the unlimited, chain diffusion of knowledge from person to person. Thanks to the experience acquired by PERC in CPR, it has been possible to confirm the level ignorance about the issue among the Ceará public. However, following the American Heart Association (AHA) guidelines released every five years, the program is raising awareness about the importance of resuscitation, training people to act satisfactorily when faced with a cardiac arrest situation.

FUNDAMENTO: A taxa normal de excreção de albumina em 24 horas é de 20 mg. A taxa persistente de 30 a 300 mg/dia é chamada de microalbuminúria (MA) e está relacionada com maior prevalência de doença cardiovascular. OBJETIVO: Determinar a prevalência de microalbuminúria em um grupo de hipertensos e em um grupo de portadores de doença coronariana; e determinar a relação da presença de microalbuminúria com hipertensão arterial, diabete melitus, dislipidemia, tabagismo e obesidade. MÉTODOS:: Determinamos a presença de microalbuminúria num grupo de hipertensos (73 indivíduos) e num grupo de coronariopatas (39 indivíduos), e comparamos com um grupo-controle (43 indivíduos). Considerou-se como microalbuminúria a relação albumina/creatinina maior que 30 e menor que 300 em amostra isolada de urina matinal. Na análise estatística, foram utilizados os testes do qui-quadrado e o teste exato de Fisher. RESULTADOS: A microalbuminúria esteve presente em 9,5% dos hipertensos, em 33% dos coronariopatas e não esteve presente em nenhum indivíduo do grupo-controle. Ao analisar a ocorrência de microalbuminúria segundo os diversos parâmetros clínicos, independentemente do grupo a que pertenciam, verificamos correlação estatisticamente significativa com idade, diabete e dislipidemia. CONCLUSÃO: 1) A prevalência de microalbuminúria em indivíduos hipertensos é elevada, sendo ainda mais elevada em portadores de doença coronariana; 2) existe correlação da presença de microalbuminúria com idade, diabete e dislipidemia.

BACKGROUND: The normal 24-hour albumin excretion rate is of 20 mg. A persistent rate of 30 to 300 mg/day is called microalbuminuria and is related to a higher prevalence of cardiovascular disease. OBJECTIVE: 1) To determine the prevalence of microalbuminuria in a group of hypertensive patients and in a group of patients with coronary artery disease; 2) To determine the relationship between the presence of microalbuminuria and hypertension, diabetes mellitus, dyslipidemia, smoking and obesity. METHODS: The presence of microalbuminuria in a group of hypertensive patients (73 individuals) and in a group of patients with coronary artery disease (39 individuals) was determined and compared with a control group (43 individuals). Microalbuminuria was defined as an albumin/creatinine ratio higher than 30 and lower than 300 in a spot morning urine sample. The chi-square test and the Fisher’s exact test were used in the statistical analysis. RESULTS: Microalbuminuria was present in 9.5% of the hypertensive individuals and in 33% of the patients with coronary artery disease, and was absent in individuals of the control group. When the occurrence of microalbuminuria was analyzed according to the different clinical parameters, regardless of the group involved, a statistically significant correlation was found with age, diabetes and dyslipidemia. CONCLUSION: 1) The prevalence of microalbuminuria in hypertensive individuals is high, and is even higher in patients with coronary artery disease; 2) There is a correlation of the presence of microalbuminuria with age, diabetes and dyslipidemia.

OBJETIVO: Identificar aspectos clínico-laboratoriais da endocardite infecciosa valvar, tratada com cirurgia, no Hospital de Messejana, Fortaleza, CE, no período de 1988 a 2003. MÉTODO: Estudo observacional, retrospectivo, da fase hospitalar, de 64 pacientes portadores de endocardite infecciosa, submetidos à substituição valvar aórtica e/ou mitral, vegectomia e plastia da tricúspide e excisão da valva pulmonar, como parte do tratamento. Analisados o sexo, a idade, o tempo decorrido entre a internação e a cirurgia e entre a internação e a alta hospitalar, a valva acometida, o resultado da hemocultura, o procedimento cirúrgico efetuado e a mortalidade. RESULTADOS: A endocardite infecciosa valvar, tratada com cirurgia, preponderou na terceira década, 81,2% dos pacientes eram masculinos. O tempo decorrido entre a internamento e a cirurgia foi menor nos pacientes que faleceram. A valva aórtica, de modo isolado ou associado, foi acometida em 65% dos casos. Hemoculturas foram positivas em 42%; em 52,4% delas, isolou-se Estafilolococo aureus. Necessitaram de substituição valvar 93,7% dos pacientes. Houve mortalidade de 14,1%, não influenciada pela idade nem pelo resultado da hemocultura. CONCLUSÃO: Endocardite infecciosa valvar, submetida ao tratamento cirúrgico, foi mais freqüente em homens e na terceira década. Acometeu preferencialmente a valva aórtica. Estafilolococo aureus foi o patógeno mais comum. Na quase totalidade dos casos, procedeu-se substituição valvar e a mortalidade hospitalar foi de 14,1%.

OBJECTIVE: To identify some aspects of the infective valve endocarditis treated by heart surgery, as well as antibiotic therapy, in a public hospital, in the city of Fortaleza, Ceará state, Brazil, from1988 to 2003. METHOD: A retrospective and observational study of 64 patients with Infective Valve Endocarditis who required aortic and/or mitral valve replacement, tricuspid vegectomy and repair or pulmonary valve valvulectomy, as well as antibiotic therapy, during their in-hospital stay. They were analyzed in respect to gender, age, time elapsed from hospital admission to the surgery, time elapsed from hospital admission to hospital discharge, valve lesion, blood culture result, surgical treatment and mortality. RESULTS: Infective valve endocarditis treated with heart surgery was more frequent in the third decade of life. Most of patients (81.2%) were males. The patients who died spent a shorter time from hospital admission to the surgery than the patients who survived. The aortic valve was affected in 65% of cases. Positivity blood culture were seen in 42% and Staphylococcus aureus was isolated in 52.4% of these cases. Valve replacement was necessary in 93.7% of cases. The in-hospital mortality rate was 14.1% which was not influenced by the age of the patient or the blood culture result. CONCLUSION: Infective valve endocarditis treated by heart surgery was more frequent in men and in the third decade of life. It mostly affected the aortic valve. Staphylococcus aureus was the more common pathogen found. Almost all the patients needed replacement of the infected valve and the in-hospital mortality rate was 14.1%.

OBJETIVO: Caracterização clínica e ecocardiográfica dos pacientes com tumores cardíacos, avaliação da terapêutica cirúrgica e da recidiva dos tumores. MÉTODO: Na primeira parte da pesquisa, o delineamento metodológico foi do tipo retrospectivo, através da identificação de tumores cardíacos e coleta de dados dos prontuários do Hospital Universitário Walter Cantídio (UFCE) e Hospital de Messejana, no período de 1981 a 2001, onde foram encontrados 19 casos de tumores cardíacos. Os pacientes foram submetidos a uma reavaliação clínica, eletro e ecocardiográfica durante o período de março a julho de 2002. RESULTADOS: Sintomas congestivos e dor torácica foram os sintomas mais freqüentes em nossa série. A localização preferencial dos tumores cardíacos em nossa série foi no átrio esquerdo. Entre os pacientes submetidos a operação, todos tiveram o tumor ressecado dos átrios, predominando a localização em átrio esquerdo (79%). O tipo histopatológico mais encontrado em nossa série foi o mixoma (78%). A mortalidade cirúrgica foi de 14%. Detectamos recidiva de tumor em um paciente. CONCLUSÕES: Tumores cardíacos foram mais encontrados no átrio esquerdo. Os tumores benignos foram mais freqüentes que os malignos. O tipo histopatológico mais encontrado foi o mixoma.

OBJECTIVE: The purpose of our paper was clinical and echocardiographic characterisation of patients with cardiac tumours and the evaluation of the surgery and tumour recurrence. METHOD: The first part of research was a retrospective investigation to identify cardiac tumours identification and to collect data from patients' records of the Messejana Hospital and Walter Cantídio University Hospital, from 1981 to 2001. In this period, 19 cases of cardiac tumours were discovered. The patients were submitted to clinical, electrocardiographic and echocardiographic re-evaluation from March to July 2002. RESULTS: Congestive symptoms and thoracic pain were the most frequent symptoms. The location in which most of the tumours were identified was left atrium. Among patients submitted to surgery, all of them had the tumour extracted from atrium. The most common histopathologic type was myxoma (78%). Surgical mortality was 14%. Tumour recurrence occurred in one patient. CONCLUSION: Cardiac tumours were more frequent in left atrium, benign tumours were more frequent than malignant tumours, and the most frequent histopathologic type was myxoma.

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 mg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 % to 18 % and to 28 % later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2 to 13.4 and to 16.2ml/kg/min later). The patient was "de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure.