Supra-Normal Left Ventricular Function

Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.

Cutaneous Markers of Cardiovascular Diseases

Cardiovascular diseases are one of the most important global medical challenges because of their high rates of morbidity and mortality. In this narrative review, the authors address the most important dermatologic signs that can be present in patients with cardiovascular disease. The early recognition of these underestimated entities is very important as it may lead to an early diagnosis and timely treatment, thus lessening the effects of long-term disease and possibly improving the prognosis.

Iron deficiency in chronic and acute heart failure: A contemporary review on intertwined conditions

Iron Deficiency (ID) is increasingly recognized as a prevalent comorbid condition in Heart Failure (HF). Despite this, the pathophysiological mechanisms for progressive ID in either chronic or acute HF are still poorly understood. Beyond the traditional factors for iron deficit in the general population, we ought to review the specificities of such paucity in the HF patient, particularly focusing on the interplay between heightened inflammation, overactivity of the sympathetic nervous system and the so-called cardio-renal-anaemia-ID syndrome. Currently, ID constitutes not only an independent prognostic marker but also a novel safe therapeutic target. Particularly, in selected stable HF patients with reduced left ventricular ejection fraction, intravenous (IV) iron improves symptomatic burden and reduces hospitalizations due to worsening HF. On this topic, the main trials of IV iron with either iron sucrose (Toblli et al., FERRIC-HF and IRON-HF) or ferric carboxymaltose (FAIR-HF, CONFIRM-HF and EFFECT-HF) will be summarized and discussed. Finally, we debate the gaps in knowledge of ID in special populations, namely the unreliability of routine plasmatic surrogate markers to assess iron status in acute and advanced HF, the challenging patient with both HF and Chronic Kidney Disease, as well as efficacy and safety concerns in these settings and the potential role of iron correction in cardiac resynchronization therapy candidates.

Mid-regional pro-adrenomedullin and ST2 in heart failure: Contributions to diagnosis and prognosis

Heart failure has a high prevalence in developed countries. It is a frequent cause of hospital admission and has an important impact on morbidity, mortality and healthcare costs. Biomarkers have been widely studied in heart failure, as they improve diagnosis and prognostic assessment. Natriuretic peptides are already a part of daily clinical practice but several other biomarkers are being studied. This review focuses on mid-regional pro-adrenomedullin (MR-proADM) and ST2. Neither of these biomarkers is useful in the diagnosis of acute heart failure. However, both have considerable short- and long-term prognostic value in patients with acute and with stable chronic heart failure. The utility of these two biomarkers in guiding heart failure treatment is yet to be established. ST2 appears to have some advantages compared to MR-proADM, because it is more closely associated with ventricular remodeling and fibrosis.

Arrhythmogenic right ventricular dysplasia: Atypical clinical presentation

A 67-year-old man was admitted to our hospital after episodes of syncope preceded by malaise and diffuse neck and chest discomfort. No family history of cardiac disease was reported. Laboratory workup was within normal limits, including D-dimers, serum troponin I and arterial blood gases. The electrocardiogram showed sinus rhythm with T-wave inversion in leads V1 to V3. Computed tomography angiography to investigate pulmonary embolism showed no abnormal findings. Transthoracic echocardiography (TTE) displayed massive enlargement of the right ventricle with intact interatrial septum and no pulmonary hypertension. Cardiac magnetic resonance imaging (MRI) confirmed right ventricular (RV) dilatation and revealed marked hypokinesia/akinesia of the lateral wall. Exercise stress testing was negative for ischemia. According to the 2010 Task Force criteria for arrhythmogenic right ventricular dysplasia (ARVD), this patient presented two major criteria (global or regional dysfunction and structural alterations: by MRI, regional RV akinesia or dyskinesia or dyssynchronous RV contraction and RV ejection fraction ≤40%, and repolarization abnormalities: inverted T waves in right precordial leads [V1, V2, and V3]); and one minor criterion (>500 ventricular extrasystoles per 24 hours by Holter), and so a diagnosis of ARVD was made. After electrophysiologic study (EPS) the patient received an implantable cardioverter-defibrillator (ICD). This late clinical presentation of ARVD highlights the importance of TTE screening, possibly complemented by MRI. The associated risk of sudden death was assessed by EPS leading to the implantation of an ICD. Genetic association studies should be offered to the offspring of all ARVD patients.

Acute decompensated heart failure (ADHF): A comprehensive contemporary review on preventing early readmissions and postdischarge death

Heart failure (HF) is an increasingly prevalent syndrome and a leading cause of both first hospitalization and readmissions. Strikingly, up to 25% of the patients are readmitted within 30 to 60-days, accounting for HF as the primary cause for readmission in the adult population. Given its poor prognosis, one could describe it as a "malignant condition". Acute decompensation is intrinsically related to increased right heart tele-diastolic pressures and often related to congestive symptoms. In-hospital strategies to adequately compensate and timely discharge patients are limited. Conversely, the fragile early postdischarge phase is a vulnerable period when one could potentially intervene cost-effectively to improve survival and to reduce morbidity. Promising transitional hospital-to-home programs may have a broader role in the near future, namely for selected higher risk patients. However, identifying patients at risk for hospital readmission has been challenging. Novel approaches, such as ferric carboxymaltose and valsartan/sacubitril, and reemerging drugs, particularly digoxin, may reduce hospitalizations. Despite this, optimizing the use of "older" therapies is still warranted. Right heart pressures monitoring may provide novel insights into promptly outpatient management. Unfortunately, randomized trials in the specific ADHF population are scarce. A novel paradigmatic approach is needed in order to suitably improve the currently poor prognosis of ADHF. Both improving survival and reducing hospitalizations are, therefore, primordial therapy goals. Lastly, no single drug has consistently proved to improve survival in HF with preserved ejection fraction (HFpEF); yet, some approaches may efficiently reduce hospitalizations. Awareness on HFpEF management beyond the failing heart is imperative.

BNP and ANP as diagnostic and predictive markers in heart failure with left ventricular systolic dysfunction

Background

The prevalence of chronic heart failure (CHF) with systolic dysfunction is increasing. Plasma natriuretic peptides have been envisaged as diagnostic and predictive markers.

Aims

To investigate the relationship between the levels of B-type natriuretic peptide (BNP) and A-type natriuretic peptide (ANP) and the clinical and functional parameters of CHF in outpatients with CHF at baseline, compared with normal healthy controls; to find out the differences in a randomised controlled trial between patients treated with an angiotensin-converting enzyme (ACE) inhibitor, captopril, or an angiotensin receptor blocker (ARB), irbesartan. These differences were assessed throughout the six-month treatment period and at the sixth month.

Methods Plasma BNP (pmol/L) and ANP (pmol/L) were

determined in 68 hypertensive patients with dilated cardiomyopathy, NYHA class III-IV and ejection fraction (EF) <40%, and in 26 normal controls. Statistical analysis for BNP and ANP was done by Student's t-test. The patient group was randomly subdivided into two subgroups of 34 patients, each treated with either an ARB, irbesartan, or an ACE inhibitor (ACE-I), captopril. BNP and ANP were measured in both subsamples and correlated with clinical, functional and neurohormonal parameters throughout a follow-up period of six months and at the sixth month.

Results

The mean EF in the patient sample was 33.43±6.52% and in the controls was 61.96 ±3.53% (p=0.000). The mean BNP (pmol/L) in patients was 44.78±54.36 and in the controls was 7.12±8.28 (p=0.000) and the mean ANP (pmol/L) was 30.32±25.97 in patients and 11.18±7.92 in controls (p=0.000). A statistically significant difference was found between patients and healthy controls. Significant correlations were found between natriuretic peptides and EF. Between the baseline phase and the sixth month, BNP and ANP decreased significantly in the ARB group. At the sixth month, both BNP and ANP were lower in the ARB group. Evidence of clinical benefit was found with both ARB or ACE-I treatment throughout the six months, with patients moving from classes III and IV to class II NYHA. Improvement of EF was also found, with transition of patients with lower EF (even <30%) to higher values. EF was higher in the ARB group at the sixth month.

Conclusions

BNP and ANP can be useful diagnostic tools in hypertensive CHF patients with moderate-to-severe LV dysfunction. The decrease in BNP and ANP in the ARB group throughout six months, as well as the lower value at the sixth month, suggest a prognostic value of these parameters.

Giant cell arteritis: a closer look at its ophthalmological manifestations

Giant cell arteritis with ocular involvement is an ocular emergency. Arteritic anterior ischaemic optic neuropathy (AAION) is the most common ophthalmological manifestation associated with this disease. Visual loss is usually permanent with rare cases showing visual recovery. Visual improvement, if it occurs, is generally limited, and the visual field defects are persistent and severe. The main goal of AAION treatment is the preservation of vision in the fellow eye. In patients with neurophthalmological manifestations, high-dose corticosteroids should be initiated immediately and aggressively, and maintained thereafter. We present a case of AAION and severe vision loss where significant visual recovery was seen after treatment.

Galectin-3, a prognostic marker--and a therapeutic target?

The natriuretic peptides BNP and NT-proBNP are currently the most commonly used biomarkers in heart failure, but they have limitations. There is thus a need to identify new biomarkers that may prove useful, alone or in combination, for screening, diagnosis and prognosis. Galectin-3 is a protein involved in a variety of cellular signaling pathways and is found in many tissues. Its expression is low in normal hearts but elevated in fibrotic hearts. Among other effects, it promotes fibroblast proliferation and collagen synthesis, contributing to the cardiac remodeling that is central to the development and progression of heart failure. Heart failure associated with elevated galectin-3 (>17.8 ng/ml) affects 30-50% of patients with chronic heart failure, and is a marker of worse prognosis, with higher rates of short-term rehospitalization and mortality. It is thought that galectin-3 inhibition, or even genetic disruption, may reverse or delay disease progression. Galectin-3 appears to have greater prognostic value than natriuretic peptides when assessed separately, however, when combined their prognostic value is even higher. Galectin-3, associated with BNP or NT-proBNP, may help improve the diagnosis and prognosis of heart failure.

Paralisia facial bilateral e leucemia mielóide aguda: uma associação pouco comum

A leucemia mielóide aguda (LMA) é uma doença maligna do tecido hematopoiético. A apresentação da doença pode estar relacionada com a perda de função da medula óssea ou com sintomas gerais das doenças neoplásicas. O envolvimento extra-medular é responsável por formas de apresentação menos frequentes que podem dificultar um diagnóstico precoce. A hipertrofia gengival não é incomum na LMA mas os casos de paralisia facial bilateral são raros. Neste artigo os autores apresentam o caso de um homem de 70 anos que surge com hipertrofia gengival que inicialmente não é valorizada e que desenvolve, após três semanas, uma paralisia facial periférica bilateral. O mielograma revelou uma LMA. Com a quimioterapia dirigida o doente entrou em remissão completa mas manteve a sintomatologia de apresentação da doença.

[Bilateral facial palsy and acute myeloid leukemia: an unusual association]

Acute myeloid leukemia (AML) is a malignant disease of the hematopoietic tissue. The disease presentation may be related to the loss of bone marrow function or with general symptoms of neoplastic diseases. Extramedullary involvement is responsible for less frequent presentations that may hinder early diagnosis. Gingival enlargement is not uncommon in AML but cases of bilateral facial palsy are rare. In this article the authors present the case of a man of 70 who comes up with gingival hypertrophy that initially was not valued and that developed after three weeks, a bilateral facial palsy. The myelogram revealed an AML. With directed chemotherapy the patient reached complete remission but kept the symptoms of disease presentation.

Decreased erythrocyte activity of methemoglobin and glutathione reductases may explain age-related high blood pressure

OBJECTIVES

Erythrocytes may play an important role in regulating blood pressure as storage sites for nitric oxide (NO). The objective of this work was to determine whether factors related to variations in erythrocyte metabolism associated with NO bioavailability, such as the activity of two enzymes--methemoglobin reductase (MHbR) and glutathione reductase (GSHR)--may help explain age-related increased blood pressure.

METHODS

The sample consisted of 468 individuals of both sexes, 237 hypertensive (HT) and 231 normotensive (NT), aged between 18 and 98 years (48.81 +/- 19.46). The activity of MHbR (micromol.g Hb-1.min-1) and of GSHR (micromol.g Hb-1.min-1) was determined in erythrocytes by spectrophotometry. The statistical methods used were the Mann-Whitney test, Spearman's correlation coefficient and binary logistic regression.

RESULTS

In this population, age was a risk factor for hypertension (OR=1.055, 95% CI = 1.045-1.065, p < 0.001). There was a significant difference in erythrocyte activity of these enzymes between normotensive and hypertensive subjects, with lower values in hypertensives: MHbR-NT = 16.97 (3.82-34.63), HT = 16.26 (3.26-37.10), p = 0.012; and GSHR-NT=57.60 (21.59-96.58), HT = 39.26 (23.07-90.27), p < 0.001. Enzyme activity was inversely correlated with age (MHbR: r = -0.193, p < 0.001; GSHR: r = -0.757, p < 0.001). MHbR correlated directly with GSHR only in hypertensive patients (r = 0.343, p = 0.034), which was not observed in normotensives.

CONCLUSIONS

Age was a risk factor for hypertension. The erythrocyte activity of glutathione and metahemoglobin reductases, essential for redox balance and nitric oxide bioavailability in erythrocytes, may contribute only partially to the increased prevalence of age-related hypertension, and other factors should be taken into consideration, such as nutrition and antihypertensive medication.

Alterations in plasma semicarbazide-sensitive amine oxidase activity in hypertensive heart disease with left ventricular systolic dysfunction

BACKGROUND

Semicarbazide-sensitive amine oxidase (SSAO) is found in various mammalian tissues, particularly in vascular smooth muscle cells, but also in plasma. It has been suggested that it plays an important role in vascular endothelial damage and in progression of atherosclerosis through conversion of endogenous amines into cytotoxic aldehydes, ammonia and hydrogen peroxide. In patients with diabetes mellitus and chronic heart failure, plasma activity appears to rise in parallel with disease severity.

METHODS AND RESULTS

Plasma SSAO and monoamine oxidase (MAO) activity was measured in 39 patients with hypertensive heart disease and left ventricular systolic dysfunction, in NYHA heart failure class II-IV, and compared to values in 89 controls. SSAO was found to be elevated in patients compared to controls (2.781 +/- 1.599 vs. 1.627 +/- 0.751 micromol/l/h; p = 0.000). Plasma MAO was also significantly increased in the patient group (3.837 +/- 1.899 vs. 3.077 +/- 1.559 (micromol/l/h; p = 0.018). No significant differences were seen between different NYHA classes, but class IV patients presented the highest SSAO activity. SSAO and MAO activity showed a trend for a positive correlation (R = 0.265; p = 0.092).

CONCLUSION

The finding of elevated plasma SSAO and MAO activity in congestive heart failure supports the hypothesis that amine oxidases may be involved in the pathogenesis of vascular endothelial damage.

[Pulmonary abcess, a revision]

Lung abscesses are cavitating lesions containing necrotic debris caused by microbial infection. Patients with chronic lung disease, bronchial obstruction secondary to cancer, a history of aspiration or risk of aspiration caused by alcoholism, altered mental status, structural or physiologic alterations of the pharynx and esophagus, neuromuscular disorders, anesthesia, are among others at higher risk of developing lung abcess. The main bacteriological characteristics, the diagnosis, therapy and prognosis are considered. The problem of antimicrobial resistance is also referred.

GST M1/T1 and MTHFR polymorphisms as risk factors for hypertension

The aim of this study is to investigate GSTM1, GSTT1 and MTHFR genetic polymorphisms and its relation with total plasma glutathione (tGSH) levels in hypertension. Genotype distributions of GSTM1 and GSTT1 deletion polymorphisms and C677T variant of MTHFR were examined in a sample of 94 hypertensive patients with congestive heart failure and 207 healthy unrelated Portuguese individuals using PCR techniques. Plasma GST activity was determined spectrophotometrically. The antioxidant status was evaluated by fluorometric assays of tGSH. Genotype distributions of GSTT1 (chi2 test; p < 0.01) and MTHFR (chi2 test; p < 0.01) differ significantly between control and hypertensive patients with a greater prevalence of "non-null GSTT1/M1" and CT (heterozygous) genotypes. Moreover, GST activity and tGSH were markedly decreased in hypertension but there is no correlation with the studied polymorphisms. GSH depletion confirmed the possible involvement of oxidative stress in this pathology. Deletion of GSTT1 gene might be considered as protective factor for hypertension.

[Pulmonary embolism. Modern concepts]

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography have shown promise. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractioned heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused in the epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.

[Pulmonary thromboembolism -- current concepts]

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography are promising. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractionated heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused on epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.

[Hypothyroid coma and thyrotoxic crisis]

Two clinical cases of endocrinologic emergency are presented: myxedema coma and thyrotoxic crisis. These are very severe situations with a high mortality rate. In myxedema coma it reaches 50% and in thyrotoxic crisis the range is between 25 and 30%. These entities are not the always present in mind because of their rarity. Consequently, they may well be undiagnosed. In our cases, the myxedema coma was initially diagnosed as brainstem stroke, and the hyperthyroidism was taken for concealed malignant tumor. The management of both situations is briefly commented.

[A false incisional hernia during coumarin anticoagulation]

This short clinical report presents a case of giant pelvic hematoma with infiltration of the abdominal wall, initially misdiagnosed as incisional hernia by means of the old McBurney laparotomy. The patient, a 56-year-old female, was under chronic coumarin anticoagulation to prevent systemic embolism recurrence (rheumatic polyvalvular disease, atrial fibrillation, and previous brain embolism). On admission, the I.N.R. was 6.6. The risks versus benefits dilemma of chronic oral anticoagulation is briefly commented.

[The ventricular dysrhythmia profile in patients with mitral valve pathology]

OBJECTIVE

To study the relation between ventricular arrhythmias and echocardiographic left ventricular data, in patients with mitral valve pathology.

DESIGN

Retrospective study, based on Holter department data on ventricular arrhythmias.

POPULATION

We studied 128 patients: 36 were male, 92 were female. Their mean age was 52 +/- 11 years. Three groups were outlined: 54 patients had mitral stenosis (ME), 15 patients had mitral disease (MD) and 59 had associated aortic pathology (MA).

METHODS

Patients clinical records were reviewed according to an evaluating protocol. In each Holter recorded the number of premature ventricular contractions per hour (PVC/h), as well as the existence of complex ectopic forms (CF) was considered. Echocardiographic left ventricular data used was: diastolic diameter (DD), systolic diameter (DS) and shortening fraction (SF). Treatment was not significantly different between the three groups, when 24 hour monitoring was performed.

RESULTS

We found the average number of PVC/h to be 14 +/- 45 in the ME group, 58 +/- 85 in the MD group and 52 +/- 11 in the MA group. There is significant difference between ME and either DM, or MA. In patients with ME significant relations were found between the occurrence of CF a greater DS (p < 0.01) and a lesser SF (p = 0.02). No significance was found for the occurrence of PVC. In patients diagnosed as DM, the occurrence of PVC/h (> or = 10) was related with greater DD (p = 0.01) or DS (p = 0.04), but there was no relation to SF. Finally in the MA group PVC occurrence was strongly related (p < 0.01) with all the echocardiographic values and thinner relations were found towards SF (p = 0.02 for DD, p = 0.03 for DS and p = 0.05 for SF).

CONCLUSIONS

Ventricular arrhythmic occurrence is less frequent in ME. However, in the three groups, there is worsening left ventricular arrhythmic frequency in direct relation to greater ventricular dimensions, or compromised systolic function.

[Arterial hypertension in the elderly and renal function]

STUDY OBJECTIVE

to evaluate the effects of antihypertensive treatment on renal function, in an elderly population of 29 patients with arterial hypertension.

DESIGN

retrospective study of the first six months follow-up.

SETTING

outpatients clinic of arterial hypertension in the elderly at a central hospital.

PATIENTS AND METHODS

twenty nine elderly (> or = 65 years old) patients with a mean age of 71.8 +/- 5.6 years, with arterial hypertension (> or = 160/95 mmHg) submitted to antihypertensive treatment. Fourteen males and fifteen females. The systolic, diastolic and mean blood pressure was determined with a DINAMAP 1846, previously and at the first, third and sixth month of antihypertensive treatment (diuretic, calcium antagonists and angiotensin converting enzyme inhibitors). The serum creatinine was evaluated in the beginning of treatment and six months later. Means (+/- standard deviation) were compared with Student's t-test (statistically significant findings < 0.05).

MEASUREMENTS AND RESULTS

the initial mean arterial pressure was 127.0 +/- 17 mmHg; with the antihypertensive treatment, was 119.1 +/- 16 mmHg in the first month, 114.4 +/- 12 mmHg in the third and 117.6 +/- 12 mmHg in the sixth month. The serum creatinine was 1.26 +/- 0.75 mg/dl in the beginning of the study and the final result was 1.30 +/- 0.74 mg/dl (p-NS).

CONCLUSIONS

the antihypertensive treatment was effective in reducing the blood pressure, without a significant increase in serum creatinine.

[Arterial hypertension and ischemic cardiopathy]

Up update of the literature related with the relationship between arterial hypertension and ischemic heart disease is done. The epidermiological aspects, J-curve phenomenon, relationship between arterial hypertension and acute myocardial infarction and the consequences of left ventricular hypertrophy are analysed.

[Non-invasive evaluation of a population with WPW syndrome]

OBJECTIVE

Evaluation of a WPW Syndrome population by non invasive methods; identification of the sudden death risk; results of treatment and patient selection for Electrophysiologic Studies (EPS).

DESIGN

Retrospective study.

SETTING

Arrhythmology Outpatients Clinic from a Cardiac Department.

PATIENTS

Successive patients older than 12 years with a WPW pattern on the ECG and history of paroxysmal tachycardia followed-up for a period of 46 +/- 29 months.

MATERIAL AND METHODS

The clinical, ECG, Holter, stress test and echocardiographic data from 32 patients, were analysed. A study evaluating clinical follow up and the results of treatment was done.

RESULTS

The group of patients was very symptomatic. The main complaint was a feeling of tachycardia (84.4%). Orthodromic tachycardia was documented in 7 cases and atrial fibrillation with rapid ventricular rate in five. Intermittent delta wave pattern was found in 21 patients, with 11 cases identified by Holter and 4 by stress test. A predominant left accessory pathway was found (47%), but the anteroseptal location was frequent too (25%). The echocardiogram was not useful in any case. Eighty per cent of the patients became asymptomatic with medical treatment. Beta blockers and amiodarone (the last chance) were the most useful drugs. No mortality was found in the study group. EPS was considered for the 5 patients with paroxysmal atrial fibrillation and the 7 cases resistant to medical treatment.

CONCLUSIONS

The difficulty to define the risk of a population with WPW Syndrome by non invasive methods was demonstrated. Eighteen one cases were included in a low risk group, due to the intermittent WPW pattern in the ECG. A high risk group was considered for the 5 patients with atrial fibrillation with fast ventricular rate. The risk was not established in 9 cases. Most of the patients became asymptomatic by medical treatment.