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estes doentes apresentam frequentemente uma doen&#231;a latente do sistema de condu&#231;&#227;o&#44; existindo poucos dados relativos &#224; recorr&#234;ncia de bradidisrritimias nesta popula&#231;&#227;o e &#224; necessidade futura de implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#8208;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">De acordo com estudos pr&#233;vios&#44; cerca de 25&#37; das bradidisrritmias n&#227;o s&#227;o causadas pela terap&#234;utica&#44; mas&#44; sim&#44; reveladas por esta&#44; sendo os beta&#8208;bloqueantes os &#171;f&#225;rmacos <span class="elsevierStyleItalic">culprits</span>&#187; mais frequentes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As altera&#231;&#245;es metab&#243;licas&#44; nomeadamente as altera&#231;&#245;es i&#243;nicas&#44; apresentam na sua maioria um perfil benigno&#44; com maior percentagem de revers&#227;o da bradidisrritmia&#44; sendo por este motivo frequentemente exclu&#237;das de estudos em bradidisrritmias iatrog&#233;nicas&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">No presente estudo pretendemos avaliar a necessidade de implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo em internamento ou ap&#243;s a alta numa amostra de doentes com bradidisrritmia associada a iatrogenia medicamentosa ou a outra causa potencialmente revers&#237;vel&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Amostra</span><p id="par0030" class="elsevierStylePara elsevierViewall">A amostra deste estudo foi constitu&#237;da por 153 doentes consecutivos admitidos no servi&#231;o de urg&#234;ncia num per&#237;odo de seis anos&#44; entre 2010 e 2015&#44; com o diagn&#243;stico principal de bradidisrritmia sintom&#225;tica &#40;doen&#231;a do n&#243;dulo AV&#58; bloqueio auriculoventricular completo &#91;BAVC&#93; e bloqueio auriculoventricular de 2&#46;&#176; grau &#91;BAV2&#93;&#59; bradicardia sinusal &#91;BS&#93; e bradifibrilha&#231;&#227;o auricular &#91;BFA&#93;&#41;&#44; no contexto de iatrogenia medicamentosa e&#47;ou altera&#231;&#245;es metab&#243;licas&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vari&#225;veis</span><p id="par0035" class="elsevierStylePara elsevierViewall">A popula&#231;&#227;o do estudo foi caracterizada de acordo com as caracter&#237;sticas basais&#44; quadro cl&#237;nico&#44; tipo de bradidisrritmia&#44; terap&#234;utica de ambulat&#243;rio e altera&#231;&#245;es i&#243;nicas&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de BAV 2&#46;&#176; grau neste estudo corresponde especificamente &#224; condu&#231;&#227;o auricular 2&#58;1&#44; sem registo na nossa amostra de algum caso de bloqueio Mobitz tipo I ou II&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os doentes com FA e BAVC foram englobados no grupo do BAVC&#44; no grupo FA apenas foram inclu&#237;dos doentes com resposta ventricular lenta sem perturba&#231;&#227;o da condu&#231;&#227;o AV&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Na iatrogenia medicamentosa foram considerados os seguintes f&#225;rmacos&#58; beta&#8208;bloqueantes&#59; antagonistas dos canais de c&#225;lcio&#59; antiarr&#237;tmicos&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nas altera&#231;&#245;es metab&#243;licas&#44; apenas foi considerada a hipercaliemia&#44; sendo inclu&#237;dos no estudo doentes com n&#237;veis de pot&#225;ssio s&#233;rico &#62; 6&#46;5 mEq&#47;L&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Na avalia&#231;&#227;o do impacto da terap&#234;utica farmacol&#243;gica com a necessidade de PM&#44; a amiodarona foi agrupada &#224; digoxina de modo a conseguir uma amostra maior de antiarr&#237;tmicos quando comparado com o grupo dos beta&#8208;bloqueantes e tendo em conta a frequ&#234;ncia destes antiarr&#237;tmicos isolados e combinados na faixa et&#225;ria da popula&#231;&#227;o em estudo&#44; ao contr&#225;rio do sotalol e propafenona que s&#227;o menos frequentes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095"><span class="elsevierStyleItalic">Endpoint</span></span><p id="par0065" class="elsevierStylePara elsevierViewall">Com base na resposta &#224; suspens&#227;o do f&#225;rmaco e&#47;ou &#224; corre&#231;&#227;o i&#243;nica&#44; avali&#225;mos a percentagem de doentes em que houve necessidade de implanta&#231;&#227;o de PM no internamento ou durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; para a popula&#231;&#227;o total e para cada tipo de bradidisrritmia&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100"><span class="elsevierStyleItalic">Follow&#8208;up</span></span><p id="par0070" class="elsevierStylePara elsevierViewall">A dura&#231;&#227;o m&#233;dia do <span class="elsevierStyleItalic">follow&#8208;up</span> foi 24 &#177; 2 meses&#44; e durante este per&#237;odo foi avaliada a recorr&#234;ncia de bradidisrritmia clinicamente significativa e sintom&#225;tica&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">An&#225;lise estat&#237;stica</span><p id="par0075" class="elsevierStylePara elsevierViewall">Para realizar a an&#225;lise estat&#237;stica utilizou&#8208;se o programa <span class="elsevierStyleItalic">IBM SPSS Statistics vers&#227;o 20</span> para <span class="elsevierStyleItalic">Windows 8&#46;</span> As vari&#225;veis cont&#237;nuas foram expressas em valor m&#233;dio &#177; desvio&#8208;padr&#227;o e comparadas com o <span class="elsevierStyleItalic">test T&#8208;Student&#769;s&#46;</span> As vari&#225;veis categ&#243;ricas foram expressas em valor absoluto e&#47;ou percentagem e comparadas com o teste qui&#8208;quadrado&#46; As associa&#231;&#245;es foram consideradas estatisticamente significativas na presen&#231;a de p&#8208;value &#60; 0&#44;05&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><p id="par0080" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas basais da popula&#231;&#227;o total e de acordo com o tipo de bradidisrritmia s&#227;o apresentadas nas <a class="elsevierStyleCrossRefs" href="#tbl0005">tabelas 1 e 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Estudaram&#8208;se 153 doentes com idade m&#233;dia de 82 &#177; 11 anos&#44; sendo 47&#37; &#40;n &#61; 72&#41; do sexo masculino&#46; Cerca de 63&#37; &#40;n &#61; 97&#41; dos doentes apresentavam BAVC&#44; 16&#37; &#40;n &#61; 24&#41; Bradicardia sinusal&#44; 12&#37; &#40;n &#61; 18&#41; BAV 2&#46;&#176; grau e 9&#37; &#40;n &#61; 14&#41; Bradifibrilha&#231;&#227;o auricular&#46; A apresenta&#231;&#227;o cl&#237;nica mais frequente foi s&#237;ncope&#44; presente em 42&#37; &#40;n &#61; 64&#41; dos doentes&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A etiologia potencialmente revers&#237;vel associada &#224;s altera&#231;&#245;es eletrocardiogr&#225;ficas em 85&#37; &#40;n &#61; 130&#41; dos doentes foi atribu&#237;da &#224; terap&#234;utica farmacol&#243;gica&#59; em 12&#37; &#40;n &#61; 19&#41; terap&#234;utica farmacol&#243;gica associada a altera&#231;&#245;es i&#243;nicas e 3&#37; &#40;n &#61; 4&#41; a altera&#231;&#245;es i&#243;nicas isoladas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Dos doentes com iatrogenia medicamentosa isolada&#44; 38&#37; &#40;n &#61;49&#41; dos doentes encontrava&#8208;se sob terap&#234;utica beta&#8208;bloqueante&#44; 15&#37; &#40;n &#61; 20&#41; sob amiodarona&#44; 12&#37; &#40;n &#61; 16&#41; sob antagonistas dos canais de c&#225;lcio&#44; 5&#37; &#40;n &#61; 6&#41; sob digoxina&#59; 2&#37; &#40;n &#61; 2&#41; sob sotalol&#44; 3&#37; &#40;n &#61; 4&#41; sob propafenona e&#44; por sua vez&#44; 25&#37; &#40;n &#61; 33&#41; sob terap&#234;utica dupla ou tripla &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A implanta&#231;&#227;o de PM foi necess&#225;ria em 55&#37; &#40;n &#61; 84&#41; da popula&#231;&#227;o&#44; sendo que em 40&#37; dos doentes &#40;n &#61; 61&#41; este foi implantado no primeiro internamento&#46; Cerca de 15&#37; &#40;n &#61; 23&#41; da popula&#231;&#227;o apresentou revers&#227;o da bradidisrritmia ap&#243;s a suspens&#227;o do f&#225;rmaco&#47;corre&#231;&#227;o i&#243;nica&#44; contudo&#44; ao fim de um tempo mediano de 18 meses&#44; os doentes apresentaram novo epis&#243;dio de bradidisrritmia&#44; sem uma aparente etiologia revers&#237;vel e com necessidade de implanta&#231;&#227;o PM&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Dos doentes submetidos a implanta&#231;&#227;o de PM&#44; o BAVC foi o tipo de bradidisrritmia mais frequente&#44; presente em 77&#37; &#40;n &#61; 65&#41; destes doentes&#44; seguindo&#8208;se o BAV 2&#46;&#176; grau em 17&#37; &#40;n &#61; 14&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Cerca de 62&#37; &#40;n &#61; 81&#41; dos doentes sob terap&#234;utica farmacol&#243;gica&#44; apesar da suspens&#227;o da terap&#234;utica apresentaram necessidade de implanta&#231;&#227;o PM&#46; A terap&#234;utica farmacol&#243;gica isolada esteve associada a menor reversibilidade da bradidisrritmia&#44; com significado estat&#237;stico&#44; quando comparada com as restantes causas potencialmente revers&#237;veis &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Quarenta e seis por cento dos doentes estava medicado com um beta&#8208;bloqueante&#44; 24&#37; faziam amiodarona e&#47;ou digoxina e 12&#37; estavam sob antagonistas dos canais de c&#225;lcio&#44; contudo sem significado estat&#237;stico &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A necessidade de PM provis&#243;rio ocorreu em 28&#37; &#40;n &#61; 43&#41; da popula&#231;&#227;o&#44; sobretudo em contexto de BAVC&#44; destes 53&#37; &#40;n &#61; 23&#41; apresentou indica&#231;&#227;o para PM definitivo&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Doentes com revers&#227;o da bradidisrritmia e sem necessidade de PM apresentaram significativamente mais insufici&#234;ncia renal &#40;24 <span class="elsevierStyleItalic">versus</span> 5&#59; p &#60; 0&#44;001&#41;&#46; Dos doentes sem necessidade de PM a grande maioria tinha HTA &#40;hipertens&#227;o arterial&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Quatro doentes morreram&#44; sendo que tr&#234;s doentes faleceram previamente &#224; implanta&#231;&#227;o de PM no internamento e um doente faleceu no internamento ap&#243;s implanta&#231;&#227;o do PM&#46; N&#227;o houve qualquer registo de morte nos doentes ap&#243;s a alta sem PM&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discuss&#227;o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Nesta popula&#231;&#227;o&#44; a maioria dos doentes apresentou necessidade de implanta&#231;&#227;o de PM ap&#243;s a suspens&#227;o&#47;corre&#231;&#227;o da potencial causa revers&#237;vel&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A propor&#231;&#227;o de doentes que descontinua a terap&#234;utica e que requer a implanta&#231;&#227;o de PM &#233; desconhecida e o progn&#243;stico destes doentes ap&#243;s a alta sem PM &#233; igualmente desconhecido&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Em rela&#231;&#227;o &#224;s altera&#231;&#245;es metab&#243;licas a informa&#231;&#227;o &#233; escassa&#44; tendo em conta o aparente perfil benigno s&#227;o exclu&#237;das da maioria dos estudos de bradidisrritmias iatrog&#233;nicas&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As altera&#231;&#245;es i&#243;nicas isoladas&#44; apesar do n&#250;mero reduzido de doentes com hipercaliemia estiveram em 75&#37; dos casos associadas a uma verdadeira bradidisrritmia iatrog&#233;nica com normaliza&#231;&#227;o do ritmo ap&#243;s a corre&#231;&#227;o da altera&#231;&#227;o&#44; sendo que apenas um doente apresentou necessidade de PM&#44; o que &#233; favor do seu car&#225;cter mais benigno&#46; Por sua vez&#44; 96&#37; &#40;n &#61; 81&#41; dos doentes que necessitaram de PM estavam sob terap&#234;utica farmacol&#243;gica&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Cerca de 25&#37; de doentes com bradidisrritmia induzida pela terap&#234;utica&#44; a disritmia n&#227;o &#233; causada pela terap&#234;utica mas&#44; sim&#44; revelada por esta&#44; sendo os beta&#8208;bloqueantes os principais &#171;f&#225;rmacos <span class="elsevierStyleItalic">culprits</span>&#187;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Zelter&#44; <span class="elsevierStyleItalic">et al&#46;</span> demonstraram que 56&#37; dos doentes com resolu&#231;&#227;o inicial do BAV ap&#243;s suspens&#227;o da terap&#234;utica apresentaram recorr&#234;ncia da bradidisrritmia e Knudsen&#44; <span class="elsevierStyleItalic">et al&#46;</span> retiraram a mesma conclus&#227;o em 25&#37; dos seus doentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;6</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Nesta popula&#231;&#227;o&#44; 25&#37; dos doentes que tiveram alta sem PM&#44; por aparente resolu&#231;&#227;o da bradidisrritmia&#44; apresentaram recorr&#234;ncia das altera&#231;&#245;es eletrocardiogr&#225;ficas com necessidade de PM durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">De acordo com a literatura&#44; f&#225;rmacos em doses terap&#234;uticas&#44; geralmente n&#227;o causam bradicardia significativa em doentes sem patologia card&#237;aca estrutural&#44; no entanto&#44; na presen&#231;a de doen&#231;a latente do n&#243;dulo sinusal e&#47;ou n&#243;dulo AV&#44; a terap&#234;utica farmacol&#243;gica pode ser o <span class="elsevierStyleItalic">trigger</span> para induzir a bradidisrritmia&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#8208;6</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Apesar de sem significado estat&#237;stico&#44; os beta&#8208;bloqueantes foram os f&#225;rmacos com menor reversibilidade da bradidisrritmia ap&#243;s a sua suspens&#227;o quando comparados com os antiarr&#237;tmicos&#44; o que foi igualmente evidenciado em outros estudos publicados&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2&#44;5</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Apesar da idade avan&#231;ada e antecedentes de cardiopatia isqu&#233;mica serem considerados preditores de risco pr&#243;&#8208;arr&#237;tmico&#44; nesta popula&#231;&#227;o este grupo de doentes n&#227;o apresentou maior taxa de implanta&#231;&#227;o de PM&#44; embora a idade m&#233;dia da popula&#231;&#227;o seja superior a 65 anos e 26&#37; tenha doen&#231;a coron&#225;ria&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">A bradidisrritmia no contexto de fibrilha&#231;&#227;o auricular &#233; relativamente frequente&#44; por sua vez&#44; a necessidade de PM&#44; de acordo com alguns estudos&#44; &#233; de 1&#44;4&#37; nos doentes sob amiodarona e 2&#44;5&#37; sob sotalol&#46; Israel&#44; <span class="elsevierStyleItalic">et al&#46;</span> mostraram que em 78 doentes com dupla cam&#226;ra com adapta&#231;&#227;o de frequ&#234;ncia card&#237;aca &#40;DDDR&#41; implantado no contexto de bradicardia sintom&#225;tica e FA parox&#237;stica&#47;permanente&#44; a bradicardia foi induzida por f&#225;rmacos em 33&#37; dos doentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;5</span></a> No nosso estudo&#44; apenas dois doentes&#44; ap&#243;s suspens&#227;o&#47;corre&#231;&#227;o da potencial causa revers&#237;vel&#44; apresentaram necessidade de PM&#44; o que &#233; a favor de um perfil com maior benignidade&#44; logo&#44; mais reversibilidade da bradifibrilha&#231;&#227;o auricular&#44; quando comparada com a doen&#231;a do n&#243;dulo AV&#46; Nenhum dos doentes com bradifibrilha&#231;&#227;o auricular que teve alta sem PM apresentou ao longo do <span class="elsevierStyleItalic">follow&#8208;up</span> novo epis&#243;dio de disritmia com necessidade de PM&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">A doen&#231;a do n&#243;dulo AV &#40;BAVC e BAV 2&#46;&#176; grau&#41; apresentou menor reversibilidade&#44; sendo necess&#225;ria implanta&#231;&#227;o de PM em 55&#37; &#40;n &#61; 79&#41; dos doentes&#46; Cerca de 37&#37; &#40;n &#61; 21&#41; dos doentes com doen&#231;a do n&#243;dulo AV que tiveram alta sem PM apresentaram recorr&#234;ncia da disrritmia no <span class="elsevierStyleItalic">follow&#8208;up</span>&#46; Esta informa&#231;&#227;o coloca uma quest&#227;o pertinente&#58; devemos ponderar a implanta&#231;&#227;o PM logo ap&#243;s o primeiro epis&#243;dio desta disritmia&#63; Esta &#233; uma quest&#227;o com que v&#225;rios autores se depararam e para a qual ainda n&#227;o h&#225; uma resposta exata&#46; V&#225;rios estudos evidenciam que a doen&#231;a do n&#243;dulo AV n&#227;o surge em cora&#231;&#245;es normais&#44; quando surge&#44; mesmo que induzida pela terap&#234;utica&#44; est&#225; associada a doen&#231;a latente do sistema de condu&#231;&#227;o&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">No presente estudo&#44; a grande maioria dos doentes com insufici&#234;ncia renal apresentou revers&#227;o da bradidisrritmia e&#44; consequentemente&#44; n&#227;o teve necessidade de implanta&#231;&#227;o de PM&#46; De acordo com a literatura&#44; a necessidade de PM &#233; mais frequente nos doentes com insufici&#234;ncia renal cr&#243;nica do que na popula&#231;&#227;o em geral&#46; O aumento de dist&#250;rbios da condu&#231;&#227;o AV em doentes com insufici&#234;ncia renal cr&#243;nica avan&#231;ada pode n&#227;o ser apenas consequ&#234;ncia da hipercaliemia&#44; mas por outros fatores como altera&#231;&#245;es no metabolismo do c&#225;lcio&#44; levando a fibrose e calcifica&#231;&#227;o das vias de condu&#231;&#227;o&#47;mioc&#225;rdio&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Provavelmente&#44; a gravidade da insufici&#234;ncia renal na nossa popula&#231;&#227;o era menor&#44; existindo revers&#227;o da bradidisrritmia apenas com corre&#231;&#227;o da iatrogenia &#40;metab&#243;lica e&#47;ou farmacol&#243;gica&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A HTA &#233; uma comorbilidade cardiovascular frequente na popula&#231;&#227;o geral&#44; bem como no nosso estudo&#46; A HTA de acordo com a gravidade e dura&#231;&#227;o induz <span class="elsevierStyleItalic">remodelling</span> card&#237;aco&#44; o que pode interferir com a atividade el&#233;trica&#44; sendo frequente as disritmias&#44; sobretudo supraventriculares e ventriculares&#46; Os estudos multic&#234;ntricos referentes a altera&#231;&#245;es na condu&#231;&#227;o AV s&#227;o raros&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">A instabilidade hemodin&#226;mica e a consequente necessidade de PM provis&#243;rio n&#227;o foram associadas significativamente a maior necessidade de implanta&#231;&#227;o de PM definitivo&#44; provavelmente na presen&#231;a de uma amostra maior mais conclus&#245;es poderiam ser obtidas&#46; Nesta popula&#231;&#227;o a instabilidade hemodin&#226;mica n&#227;o foi associada &#224; perman&#234;ncia da bradidisrritmia&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Os tr&#234;s doentes que faleceram no internamento&#44; perante a instabilidade hemodin&#226;mica tiveram necessidade de PM provis&#243;rio&#44; contudo sem uma resposta eficaz e a morte n&#227;o foi considerada complica&#231;&#227;o deste procedimento&#46; Estes doentes apresentavam uma idade avan&#231;ada &#40;&#62; 80 anos&#41; e consequentemente diversas comorbilidades associadas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Apesar da recorr&#234;ncia de bradidisritmia&#44; a aus&#234;ncia de mortalidade cardiovascular no <span class="elsevierStyleItalic">follow&#8208;up</span> transmite alguma seguran&#231;a em rela&#231;&#227;o &#224; atual pr&#225;tica cl&#237;nica&#44; em que a maioria dos doentes ap&#243;s resolvida a aparente iatrogenia tem alta sem PM definitivo&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limita&#231;&#245;es</span><p id="par0215" class="elsevierStylePara elsevierViewall">A natureza retrospetiva do estudo e a reduzida dimens&#227;o da amostra constituem as principais limita&#231;&#245;es do estudo&#46; Por sua vez&#44; o per&#237;odo relativamente curto de <span class="elsevierStyleItalic">follow&#8208;up</span> pode subestimar a frequ&#234;ncia de bradicardia&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">N&#227;o foi poss&#237;vel avaliar para todos os doentes a dosagem de cada f&#225;rmaco associado &#224; bradidisrritmia&#44; por falta desse registo na admiss&#227;o dos doentes&#44; bem como a informa&#231;&#227;o referente ao ritmo de escape e largura do QRS&#46; Esta &#250;ltima caracter&#237;stica cl&#237;nica tamb&#233;m n&#227;o foi poss&#237;vel caracterizar pela aus&#234;ncia de ECG &#40;eletrocardiograma&#41; digitalizados no per&#237;odo temporal do estudo&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Os doentes n&#227;o foram avaliados com monitoriza&#231;&#227;o de ambulat&#243;rio de 24<span class="elsevierStyleHsp" style=""></span>h &#40;Holter&#41;&#46; Os doentes podiam apresentar bradicardias assintom&#225;ticas ou bloqueios auriculoventriculares que poderiam ser identificados no Holter&#46; No estudo apenas avali&#225;mos as bradicardias sintom&#225;ticas com indica&#231;&#227;o para PM definitivo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclus&#245;es</span><p id="par0230" class="elsevierStylePara elsevierViewall">Em doentes admitidos com bradidisrritmia associada a uma causa potencialmente revers&#237;vel&#44; principalmente no contexto de iatrogenia farmacol&#243;gica&#44; elevada percentagem de doentes apresenta persist&#234;ncia ou recorr&#234;ncia do quadro com necessidade de coloca&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Os doentes com iatrogenia associada a doen&#231;a do nodulo AV constituem um subgrupo de doentes com risco de recorr&#234;ncia mais elevado&#44; necessitando de maior vigil&#226;ncia durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; devendo&#8208;se ponderar nestes doentes a coloca&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo no primeiro epis&#243;dio&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflitos de interesse</span><p id="par0240" class="elsevierStylePara elsevierViewall">Os autores n&#227;o declaram conflitos de interesse&#46;</p></span></span>"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Na bradidisrritmia &#40;BD&#41;&#44; associada a iatrogenia medicamentosa ou potenciais causas revers&#237;veis&#44; est&#225; recomendada a suspens&#227;o ou corre&#231;&#227;o das mesmas&#44; antes da implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span> definitivo &#40;PM&#41;&#46; No entanto&#44; estes doentes &#40;dts&#41; apresentam frequentemente doen&#231;a do sistema de condu&#231;&#227;o&#44; existindo poucos dados relativos &#224; recorr&#234;ncia de BD e &#224; necessidade futura de PM&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avalia&#231;&#227;o da necessidade de coloca&#231;&#227;o de PM em dts com BD iatrog&#233;nica ou associada a outra causa potencialmente revers&#237;vel&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram avaliados dts consecutivos sintom&#225;ticos admitidos no servi&#231;o de urg&#234;ncia com o diagn&#243;stico de BD &#40;Doen&#231;a do n&#243;dulo AV &#8211; bloqueio auriculoventricular e bloqueio auriculoventricular 2&#46;&#176; grau &#40;2&#58;1&#41;&#59; Bradicardia Sinusal &#40;BS&#41; e Bradifibrilha&#231;&#227;o auricular &#40;BFA&#41;&#41; no contexto de iatrogenia medicamentosa ou altera&#231;&#245;es metab&#243;licas&#46; Foi avaliada a percentagem de dts com necessidade de coloca&#231;&#227;o de PM&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Estudaram&#8208;se 153 dts &#40;47&#37; sexo masculino&#41; admitidos com BS 16&#37;&#59; bloqueio auriculoventricular 63&#37;&#59; bloqueio auriculoventricular 2&#46;&#176; grau 12&#37;&#59; BFA 10&#37;&#46; Verificou&#8208;se iatrogenia medicamentosa em 85&#37; dos dts&#44; hipercaliemia em 3&#37; e etiologia combinada em 12&#37;&#46; Ap&#243;s suspens&#227;o da &#171;iatrogenia&#187;&#44; 55&#37; dos dts &#40;n &#61; 84&#41; colocou PM&#44; sendo o bloqueio auriculoventricular o tipo de bradidisrritmia mais frequente&#44; presente em 77&#37; &#40;n &#61; 65&#41; destes doentes&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclus&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Em dts admitidos com BD associada a uma potencial causa revers&#237;vel&#44; elevada percentagem de dts apresentam persist&#234;ncia ou recorr&#234;ncia do quadro com necessidade de PM&#46; Os dts com iatrogenia associada a doen&#231;a do n&#243;dulo AV constituem um subgrupo com risco de recorr&#234;ncia mais elevado&#44; necessitando de maior vigil&#226;ncia durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; devendo&#8208;se ponderar PM no primeiro epis&#243;dio&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In iatrogenic or potentially reversible bradyarrhythmia&#44; drug discontinuation or metabolic correction is recommended before permanent cardiac pacemaker &#40;PM&#41; implantation&#46; These patients often have conduction system disease and there are few data on recurrence or the need for a permanent PM&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">To analyze the need for PM implantation in patients with iatrogenic bradyarrhythmia or bradyarrhythmia associated with other potentially reversible causes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">We assessed consecutive symptomatic patients admitted to the emergency department with a primary diagnosis of bradyarrhythmia &#40;atrioventricular &#91;AV&#93; node disease &#8211; complete or second&#8208;degree AV block &#40;AVB&#41; &#91;CAVB&#58; 2nd&#8208;degree AVB &#8211; 2&#58;1&#93;&#44; sinus bradycardia &#91;SB&#93; and atrial fibrillation &#91;AF&#93; with slow ventricular response &#91;SVR&#93;&#41; in the context of iatrogenic causes or metabolic abnormalities&#46; We determined the percentage of patients who required PM implantation&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">We studied 153 patients &#40;47&#37; male&#41; admitted for iatrogenic or potentially reversible bradyarrhythmia&#46; Diagnoses were SB 16&#37;&#44; CAVB 63&#37;&#44; second&#8208;degree AVB 12&#37;&#44; and AF with SVR 10&#37;&#46; Eighty&#8208;five percent of patients were under negative chronotropic therapy&#44; 3&#37; had hyperkalemia and 12&#37; had a combined etiology&#46; After correction of the cause&#44; 55&#37; of patients &#40;n&#61;84&#41; needed a PM&#46; In these patients the most common type of bradyarrhythmia was CAVB&#44; in 77&#37; &#40;n&#61;65&#41; patients&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">In a high percentage of patients with bradyarrhythmia associated with a potentially reversible cause&#44; the arrhythmia recurs or does not resolve during follow&#8208;up&#46; Patients with AV node disease constitute a subgroup with a higher risk of recurrence who require greater vigilance during follow&#8208;up and should be considered for PM implantation after the first episode&#46;</p></span>"
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagrama&#58; Descri&#231;&#227;o da popula&#231;&#227;o com bradidisrritmia iatrog&#233;nica de acordo com a etiologia e a resposta &#224; suspens&#227;o da causa potencialmente revers&#237;vel&#46; PM&#58; <span class="elsevierStyleItalic">pacemaker</span> definitivo&#46;</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">BS&#58; bradicardia sinusal&#59; BAVC&#58; bloqueio auriculoventricular completo&#59; BFA&#58; bradifibrilha&#231;&#227;o auricular&#59; HTA&#58; hipertens&#227;o arterial&#59; DRC&#58; doen&#231;a renal cr&#243;nica&#59; PM&#58; <span class="elsevierStyleItalic">pacemaker</span>&#59; ACC&#58; antagonista dos canais de c&#225;lcio&#59; BB&#58; beta&#8208;bloqueantes&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Popula&#231;&#227;o &#40;n &#61; 153&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BS &#40;n &#61; 24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BAVC &#40;n &#61; 97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BAV 2&#46;&#176; grau &#40;n &#61; 18&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BFA &#40;n &#61; 14&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Idade &#40;anos&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">80 &#177; 12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84 &#177; 10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">78 &#177; 13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47&#37; &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&#37; &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44&#37; &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#37; &#40;n &#61; 9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes Pessoais</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiopatia Isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia card&#237;aca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#37; &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HTA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">92&#37; &#40;141&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">92&#37; &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93&#37; &#40;90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89&#37; &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93&#37; &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes <span class="elsevierStyleItalic">mellitus</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ncope&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tonturas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prosta&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cansa&#231;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mal&#8208;estar inespec&#237;fico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dor precordial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dispneia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Morte Intra&#8208;hospitalar</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pr&#233;&#8208; PM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ap&#243;s PM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necessidade de pm provis&#243;rio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Digoxina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Propafenona&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; sotalol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#37; &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; propafenona&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; AA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#37; &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#37; &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; digoxina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; ACC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#37; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; AA &#43; digoxina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACC &#43; sotalol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Digoxina &#43; AA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&#37; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BB &#43; ACC &#43; digoxina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACC &#43; AA &#43; digoxina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Altera&#231;&#245;es I&#243;nicas</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipercaliemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Terap&#234;utica &#43; altera&#231;&#245;es i&#243;nicas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PM internamento &#40;n &#61; 61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sem necessidade PM &#40;n &#61; 92&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&#8208;<span class="elsevierStyleItalic">value</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PM total &#40;n &#61; 84&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sem necessidade PM &#40;n &#61; 69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sexo Masculino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49&#37; &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#37; &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49&#37; &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45&#37; &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiopatia isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#37; &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#37; &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#37; &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#37; &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia card&#237;aca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#37; &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#37; &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HTA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#37; &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#37; &#40;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#37; &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#37; &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes <span class="elsevierStyleItalic">mellitus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#37; &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#37; &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#37; &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#37; &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#37; &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#37; &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#37; &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#37; &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia renal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#37; &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#37; &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#37; &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necessidade de PM provis&#243;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#37; &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#37; &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#37; &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bradicardia sinusal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#37; &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#37; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BAV completo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">77&#37; &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#37; &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BAV 2&#46;&#176; grau &#40;2&#58;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#37; &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">8&#37; &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">17&#37; &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">6&#37; &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bradifibrilha&#231;&#227;o auricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#37; &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#37; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#37; &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F&#225;rmacos &#43; altera&#231;&#227;o i&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Altera&#231;&#245;es i&#243;nicas &#40;hipercaliemia&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PM internamento&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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Partilhar
Informação da revista
Vol. 38. Núm. 2.
Páginas 105-111 (fevereiro 2019)
Visitas
6235
Vol. 38. Núm. 2.
Páginas 105-111 (fevereiro 2019)
Artigo Original
Open Access
Bradidisrritmia puramente iatrogénica…existe?
Permanent cardiac pacing for patients with iatrogenic or potentially reversible bradyarrhythmia
Visitas
6235
Tatiana Duarte
Autor para correspondência
tatiana.isabel.duarte@gmail.com

Autor para correspondência.
, Sara Gonçalves, Catarina Sá, Rita Marinheiro, Marta Fonseca, José Farinha, Rita Rodrigues, Filipe Seixo, Leonor Parreira, Rui Caria
Serviço de Cardiologia, Centro Hospitalar de Setúbal, Setúbal, Portugal
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Rev Port Cardiol. 2019;38:113-510.1016/j.repc.2019.02.004
Sérgio Barra
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Introdução

Na bradidisrritmia (BD), associada a iatrogenia medicamentosa ou potenciais causas reversíveis, está recomendada a suspensão ou correção das mesmas, antes da implantação de pacemaker definitivo (PM). No entanto, estes doentes (dts) apresentam frequentemente doença do sistema de condução, existindo poucos dados relativos à recorrência de BD e à necessidade futura de PM.

Objetivo

Avaliação da necessidade de colocação de PM em dts com BD iatrogénica ou associada a outra causa potencialmente reversível.

Métodos

Foram avaliados dts consecutivos sintomáticos admitidos no serviço de urgência com o diagnóstico de BD (Doença do nódulo AV – bloqueio auriculoventricular e bloqueio auriculoventricular 2.° grau (2:1); Bradicardia Sinusal (BS) e Bradifibrilhação auricular (BFA)) no contexto de iatrogenia medicamentosa ou alterações metabólicas. Foi avaliada a percentagem de dts com necessidade de colocação de PM.

Resultados

Estudaram‐se 153 dts (47% sexo masculino) admitidos com BS 16%; bloqueio auriculoventricular 63%; bloqueio auriculoventricular 2.° grau 12%; BFA 10%. Verificou‐se iatrogenia medicamentosa em 85% dos dts, hipercaliemia em 3% e etiologia combinada em 12%. Após suspensão da «iatrogenia», 55% dos dts (n = 84) colocou PM, sendo o bloqueio auriculoventricular o tipo de bradidisrritmia mais frequente, presente em 77% (n = 65) destes doentes.

Conclusão

Em dts admitidos com BD associada a uma potencial causa reversível, elevada percentagem de dts apresentam persistência ou recorrência do quadro com necessidade de PM. Os dts com iatrogenia associada a doença do nódulo AV constituem um subgrupo com risco de recorrência mais elevado, necessitando de maior vigilância durante o follow‐up, devendo‐se ponderar PM no primeiro episódio.

Palavras‐chave:
Bradidisrritmia iatrogénica
Pacemaker definitivo
Abstract
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.

Keywords:
Iatrogenic bradyarrhythmia
Permanent cardiac pacing
Texto Completo
Introdução

A bradidisrritmia, no contexto de iatrogenia medicamentosa ou de potenciais causas reversíveis é uma situação clínica comum, contudo deficientemente caracterizada.1 De acordo com as atuais Guidelines, está recomendada a suspensão ou correção da potencial causa reversível, antes da implantação de pacemaker definitivo.2,3

No entanto, estes doentes apresentam frequentemente uma doença latente do sistema de condução, existindo poucos dados relativos à recorrência de bradidisrritimias nesta população e à necessidade futura de implantação de pacemaker.4‐6

De acordo com estudos prévios, cerca de 25% das bradidisrritmias não são causadas pela terapêutica, mas, sim, reveladas por esta, sendo os beta‐bloqueantes os «fármacos culprits» mais frequentes.4

As alterações metabólicas, nomeadamente as alterações iónicas, apresentam na sua maioria um perfil benigno, com maior percentagem de reversão da bradidisrritmia, sendo por este motivo frequentemente excluídas de estudos em bradidisrritmias iatrogénicas.5

No presente estudo pretendemos avaliar a necessidade de implantação de pacemaker definitivo em internamento ou após a alta numa amostra de doentes com bradidisrritmia associada a iatrogenia medicamentosa ou a outra causa potencialmente reversível.

MétodosAmostra

A amostra deste estudo foi constituída por 153 doentes consecutivos admitidos no serviço de urgência num período de seis anos, entre 2010 e 2015, com o diagnóstico principal de bradidisrritmia sintomática (doença do nódulo AV: bloqueio auriculoventricular completo [BAVC] e bloqueio auriculoventricular de 2.° grau [BAV2]; bradicardia sinusal [BS] e bradifibrilhação auricular [BFA]), no contexto de iatrogenia medicamentosa e/ou alterações metabólicas.

Variáveis

A população do estudo foi caracterizada de acordo com as características basais, quadro clínico, tipo de bradidisrritmia, terapêutica de ambulatório e alterações iónicas.

O diagnóstico de BAV 2.° grau neste estudo corresponde especificamente à condução auricular 2:1, sem registo na nossa amostra de algum caso de bloqueio Mobitz tipo I ou II.

Os doentes com FA e BAVC foram englobados no grupo do BAVC, no grupo FA apenas foram incluídos doentes com resposta ventricular lenta sem perturbação da condução AV.

Na iatrogenia medicamentosa foram considerados os seguintes fármacos: beta‐bloqueantes; antagonistas dos canais de cálcio; antiarrítmicos.

Nas alterações metabólicas, apenas foi considerada a hipercaliemia, sendo incluídos no estudo doentes com níveis de potássio sérico > 6.5 mEq/L.

Na avaliação do impacto da terapêutica farmacológica com a necessidade de PM, a amiodarona foi agrupada à digoxina de modo a conseguir uma amostra maior de antiarrítmicos quando comparado com o grupo dos beta‐bloqueantes e tendo em conta a frequência destes antiarrítmicos isolados e combinados na faixa etária da população em estudo, ao contrário do sotalol e propafenona que são menos frequentes.

Endpoint

Com base na resposta à suspensão do fármaco e/ou à correção iónica, avaliámos a percentagem de doentes em que houve necessidade de implantação de PM no internamento ou durante o follow‐up, para a população total e para cada tipo de bradidisrritmia.

Follow‐up

A duração média do follow‐up foi 24 ± 2 meses, e durante este período foi avaliada a recorrência de bradidisrritmia clinicamente significativa e sintomática.

Análise estatística

Para realizar a análise estatística utilizou‐se o programa IBM SPSS Statistics versão 20 para Windows 8. As variáveis contínuas foram expressas em valor médio ± desvio‐padrão e comparadas com o test T‐Student́s. As variáveis categóricas foram expressas em valor absoluto e/ou percentagem e comparadas com o teste qui‐quadrado. As associações foram consideradas estatisticamente significativas na presença de p‐value < 0,05.

Resultados

As características basais da população total e de acordo com o tipo de bradidisrritmia são apresentadas nas tabelas 1 e 2.

Tabela 1.

Características basais da população total e de acordo com o tipo de bradidisrritmia

  População (n = 153)  BS (n = 24)  BAVC (n = 97)  BAV 2.° grau (n = 18)  BFA (n = 14) 
Características Basais
Idade (anos)  82 ± 11  80 ± 12  84 ± 10  78 ± 13  82 ± 7 
Sexo masculino  47% (72)  42% (10)  44% (43)  61% (11)  64% (n = 9) 
Antecedentes Pessoais
Cardiopatia Isquémica  26% (39)  8% (2)  27% (26)  22% (4)  50% (7) 
Insuficiência cardíaca  9% (13)  17% (4)  6% (6)  21% (3) 
HTA  92% (141)  92% (22)  93% (90)  89% (16)  93% (13) 
Diabetes mellitus  29% (44)  17% (4)  32% (31)  28% (5)  29% (4) 
Dislipidemia  41% (62)  38% (9)  40% (37)  44% (8)  43% (6) 
DRC  19% (29)  25% (6)  18% (17)  11% (2)  29% (4) 
Sintomas
Síncope  43% (66)  33% (8)  52% (50)  39% (7)  7% (1) 
Tonturas  39% (25)  21% (5)  23% (22)  28% (5)  50% (7) 
Prostação  10% (16)  13% (3)  8% (8)  1% (1)  21% (3) 
Cansaço  20% (30)  21% (5)  14% (14)  4% (4)  7% (1) 
Mal‐estar inespecífico  1% (2)  1% (1)  14% (2) 
Dor precordial  2% (3)  4% (1)  6% (1)  7% (1) 
Dispneia  2% (3)  4% (1)  2% (2) 
Morte Intra‐hospitalar
Pré‐ PM  2% (3)  3% (3) 
Após PM  0,6% (1)  1%(1) 
Necessidade de pm provisório  28% (43)  4% (1)  42% (41)  5% (1) 
Terapêutica
BB  32% (49)  17% (4)  35% (34)  44% (8)  21% (3) 
ACC  10% (16)  8% (2)  9% (9)  22% (4) 
AA  13% (20)  13% (3)  13% (13)  22% (4) 
Digoxina  4% (6)  8% (2)  3% (3)  7% (1) 
Sotalol  1% (2)  2% (2) 
Propafenona  3% (4)  4% (1)  2% (2)  6% (1) 
BB + sotalol  5% (7)  4% (1)  4% (4)  14% (2) 
BB + propafenona  2% (3)  2% (2)  7% (1) 
BB + AA  7% (10)  17% (4)  5% (5)  7% (1) 
BB + digoxina  1% (2)  1% (1) 
BB + ACC  2% (3)  4% (1)  2% (2) 
BB + AA + digoxina  0,6% (1)  1% (1) 
ACC + sotalol  0,6% (1)  1% (1) 
Digoxina + AA  3% (4)  1% (1)  21% (3) 
BB + ACC + digoxina  0,6% (1)  7% (1) 
ACC + AA + digoxina  0,6% (1)  7% (1) 
Alterações Iónicas
Hipercaliemia  3% (4)  3% (3)  6% (1) 
Etiologia Combinada
Terapêutica + alterações iónicas  12% (19)  25% (6)  12% (12)  7% (1) 

BS: bradicardia sinusal; BAVC: bloqueio auriculoventricular completo; BFA: bradifibrilhação auricular; HTA: hipertensão arterial; DRC: doença renal crónica; PM: pacemaker; ACC: antagonista dos canais de cálcio; BB: beta‐bloqueantes.

Tabela 2.

Características basais de acordo com a implantação de pacemaker

  PM internamento (n = 61)  Sem necessidade PM (n = 92)  p‐value  PM total (n = 84)  Sem necessidade PM (n = 69)  p‐value 
Características Basais
Idade (anos)  82 ± 12  82 ± 10  ns  82 ± 11  82 ± 10  ns 
Sexo Masculino  49% (30)  46% (42)  ns  49% (41)  45% (31)  ns 
Antecedentes Pessoais
Cardiopatia isquémica  25% (15)  26% (24)  ns  29% (24)  22% (15)  ns 
Insuficiência cardíaca  3% (2)  12% (11)  ns  5% (4)  13% (9)  ns 
HTA  90% (55)  93% (86)  < 0,001  87% (73)  99% (68)  0,008 
Diabetes mellitus  25% (15)  32% (29)  ns  31% (26)  26% (18)  ns 
Dislipidemia  48% (29)  36% (33)  ns  46% (39)  33% (23)  ns 
Insuficiência renal  5% (3)  28% (26)  < 0,001  6% (5)  35% (24)  < 0,001 
Necessidade de PM provisório  3% (2)  22% (20)  ns  27% (23)  29% (20)  ns 
Tipo de Bradidisrritmia
Bradicardia sinusal  2% (1)  25% (23)  < 0,001  4% (3)  30% (21)  < 0,001 
BAV completo  77% (47)  54% (50)    77% (65)  46% (32)   
BAV 2.° grau (2:1)  18% (11)  8% (7)    17% (14)  6% (4)   
Bradifibrilhação auricular  3% (2)  13% (12)    2% (2)  17% (12)   

PM: pacemaker; HTA: hipertensão.

Estudaram‐se 153 doentes com idade média de 82 ± 11 anos, sendo 47% (n = 72) do sexo masculino. Cerca de 63% (n = 97) dos doentes apresentavam BAVC, 16% (n = 24) Bradicardia sinusal, 12% (n = 18) BAV 2.° grau e 9% (n = 14) Bradifibrilhação auricular. A apresentação clínica mais frequente foi síncope, presente em 42% (n = 64) dos doentes.

A etiologia potencialmente reversível associada às alterações eletrocardiográficas em 85% (n = 130) dos doentes foi atribuída à terapêutica farmacológica; em 12% (n = 19) terapêutica farmacológica associada a alterações iónicas e 3% (n = 4) a alterações iónicas isoladas (Figura 1).

Figura 1.

Diagrama: Descrição da população com bradidisrritmia iatrogénica de acordo com a etiologia e a resposta à suspensão da causa potencialmente reversível. PM: pacemaker definitivo.

(0.16MB).

Dos doentes com iatrogenia medicamentosa isolada, 38% (n =49) dos doentes encontrava‐se sob terapêutica beta‐bloqueante, 15% (n = 20) sob amiodarona, 12% (n = 16) sob antagonistas dos canais de cálcio, 5% (n = 6) sob digoxina; 2% (n = 2) sob sotalol, 3% (n = 4) sob propafenona e, por sua vez, 25% (n = 33) sob terapêutica dupla ou tripla (Tabela 1).

A implantação de PM foi necessária em 55% (n = 84) da população, sendo que em 40% dos doentes (n = 61) este foi implantado no primeiro internamento. Cerca de 15% (n = 23) da população apresentou reversão da bradidisrritmia após a suspensão do fármaco/correção iónica, contudo, ao fim de um tempo mediano de 18 meses, os doentes apresentaram novo episódio de bradidisrritmia, sem uma aparente etiologia reversível e com necessidade de implantação PM.

Dos doentes submetidos a implantação de PM, o BAVC foi o tipo de bradidisrritmia mais frequente, presente em 77% (n = 65) destes doentes, seguindo‐se o BAV 2.° grau em 17% (n = 14) (Tabela 2).

Cerca de 62% (n = 81) dos doentes sob terapêutica farmacológica, apesar da suspensão da terapêutica apresentaram necessidade de implantação PM. A terapêutica farmacológica isolada esteve associada a menor reversibilidade da bradidisrritmia, com significado estatístico, quando comparada com as restantes causas potencialmente reversíveis (Tabela 3).

Tabela 3.

«Etiologia» da bradidisrritmia de acordo com a colocação de pacemaker

PM total  Fármacos  Fármacos + alteração iónica  Alterações iónicas (hipercaliemia)  p‐value 
Sim  81  < 0,001 
Não  49  17   
PM internamento  Fármacos  Fármacos + Alteração iónica  Alterações iónicas (Hipercaliemia)  p‐value 
Sim  61  < 0,001 
Não  69  19   

PM: pacemaker.

Quarenta e seis por cento dos doentes estava medicado com um beta‐bloqueante, 24% faziam amiodarona e/ou digoxina e 12% estavam sob antagonistas dos canais de cálcio, contudo sem significado estatístico (Tabela 4).

Tabela 4.

Necessidade de implantação de PM de acordo com a terapêutica farmacológica

  PM internamento (n = 61)  PM total (n = 84)  p‐value 
Beta‐bloqueantes (n = 49)  48% (n = 29)  46% (n = 39)  ns 
Amiodarona e/ou digoxina(n = 30)  25% (n = 15)  24% (n = 20)  ns 
Antagonistas dos canais de cálcio (n = 16)  11% (n = 7)  12% (n = 10)  ns 

PM: pacemaker.

A necessidade de PM provisório ocorreu em 28% (n = 43) da população, sobretudo em contexto de BAVC, destes 53% (n = 23) apresentou indicação para PM definitivo.

Doentes com reversão da bradidisrritmia e sem necessidade de PM apresentaram significativamente mais insuficiência renal (24 versus 5; p < 0,001). Dos doentes sem necessidade de PM a grande maioria tinha HTA (hipertensão arterial) (Tabela 1).

Quatro doentes morreram, sendo que três doentes faleceram previamente à implantação de PM no internamento e um doente faleceu no internamento após implantação do PM. Não houve qualquer registo de morte nos doentes após a alta sem PM.

Discussão

Nesta população, a maioria dos doentes apresentou necessidade de implantação de PM após a suspensão/correção da potencial causa reversível.

A proporção de doentes que descontinua a terapêutica e que requer a implantação de PM é desconhecida e o prognóstico destes doentes após a alta sem PM é igualmente desconhecido.2 Em relação às alterações metabólicas a informação é escassa, tendo em conta o aparente perfil benigno são excluídas da maioria dos estudos de bradidisrritmias iatrogénicas.

As alterações iónicas isoladas, apesar do número reduzido de doentes com hipercaliemia estiveram em 75% dos casos associadas a uma verdadeira bradidisrritmia iatrogénica com normalização do ritmo após a correção da alteração, sendo que apenas um doente apresentou necessidade de PM, o que é favor do seu carácter mais benigno. Por sua vez, 96% (n = 81) dos doentes que necessitaram de PM estavam sob terapêutica farmacológica.

Cerca de 25% de doentes com bradidisrritmia induzida pela terapêutica, a disritmia não é causada pela terapêutica mas, sim, revelada por esta, sendo os beta‐bloqueantes os principais «fármacos culprits».4

Zelter, et al. demonstraram que 56% dos doentes com resolução inicial do BAV após suspensão da terapêutica apresentaram recorrência da bradidisrritmia e Knudsen, et al. retiraram a mesma conclusão em 25% dos seus doentes.2,6

Nesta população, 25% dos doentes que tiveram alta sem PM, por aparente resolução da bradidisrritmia, apresentaram recorrência das alterações eletrocardiográficas com necessidade de PM durante o follow‐up.

De acordo com a literatura, fármacos em doses terapêuticas, geralmente não causam bradicardia significativa em doentes sem patologia cardíaca estrutural, no entanto, na presença de doença latente do nódulo sinusal e/ou nódulo AV, a terapêutica farmacológica pode ser o trigger para induzir a bradidisrritmia.4‐6

Apesar de sem significado estatístico, os beta‐bloqueantes foram os fármacos com menor reversibilidade da bradidisrritmia após a sua suspensão quando comparados com os antiarrítmicos, o que foi igualmente evidenciado em outros estudos publicados.1,2,5

Apesar da idade avançada e antecedentes de cardiopatia isquémica serem considerados preditores de risco pró‐arrítmico, nesta população este grupo de doentes não apresentou maior taxa de implantação de PM, embora a idade média da população seja superior a 65 anos e 26% tenha doença coronária.1,5

A bradidisrritmia no contexto de fibrilhação auricular é relativamente frequente, por sua vez, a necessidade de PM, de acordo com alguns estudos, é de 1,4% nos doentes sob amiodarona e 2,5% sob sotalol. Israel, et al. mostraram que em 78 doentes com dupla camâra com adaptação de frequência cardíaca (DDDR) implantado no contexto de bradicardia sintomática e FA paroxística/permanente, a bradicardia foi induzida por fármacos em 33% dos doentes.1,5 No nosso estudo, apenas dois doentes, após suspensão/correção da potencial causa reversível, apresentaram necessidade de PM, o que é a favor de um perfil com maior benignidade, logo, mais reversibilidade da bradifibrilhação auricular, quando comparada com a doença do nódulo AV. Nenhum dos doentes com bradifibrilhação auricular que teve alta sem PM apresentou ao longo do follow‐up novo episódio de disritmia com necessidade de PM.

A doença do nódulo AV (BAVC e BAV 2.° grau) apresentou menor reversibilidade, sendo necessária implantação de PM em 55% (n = 79) dos doentes. Cerca de 37% (n = 21) dos doentes com doença do nódulo AV que tiveram alta sem PM apresentaram recorrência da disrritmia no follow‐up. Esta informação coloca uma questão pertinente: devemos ponderar a implantação PM logo após o primeiro episódio desta disritmia? Esta é uma questão com que vários autores se depararam e para a qual ainda não há uma resposta exata. Vários estudos evidenciam que a doença do nódulo AV não surge em corações normais, quando surge, mesmo que induzida pela terapêutica, está associada a doença latente do sistema de condução.2,4

No presente estudo, a grande maioria dos doentes com insuficiência renal apresentou reversão da bradidisrritmia e, consequentemente, não teve necessidade de implantação de PM. De acordo com a literatura, a necessidade de PM é mais frequente nos doentes com insuficiência renal crónica do que na população em geral. O aumento de distúrbios da condução AV em doentes com insuficiência renal crónica avançada pode não ser apenas consequência da hipercaliemia, mas por outros fatores como alterações no metabolismo do cálcio, levando a fibrose e calcificação das vias de condução/miocárdio.7 Provavelmente, a gravidade da insuficiência renal na nossa população era menor, existindo reversão da bradidisrritmia apenas com correção da iatrogenia (metabólica e/ou farmacológica).

A HTA é uma comorbilidade cardiovascular frequente na população geral, bem como no nosso estudo. A HTA de acordo com a gravidade e duração induz remodelling cardíaco, o que pode interferir com a atividade elétrica, sendo frequente as disritmias, sobretudo supraventriculares e ventriculares. Os estudos multicêntricos referentes a alterações na condução AV são raros.8

A instabilidade hemodinâmica e a consequente necessidade de PM provisório não foram associadas significativamente a maior necessidade de implantação de PM definitivo, provavelmente na presença de uma amostra maior mais conclusões poderiam ser obtidas. Nesta população a instabilidade hemodinâmica não foi associada à permanência da bradidisrritmia.

Os três doentes que faleceram no internamento, perante a instabilidade hemodinâmica tiveram necessidade de PM provisório, contudo sem uma resposta eficaz e a morte não foi considerada complicação deste procedimento. Estes doentes apresentavam uma idade avançada (> 80 anos) e consequentemente diversas comorbilidades associadas.

Apesar da recorrência de bradidisritmia, a ausência de mortalidade cardiovascular no follow‐up transmite alguma segurança em relação à atual prática clínica, em que a maioria dos doentes após resolvida a aparente iatrogenia tem alta sem PM definitivo.

Limitações

A natureza retrospetiva do estudo e a reduzida dimensão da amostra constituem as principais limitações do estudo. Por sua vez, o período relativamente curto de follow‐up pode subestimar a frequência de bradicardia.

Não foi possível avaliar para todos os doentes a dosagem de cada fármaco associado à bradidisrritmia, por falta desse registo na admissão dos doentes, bem como a informação referente ao ritmo de escape e largura do QRS. Esta última característica clínica também não foi possível caracterizar pela ausência de ECG (eletrocardiograma) digitalizados no período temporal do estudo.

Os doentes não foram avaliados com monitorização de ambulatório de 24h (Holter). Os doentes podiam apresentar bradicardias assintomáticas ou bloqueios auriculoventriculares que poderiam ser identificados no Holter. No estudo apenas avaliámos as bradicardias sintomáticas com indicação para PM definitivo.

Conclusões

Em doentes admitidos com bradidisrritmia associada a uma causa potencialmente reversível, principalmente no contexto de iatrogenia farmacológica, elevada percentagem de doentes apresenta persistência ou recorrência do quadro com necessidade de colocação de pacemaker definitivo.

Os doentes com iatrogenia associada a doença do nodulo AV constituem um subgrupo de doentes com risco de recorrência mais elevado, necessitando de maior vigilância durante o follow‐up, devendo‐se ponderar nestes doentes a colocação de pacemaker definitivo no primeiro episódio.

Conflitos de interesse

Os autores não declaram conflitos de interesse.

Bibliografia
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