Editorial comment
Iatrogenic bradyarrhythmia: A benign phenomenon?
Bradiarritmia iatrogénica: um fenómeno benigno?
a Cardiology Department, Hospital da Luz Arrabida, V. N. Gaia, Portugal
b Cardiology Department, Hospital da Luz Guimarães, Guimarães, Portugal
c Cardiology Department, Centro Hospitalar de Vila Nova de Gaia, V. N. Gaia, Portugal
d Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
Lido
4552
Vezesque se leu este artigo
1567
Total PDF
2985
Total HTML
Compartilhar estatísticas
array:26 [ "pii" => "S0870255119301349" "issn" => "08702551" "doi" => "10.1016/j.repc.2019.02.004" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "1353" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2019" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2019;38:113-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 960 "formatos" => array:3 [ "EPUB" => 89 "HTML" => 679 "PDF" => 192 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2174204919300583" "issn" => "21742049" "doi" => "10.1016/j.repce.2019.03.004" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "1353" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2019;38:113-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 584 "formatos" => array:3 [ "EPUB" => 72 "HTML" => 361 "PDF" => 151 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Iatrogenic bradyarrhythmia: A benign phenomenon?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "113" "paginaFinal" => "115" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Bradiarritmia iatrogénica: um fenómeno benigno?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1863 "Ancho" => 3167 "Tamanyo" => 353903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm with suggestions for the decision-making process in patients with drug-related bradycardia. AF: atrial fibrillation; AV: atrioventricular; ECG: electrocardiographic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sérgio Barra" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Sérgio" "apellidos" => "Barra" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:2 [ "pt" => array:9 [ "pii" => "S0870255117309897" "doi" => "10.1016/j.repc.2018.05.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117309897?idApp=UINPBA00004E" ] "en" => array:9 [ "pii" => "S0870255119301349" "doi" => "10.1016/j.repc.2019.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255119301349?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300583?idApp=UINPBA00004E" "url" => "/21742049/0000003800000002/v1_201904100624/S2174204919300583/v1_201904100624/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0870255118300155" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.06.004" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "1276" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2019;38:117-24" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1410 "formatos" => array:3 [ "EPUB" => 78 "HTML" => 954 "PDF" => 378 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artigo Original</span>" "titulo" => "Acidente vascular cerebral isquémico em doentes previamente anticoagulados por fibrilhação auricular não valvular: por que acontece?" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "117" "paginaFinal" => "124" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Ischemic stroke in patients previously anticoagulated for non‐valvular atrial fibrillation: Why does it happen?" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1057 "Ancho" => 2022 "Tamanyo" => 105875 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Adesão terapêutica em função do <span class="elsevierStyleItalic">score</span> CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>‐Vasc.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luís Fernandes, João Sargento‐Freitas, James Milner, Alexandra Silva, Ana Novo, Tatiana Gonçalves, Ana Vera Marinho, Guilherme Mariano Pego, Luís Cunha, Natália António" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Luís" "apellidos" => "Fernandes" ] 1 => array:2 [ "nombre" => "João" "apellidos" => "Sargento‐Freitas" ] 2 => array:2 [ "nombre" => "James" "apellidos" => "Milner" ] 3 => array:2 [ "nombre" => "Alexandra" "apellidos" => "Silva" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Novo" ] 5 => array:2 [ "nombre" => "Tatiana" "apellidos" => "Gonçalves" ] 6 => array:2 [ "nombre" => "Ana Vera" "apellidos" => "Marinho" ] 7 => array:2 [ "nombre" => "Guilherme" "apellidos" => "Mariano Pego" ] 8 => array:2 [ "nombre" => "Luís" "apellidos" => "Cunha" ] 9 => array:2 [ "nombre" => "Natália" "apellidos" => "António" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204919300546" "doi" => "10.1016/j.repce.2019.03.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300546?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255118300155?idApp=UINPBA00004E" "url" => "/08702551/0000003800000002/v6_201912041757/S0870255118300155/v6_201912041757/pt/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255117309897" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.05.018" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "1340" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2019;38:105-11" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 946 "formatos" => array:3 [ "EPUB" => 75 "HTML" => 593 "PDF" => 278 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artigo Original</span>" "titulo" => "Bradidisrritmia puramente iatrogénica…existe?" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "111" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Permanent cardiac pacing for patients with iatrogenic or potentially reversible bradyarrhythmia" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1800 "Ancho" => 2088 "Tamanyo" => 167466 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagrama: Descrição da população com bradidisrritmia iatrogénica de acordo com a etiologia e a resposta à suspensão da causa potencialmente reversível. PM: <span class="elsevierStyleItalic">pacemaker</span> definitivo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Duarte, Sara Gonçalves, Catarina Sá, Rita Marinheiro, Marta Fonseca, José Farinha, Rita Rodrigues, Filipe Seixo, Leonor Parreira, Rui Caria" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Tatiana" "apellidos" => "Duarte" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "Catarina" "apellidos" => "Sá" ] 3 => array:2 [ "nombre" => "Rita" "apellidos" => "Marinheiro" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "Fonseca" ] 5 => array:2 [ "nombre" => "José" "apellidos" => "Farinha" ] 6 => array:2 [ "nombre" => "Rita" "apellidos" => "Rodrigues" ] 7 => array:2 [ "nombre" => "Filipe" "apellidos" => "Seixo" ] 8 => array:2 [ "nombre" => "Leonor" "apellidos" => "Parreira" ] 9 => array:2 [ "nombre" => "Rui" "apellidos" => "Caria" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204919300583" "doi" => "10.1016/j.repce.2019.03.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300583?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117309897?idApp=UINPBA00004E" "url" => "/08702551/0000003800000002/v6_201912041757/S0870255117309897/v6_201912041757/pt/main.assets" ] "asociados" => array:1 [ 0 => array:20 [ "pii" => "S0870255117309897" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.05.018" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "1340" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2019;38:105-11" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 946 "formatos" => array:3 [ "EPUB" => 75 "HTML" => 593 "PDF" => 278 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artigo Original</span>" "titulo" => "Bradidisrritmia puramente iatrogénica…existe?" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "111" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Permanent cardiac pacing for patients with iatrogenic or potentially reversible bradyarrhythmia" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1800 "Ancho" => 2088 "Tamanyo" => 167466 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagrama: Descrição da população com bradidisrritmia iatrogénica de acordo com a etiologia e a resposta à suspensão da causa potencialmente reversível. PM: <span class="elsevierStyleItalic">pacemaker</span> definitivo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Duarte, Sara Gonçalves, Catarina Sá, Rita Marinheiro, Marta Fonseca, José Farinha, Rita Rodrigues, Filipe Seixo, Leonor Parreira, Rui Caria" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Tatiana" "apellidos" => "Duarte" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "Catarina" "apellidos" => "Sá" ] 3 => array:2 [ "nombre" => "Rita" "apellidos" => "Marinheiro" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "Fonseca" ] 5 => array:2 [ "nombre" => "José" "apellidos" => "Farinha" ] 6 => array:2 [ "nombre" => "Rita" "apellidos" => "Rodrigues" ] 7 => array:2 [ "nombre" => "Filipe" "apellidos" => "Seixo" ] 8 => array:2 [ "nombre" => "Leonor" "apellidos" => "Parreira" ] 9 => array:2 [ "nombre" => "Rui" "apellidos" => "Caria" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204919300583" "doi" => "10.1016/j.repce.2019.03.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300583?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117309897?idApp=UINPBA00004E" "url" => "/08702551/0000003800000002/v6_201912041757/S0870255117309897/v6_201912041757/pt/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Iatrogenic bradyarrhythmia: A benign phenomenon?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "113" "paginaFinal" => "115" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Sérgio Barra" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Sérgio" "apellidos" => "Barra" "email" => array:1 [ 0 => "sergioncbarra@gmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Cardiology Department, Hospital da Luz Arrabida, V. N. Gaia, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiology Department, Hospital da Luz Guimarães, Guimarães, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cardiology Department, Centro Hospitalar de Vila Nova de Gaia, V. N. Gaia, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom" "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Bradiarritmia iatrogénica: um fenómeno benigno?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1863 "Ancho" => 3167 "Tamanyo" => 353903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm with suggestions for the decision-making process in patients with drug-related bradycardia. AF: atrial fibrillation; AV: atrioventricular; ECG: electrocardiographic.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Advanced age is, unsurprisingly, one of the most important predisposing factors for adverse drug reactions (ADRs) and ADR-related hospital admissions. Elderly patients are more often on polypharmacy and have more extensive comorbidity, which increase the risk of ADRs through drug-drug or drug-disease interactions and abnormal pharmacokinetics. The higher prevalence of cognitive impairment and functional deficits in this group of patients also impacts on treatment adherence and tolerability. Among elderly patients in particular, ADRs are associated with increased morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,2</span></a> The most frequent ADRs are typically caused by cardiovascular drugs,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> and a significant percentage of all ADRs involve the cardiovascular system, the most frequent drug-related cardiovascular abnormality probably being bradycardia.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> This is commonly referred to as a type of proarrhythmia. Proarrhythmia can result from a direct effect of the drug on the electrophysiological properties of the conduction system, an abnormal amplification of its effect through drug-drug interactions, or drug-induced metabolic abnormalities. However, although drug-related bradycardia may be seen as a potentially reversible condition likely to subside after discontinuation of the offending drug, a significant percentage of these patients still receive pacemaker implantation during the index admission. Whether this is indeed the right approach in all-comers or just a more cautious, albeit potentially unnecessary one, remains to be determined. The current decision-making process is based on clinical judgment rather than on published guidelines, as little is known about the prognosis of this group of patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Gonçalves et al. present an interesting assessment of the need for permanent pacemaker implantation in elderly patients admitted to hospital due to bradycardia associated with potentially reversible causes such as antiarrhythmic drugs (including beta-blockers) or severe hyperkalemia.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Their study revealed that more than half of these patients eventually require pacemaker implantation despite discontinuation of the culprit medication and correction of potassium levels. This was particularly true for patients on antiarrhythmic drugs admitted with atrioventricular (AV) conduction abnormalities, while the risk in the setting of sinoatrial dysfunction and/or isolated hyperkalemia was significantly lower.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although there is little doubt on how to treat persistent severe and/or symptomatic bradycardia (most physicians would agree that pacemaker implantation is the right course of action in most, if not all, of these cases), it remains unclear whether prophylactic pacemaker implantation during the index admission should be offered to patients whose bradycardia resolved after the offending drug was discontinued. The present study offers valuable insight into this matter. The authors’ findings to some extent corroborate the results of the few studies performed to date on this subject and highlight the need for a greater level of attention from physicians caring for these patients. In their assessment of patients with drug-related bradycardia, Lee et al. concluded that, in approximately one quarter of cases, bradycardia persists after discontinuation of the offending drug.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Similarly, Knudsen et al. reported that 25% of patients who were discharged without a permanent pacemaker subsequently presented with recurrent AV block requiring this treatment.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Another study revealed that 56% of patients for whom drug discontinuation led to resolution of AV block had recurrence in the absence of antiarrhythmic therapy.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> These studies, together with that of Gonçalves et al., justify Zeltser's comment that AV block is commonly “related to drugs” but is rarely “caused by drugs”.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> Indeed, given the advanced age of most patients admitted due to drug-induced bradycardia, it is probable that antiarrhythmic drugs are simply unmasking underlying conduction system disease that would otherwise have gone unnoticed for some time.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The management of patients for whom drug discontinuation led to resolution of the index bradycardia involves two critical steps: a decision on whether to implant a prophylactic pacemaker during or soon after the index hospitalization; and, for those discharged without a pacemaker, a commitment to close follow-up with periodic and perhaps long-term continuous monitoring. For elderly patients whose bradycardia resolves after drug discontinuation, it is not unreasonable to offer permanent pacemaker implantation when at least one of the following criteria is met:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">High risk of recurrent severe and/or symptomatic bradycardia, such as in patients who present with high-degree AV block and have a QRS width ≥120 ms<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> (measured after the AV block subsided), or a history of heart failure and/or permanent atrial fibrillation, each of which nearly triples the odds of developing bradycardia requiring pacemaker implantation.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> Also, chronic amiodarone therapy for atrial fibrillation in women, given the long half-life of this drug and the increased risk of pacemaker implantation in elderly women taking this medication<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">History of trauma caused by the proarrhythmia or high risk of sustaining significant physical injury in the event of recurrent bradycardia, which would include a significant percentage of these patients given their advanced age and comorbidity;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Previous indication for beta-blockers on prognostic grounds, for instance those with heart failure or previous myocardial infarction, as discontinuation of this drug could lead to worse outcome.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">For patients who do not fulfill any of these criteria, particularly if the baseline arrhythmia involves the sinoatrial node rather than the AV node and the patient was taking a high-dose chronotropic drug (or multiple drugs), a conservative approach with close follow-up is reasonable. <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> provides some general guidance on how to manage these cases, although it should be stressed that common sense must prevail at all times. Formal risk stratification models such as the San Francisco Syncope Rule<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> or Risk Stratification of Syncope in the Emergency Department (ROSE)<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> score may help identify patients who can safely be discharged after presenting with syncope, but these scores have a very low specificity, which could result in unnecessary treatment or hospitalization for some patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">It should be emphasized that drug-induced bradycardia is not the only type of drug proarrhythmia of which physicians should be aware. Polymorphic ventricular tachycardia (VT) and torsade de pointes (TdP) due to drug-related acquired long QT syndrome can also be triggered by various medications, including non-cardiovascular drugs, and it should be noted that these conditions are not always truly reversible. Similar to the concept, mentioned above, of unmasking underlying conduction system disease, drug-induced inhibition of the cardiac hERG/IKr potassium channel may lead to QT prolongation and TdP in patients with other repolarization stressors, including bradycardia. As some of the major epidemiological risk factors for QT prolongation and TdP, such as older age, female gender, heart failure, history of myocardial infarction and metabolic abnormalities, are also predictors of bradyarrhythmia in patients on antiarrhythmic therapy, physicians should bear in mind that some of these patients who present with severe bradycardia may also be at risk of polymorphic VT or TdP.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The relevance and interest of the present study notwithstanding, some final points should be noted. Firstly, these data cannot be extrapolated to young or middle-aged adults admitted due to iatrogenic bradycardia, as the underlying substrate and etiology may be different in this setting. While a degenerative etiology is by far the most common in older patients, advanced AV conduction abnormalities in younger patients are often congenital or associated with autoimmune or infiltrative disorders, including cardiac sarcoidosis, or with pathological hypervagotonia, in which case the investigation is likely to proceed differently.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Secondly, as mentioned by the authors, the reader should be aware that more prolonged electrocardiographic monitoring, either in-hospital or ambulatory, could detect asymptomatic episodes of advanced AV block warranting pacemaker implantation. This would in fact strengthen the authors’ conclusions by increasing the number of patients requiring a permanent pacemaker. Thirdly, given the retrospective and single-center nature of this study, the possibility of selection bias should not be underestimated. Finally, their assessment of predictors of the need for pacemaker implantation is limited by the small size of the study sample and low number of available variables, and therefore these specific findings should be interpreted with caution.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In summary, elderly patients admitted to hospital due to presumably reversible bradycardia, in particular those with AV block, are at high risk of requiring a permanent pacemaker even after discontinuation of the culprit medication. Consideration should be given to prophylactic pacemaker implantation in patients deemed to be at higher risk of recurrence or physical injury, and others should be monitored in an observational unit and, if discharged, kept under close surveillance with periodic or continuous ambulatory monitoring.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1863 "Ancho" => 3167 "Tamanyo" => 353903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm with suggestions for the decision-making process in patients with drug-related bradycardia. AF: atrial fibrillation; AV: atrioventricular; ECG: electrocardiographic.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Onder" 1 => "C. Pedone" 2 => "F. Landi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1532-5415.2002.50607.x" "Revista" => array:6 [ "tituloSerie" => "J Am Geriatr Soc" "fecha" => "2002" "volumen" => "50" "paginaInicial" => "1962" "paginaFinal" => "1968" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12473007" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Lazarou" 1 => "B.H. Pomeranz" 2 => "P.N. Corey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.279.15.1200" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1998" "volumen" => "279" "paginaInicial" => "1200" "paginaFinal" => "1205" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9555760" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0085" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse drug reactions in a tertiary care emergency medicine ward – prevalence, preventability and reporting" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.M. Rydberg" 1 => "L. Holm" 2 => "I. Engqvist" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0162948" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "e0162948" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27622270" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0090" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Results of a systematic adverse drug reaction (ADR)-screening concerning bradycardia caused by drug interactions in departments of internal medicine in Rostock" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Haase" 1 => "M. Pietzsch" 2 => "A. Fähnrich" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5414/cpp40116" "Revista" => array:6 [ "tituloSerie" => "Int J Clin Pharmacol Ther" "fecha" => "2002" "volumen" => "40" "paginaInicial" => "116" "paginaFinal" => "119" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11911600" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0095" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Permanent cardiac pacing for iatrogenic or potentially reversible bradyarrhythmia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Duarte" 1 => "S. Gonçalves" 2 => "C. Sá" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2019" "volumen" => "38" "paginaInicial" => "104" "paginaFinal" => "110" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0100" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognosis and natural history of drug-related bradycardia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.H. Lee" 1 => "H.M. Ryu" 2 => "M.H. Bae" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4070/kcj.2009.39.9.367" "Revista" => array:6 [ "tituloSerie" => "Korean Circ J" "fecha" => "2009" "volumen" => "39" "paginaInicial" => "367" "paginaFinal" => "371" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19949620" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0105" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of drug discontinuation in patients treated with temporary pacemaker due to atrioventricular block" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.B. Knudsen" 1 => "A.M. Thøgersen" 2 => "S.P. Hjortshøj" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jce.12211" "Revista" => array:7 [ "tituloSerie" => "J Cardiovasc Electrophysiol" "fecha" => "2013" "volumen" => "24" "paginaInicial" => "1255" "paginaFinal" => "1258" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23869746" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S001650851400609X" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0110" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drug-induced atrioventricular block: prognosis after discontinuation of the culprit drug" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Zeltser" 1 => "D. Justo" 2 => "A. Halkin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2004.03.057" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2004" "volumen" => "44" "paginaInicial" => "105" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15234417" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0115" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-degree atrioventricular block during anti-arrhythmic drug treatment: use of a pacemaker with a bradycardia-detection algorithm to study the time course after drug withdrawal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Kennebäck" 1 => "F. Tabrizi" 2 => "P. Lindell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/europace/eul185" "Revista" => array:6 [ "tituloSerie" => "Europace" "fecha" => "2007" "volumen" => "9" "paginaInicial" => "186" "paginaFinal" => "191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17255148" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0120" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for bradycardia requiring pacemaker implantation in patients with atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T.W. Barrett" 1 => "R.L. Abraham" 2 => "C.A. Jenkins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2012.06.037" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2012" "volumen" => "110" "paginaInicial" => "1315" "paginaFinal" => "1321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22840846" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0125" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amiodarone and the risk of bradyarrhythmia requiring permanent pacemaker in elderly patients with atrial fibrillation and prior myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. Essebag" 1 => "T. Hadjis" 2 => "R.W. Platt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0735-1097(02)02709-2" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2003" "volumen" => "41" "paginaInicial" => "249" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12535818" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0130" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.V. Quinn" 1 => "I.G. Stiell" 2 => "D.A. McDermott" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0196-0644(03)00823-0" "Revista" => array:6 [ "tituloSerie" => "Ann Emerg Med" "fecha" => "2004" "volumen" => "43" "paginaInicial" => "224" "paginaFinal" => "232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14747812" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0135" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ROSE (risk stratification of syncope in the emergency department) study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.J. Reed" 1 => "D.E. Newby" 2 => "A.J. Coull" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2009.09.049" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2010" "volumen" => "55" "paginaInicial" => "713" "paginaFinal" => "721" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20170806" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0140" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A review on advanced atrioventricular block in young or middle-aged adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.N. Barra" 1 => "R. Providência" 2 => "L. Paiva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8159.2012.03489.x" "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "2012" "volumen" => "35" "paginaInicial" => "1395" "paginaFinal" => "1405" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22897386" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003800000002/v6_201912041757/S0870255119301349/v6_201912041757/en/main.assets" "Apartado" => array:4 [ "identificador" => "29261" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Artigos Originais" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003800000002/v6_201912041757/S0870255119301349/v6_201912041757/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255119301349?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 12 | 4 | 16 |
| 2024 Outubro | 65 | 29 | 94 |
| 2024 Setembro | 56 | 30 | 86 |
| 2024 Agosto | 60 | 30 | 90 |
| 2024 Julho | 54 | 38 | 92 |
| 2024 Junho | 47 | 24 | 71 |
| 2024 Maio | 55 | 27 | 82 |
| 2024 Abril | 44 | 26 | 70 |
| 2024 Maro | 49 | 24 | 73 |
| 2024 Fevereiro | 50 | 17 | 67 |
| 2024 Janeiro | 38 | 27 | 65 |
| 2023 Dezembro | 40 | 22 | 62 |
| 2023 Novembro | 62 | 31 | 93 |
| 2023 Outubro | 35 | 13 | 48 |
| 2023 Setembro | 44 | 22 | 66 |
| 2023 Agosto | 43 | 22 | 65 |
| 2023 Julho | 30 | 9 | 39 |
| 2023 Junho | 38 | 10 | 48 |
| 2023 Maio | 43 | 25 | 68 |
| 2023 Abril | 36 | 2 | 38 |
| 2023 Maro | 80 | 23 | 103 |
| 2023 Fevereiro | 47 | 16 | 63 |
| 2023 Janeiro | 31 | 17 | 48 |
| 2022 Dezembro | 56 | 19 | 75 |
| 2022 Novembro | 66 | 29 | 95 |
| 2022 Outubro | 67 | 32 | 99 |
| 2022 Setembro | 38 | 42 | 80 |
| 2022 Agosto | 35 | 32 | 67 |
| 2022 Julho | 38 | 40 | 78 |
| 2022 Junho | 26 | 27 | 53 |
| 2022 Maio | 33 | 36 | 69 |
| 2022 Abril | 32 | 28 | 60 |
| 2022 Maro | 38 | 54 | 92 |
| 2022 Fevereiro | 36 | 43 | 79 |
| 2022 Janeiro | 24 | 18 | 42 |
| 2021 Dezembro | 36 | 25 | 61 |
| 2021 Novembro | 35 | 41 | 76 |
| 2021 Outubro | 35 | 41 | 76 |
| 2021 Setembro | 31 | 37 | 68 |
| 2021 Agosto | 38 | 37 | 75 |
| 2021 Julho | 30 | 19 | 49 |
| 2021 Junho | 35 | 21 | 56 |
| 2021 Maio | 38 | 32 | 70 |
| 2021 Abril | 41 | 44 | 85 |
| 2021 Maro | 44 | 22 | 66 |
| 2021 Fevereiro | 50 | 12 | 62 |
| 2021 Janeiro | 42 | 27 | 69 |
| 2020 Dezembro | 40 | 17 | 57 |
| 2020 Novembro | 24 | 15 | 39 |
| 2020 Outubro | 24 | 18 | 42 |
| 2020 Setembro | 22 | 11 | 33 |
| 2020 Agosto | 22 | 8 | 30 |
| 2020 Julho | 39 | 12 | 51 |
| 2020 Junho | 30 | 8 | 38 |
| 2020 Maio | 24 | 3 | 27 |
| 2020 Abril | 36 | 17 | 53 |
| 2020 Maro | 25 | 14 | 39 |
| 2020 Fevereiro | 131 | 20 | 151 |
| 2020 Janeiro | 85 | 7 | 92 |
| 2019 Dezembro | 58 | 7 | 65 |
| 2019 Novembro | 26 | 11 | 37 |
| 2019 Outubro | 41 | 7 | 48 |
| 2019 Setembro | 104 | 8 | 112 |
| 2019 Agosto | 21 | 9 | 30 |
| 2019 Julho | 54 | 23 | 77 |
| 2019 Junho | 56 | 34 | 90 |
| 2019 Maio | 37 | 18 | 55 |
| 2019 Abril | 55 | 33 | 88 |
| 2019 Maro | 28 | 21 | 49 |
Mostrar tudo
