Atualização da diretriz brasileira de insuficiência cardíaca crônica - 2012

Ventilatory efficiency (η⩒E) of the exercise: A detailed method report

Ventilatory efficiency is a combination of the ventilatory-metabolic response stemming from non-invasive analysis of cardiopulmonary exercise testing. Despite being a recognized marker in exercise physiology, this measure presents considerable limitations, including the imprecise designation of "efficiency", broadly recognized, and recently denominated as "excess ventilation". Herein we present a detailed method, with substantial improvements, and new physiological insights, in order to better define the true ventilatory efficiency of the exercise, according to recommendations for physical/physiological processes.•"Ventilatory efficiency" of the exercise is a remarkable physiological index.•Several limitations are currently debated.•We report a new ventilatory efficiency index that match with recommendations.

Advances in symptomatic therapy for left ventricular non-compaction in children

Left ventricular non-compaction is a complex cardiomyopathy and the third largest childhood cardiomyopathy, for which limited knowledge is available. Both pathogenesis and prognosis are still under investigation. Currently, no effective treatment strategy exists to reduce its incidence or severity, and symptomatic treatment is the only clinical treatment strategy. Treatment strategies are constantly explored in clinical practice, and some progress has been made in coping with the corresponding symptoms because the prognosis of children with left ventricular non-compaction is usually poor if there are complications. In this review, we summarized and discussed the coping methods for different left ventricular non-compaction symptoms.

Case report: Myocardial noncompaction causing massive cerebral infarction in 1 patient with eyelid edema as an early manifestation and literature review

Objective

To summarize and analyze the early clinical manifestations, risk factors, treatment and prognosis of myocardial noncompaction in children, and to provide scientific basis for early and effective intervention.

Methods

Combined with a case of myocardial noncompaction with massive cerebral infarction in a child, the related research reports of myocardial noncompaction in children were analyzed retrospectively.

Results

Myocardial noncompaction in children is cardiomyopathy caused by abnormal myocardial compaction during embryonic development. Feeding intolerance, dyspnea, chest tightness, fatigue, eyelid edema and other non-specific manifestations may occur in the early stage. It is easy to miss the diagnosis and misdiagnosis in clinical diagnosis and treatment, leading to intractable heart failure, nausea and arrhythmia, thromboembolism and even sudden death and other serious complications. Early diagnosis, symptomatic treatment, control of complications and regular follow-up can prevent the occurrence of serious complications and reduce mortality.

Conclusion

There is no specific clinical manifestation in the early stage of myocardial noncompaction in children. If it is not detected early and treated symptomatically, the prognosis is poor and the mortality is high. Therefore, clinicians should fully improve the understanding of the early clinical manifestations of this disease, give early diagnosis and early intervention to children, reduce the occurrence of serious complications and improve the survival rate.

Effects of β-blocker therapy on exercise oscillatory ventilation in reduced ejection fraction heart failure patients: A case series study

BACKGROUND

Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF).

METHODS

Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post).

RESULTS

Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO₂ did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO₂ slope changed from 32.1 ± 10.6-27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02).

CONCLUSION

In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.

Mortality from Heart Failure with Mid-Range Ejection Fraction

BACKGROUND

The prognostic importance of the classification 'heart failure (HF) with mid-range ejection fraction (EF)' remains uncertain.

OBJECTIVE

To analyze the clinical characteristics, comorbidities, complications, and in-hospital and late mortality of patients classified as having HF with mid-range EF (HFmrEF - EF: 40%-49%), and to compare them to those of patients with HF with preserved EF (HFpEF - EF > 50%) and with HF with reduced EF (HFrEF - EF < 40%) on admission for decompensated HF.

METHODS

Ambispective cohort of patients admitted to the cardiac intensive care unit due to decompensated HF. Clinical characteristics, comorbidities, complications, and in-hospital and late mortality were assessed. The software R was used, with a 5% significance, for the tests chi-square, analysis of variance, Cox multivariate, and Kaplan-Meier survival curve, in addition to machine-learning techniques (Elastic Net and survival tree).

RESULTS

519 individuals were included between September 2011 and June 2019 (mean age, 74.87 ± 13.56 years; 57.6% were men). The frequencies of HFpEF, HFmrEF and HFrEF were 25.4%, 27% and 47.6%, respectively. Previous infarction was more frequent in HFmrEF. The mean follow-up time was 2.94 ± 2.55 years, with no statistical difference in mortality between the groups (53.8%, 52.1%, 57.9%). In the survival curve, there was difference between neither the HFpEF and HFmrEF groups, nor the HFpEF and HFrEF groups, but between the HFmrEF and HFrEF groups. Age over 77 years, previous HF, history of readmission, dementia and need for vasopressors were associated with higher late mortality in the survival tree.

CONCLUSION

The EF was not selected as a variable associated with mortality in patients with decompensated HF.

Muscle-Skeletal Abnormalities and Muscle Oxygenation during Isokinetic Strength Exercise in Heart Failure with Preserved Ejection Fraction Phenotype: A Cross-Sectional Study

Exercise intolerance, a hallmark of patients with heart failure (HF), is associated with muscle weakness. However, its causative microcirculatory and muscle characteristics among those with preserved or reduced ejection fraction (HFpEF or HFrEF) phenotype is unclear. The musculoskeletal abnormalities that could result in impaired peripheral microcirculation are sarcopenia and muscle strength reduction in HF, implying lowered oxidative capacity and perfusion affect transport and oxygen utilization during exercise, an essential task from the microvascular muscle function. Besides that, skeletal muscle microcirculatory abnormalities have also been associated with exercise intolerance in HF patients who also present skeletal muscle myopathy. This cross-sectional study aimed to compare the muscle microcirculation dynamics via near-infrared spectroscopy (NIRS) response during an isokinetic muscle strength test and ultrasound-derived parameters (echo intensity was rectus femoris muscle, while the muscle thickness parameter was measured on rectus femoris and quadriceps femoris) in heart failure patients with HFpEF and HFrEF phenotypes and different functional severities (Weber Class A, B, and C). Twenty-eight aged-matched patients with HFpEF (n = 16) and HFrEF (n = 12) were assessed. We found phenotype differences among those with Weber C severity, with HFrEF patients reaching lower oxyhemoglobin (O₂Hb, μM) (−10.9 ± 3.8 vs. −23.7 ± 5.7, p = 0.029) during exercise, while HFpEF reached lower O₂Hb during the recovery period (−3.0 ± 3.4 vs. 5.9 ± 2.8, p = 0.007). HFpEF with Weber Class C also presented a higher echo intensity than HFrEF patients (29.7 ± 8.4 vs. 15.1 ± 6.8, p = 0.017) among the ultrasound-derived variables. Our preliminary study revealed more pronounced impairments in local microcirculatory dynamics in HFpEF vs. HFrEF patients during a muscle strength exercise, combined with muscle-skeletal abnormalities detected via ultrasound imaging, which may help explain the commonly observed exercise intolerance in HFpEF patients.

Sodium and/or fluid restriction and nutritional parameters of adult patients with heart failure: A systematic review and meta-analysis of randomized controlled trial

INTRODUCTION

Heart failure (HF) is a clinical syndrome resulting from the structural and/or functional impairment of blood supply to tissues. Congestion and edema associated with water retention are the main symptoms presented by patients. Fluid (FR) and sodium restriction are non-pharmacological measures indicated in clinical practice to mitigate this symptom, despite their low evidence level.

AIM

Assessing the impact of sodium and/or fluid restriction on nutritional parameters of adult patients with HF, based on systematic review with meta-analysis.

METHODS

The study was conducted in June 2020, on the following databases: EMBASE, PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science. Citations were also collected in the gray literature such as thesis banks and preprints. Randomized clinical trials conducted with patients in the age group 18 years, or older, who were hospitalized or under outpatient/clinical follow-up, and who were subjected to intervention based on fluid and/or sodium restriction in comparison to the control, were herein selected.

RESULTS

Although FR-based diets are effective in reducing liquid intake, they increase individuals' thirst sensation and body weight in comparison to non-FR diets. The association between this intervention and sodium restriction is also effective in reducing liquid intake as sodium intake decreases. However, the association of the most severe (<2000 mg/day) and moderate (2000-2400 mg/day) sodium restrictions with FR has reduced energy intake, although without evidence of weight change - only the most severe sodium restriction was capable of keeping individuals' thirst sensation. In addition, moderate sodium restrictions (2300 to 3000 mg/day) in association with FR were capable of decreasing urinary sodium excretion. On the other hand, prescriptions of severe or moderate sodium restriction (<2,400 mg/d) alone have reduced individuals' body weight and BMI, although they did not change their caloric intake. However, severe sodium restriction (<2,000 mg) has led to higher body weight than the low-sodium diet (2000 to 2,4000 mg/day).

CONCLUSION

Sodium restriction may not be an effective strategy because it adversely affects individuals' weight, a fact that suggests increased congestion. Weight-based FR is supported to bethe best way to individualize this non-pharmacological treatment and it does not appear to affect nutritional parameters capable of putting patients with HF at higher malnutrition risk.

Acute and Time-Course Effects of Osteopathic Manipulative Treatment on Vascular and Autonomic Function in Patients With Heart Failure: A Randomized Trial

OBJECTIVE

The purposed of this study was to valuate the effect of osteopathic manipulative treatment (OMT) on flow-mediated dilation and heart rate variability of patients with heart failure.

BACKGROUND

Osteopathic manipulative treatment modulates both the vascular and autonomic nervous system (ANS) in healthy volunteers. However, the acute and time-course effects of the OMT on patients with an overactive ANS remain unclear.

METHODS

This randomized controlled trial study included 20 patients with heart failure aged 50 to 60 years, allocated to a single session of OMT (base of the skull, retromaxillary region, heart, and thoracic duct) or sham. Flow-mediated dilation (FMD) at the brachial artery, hemodynamic measures, and heart rate variability were assessed in 3 periods (baseline, immediately after the intervention, and after 15 minutes). Multivariate analysis of variance procedure was used to compare intervention and periods.

RESULTS

The OMT group had a greater FMD modulation compared with the sham (FMD,% =  9.5 vs. -5.6, 95% confidence interval (CI): [6.6, -12.35] vs. [-14.25, 2.8]; p = 0.001) and grater peak diameter (PD, mm =  0.77 vs -0.16 mm, 95% CI: [0.31,-1.24] vs [-0.63, 0.29]; P =  0.001), suggesting an important acute and time-course vascular effect from OMT. We also found some relevant heart rate variability modulation after 15 minutes from OMT: high frequency (HF, ms² = 295 vs -354, 95% CI: [144.2, -769]; P = .001) and low frequency (LF, ms²) = 670 vs 775, 95% CI: [-98, 3591]; P = .001), suggesting a time-course ANS modulation after OMT.

CONCLUSIONS

Osteopathic manipulative treatment was effective at increasing brachial blood flow and stimulating the vagal system in patients with heart failure. Moreover, vascular changes seem to precede the autonomic modulation.

Epidemiological profile, cardiopulmonary fitness and health-related quality of life of patients with heart failure: a longitudinal study

BACKGROUND

Heart failure (HF) is a severe and self-limiting syndrome. Its signs and symptoms are believed to predict poorer health-related quality of life scores, which are mainly influenced by deterioration in physical capacity. In the present study we try to analyze the influence of clinical and socioeconomic characteristics and physical capacity on the quality of life of people with HF diagnosis.

METHODS

A longitudinal study was conducted over 2 years with patients diagnosed with HF. To evaluate the patients the method of face-to-face visit and telephone monitoring was used. In the evaluations were applied: the Clinical and Socioeconomic Characterization Questionnaire, the Minnesota Living With Heart Failure Questionnaire (MLHFQ) for quality of life evaluation and the Veterans Specific Activity Questionnaire (VSAQ) for cardiopulmonary fitness analysis. Measures of central tendency, proportion, normality test, confidence intervals, comparison of data through paired Student t test and Wilcoxon or Mann Whitney test were performed and correlations were verified through Spearman coefficient.

RESULTS

The study included 108 patients, most of them female (50.90%) and mean age of 66.62 ± 11.33 years. The median time of HF diagnosis was 5 ± 6 years, being Chagas' disease the main etiologic cause for the disease (57.40%). As for the clinical condition, functional classes II (44.40%) and III (48.10%) of the New York Heart Association (NYHA) were the most frequent. There was a low cardiopulmonary fitness, with loss of capacity to perform daily activities (3 ± 1 to 3 ± 3) over the time of clinical follow-up. There was an increase in the MLHFQ instrument scores, from 50.98 ± 15.52 to 61.76 ± 19.95, over the analysis time. The analysis of correlations demonstrated that variables such as schooling, NYHA class, echocardiographic alterations and the drug profile have a significant relationship with the constructs of quality of life and physical fitness.

CONCLUSION

Individuals in HF have significant impairment of cardiorespiratory capacity and tend to present worsening of QL along the evolution of the disease.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers

OBJECTIVES

This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil.

METHODS

The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment.

RESULTS

Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment.

CONCLUSION

HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Left Ventricular Noncompaction: New Insights into a Poorly Understood Disease

Left ventricular noncompaction (LVNC) is a congenital pathology that directly affects the lining walls of myocardial tissue, causing trabeculations with blood filling in the inner wall of the heart, concomitantly with the development of a mesocardial thinning. Although LVNC was described for the first time as long ago as 1984, our understanding of the disease with regard to its genetic pattern, diagnosis, clinical presentation and treatment is still scanty. LVNC can present as an isolated condition or associated with congenital heart disease, genetic syndromes or neuromuscular disease. This suggests that LVNC is not a distinct form of cardiomyopathy, but rather a morphological expression of different diseases. Recognition of the disease is of fundamental importance because its clinical manifestations are variable, ranging from the absence of any symptom to congestive heart failure, lethal arrhythmias and thromboembolic events. The study of this disease has emphasized its genetic aspects, as it may be of sporadic origin or hereditary, in which case it most commonly has an autosomal dominant inheritance or one linked to the X chromosome. Echocardiography is the gold standard for diagnosis, and magnetic resonance imaging may refine the identification of the disease, especially in those patients with non-conclusive echocardiography. This article sets out to review the main characteristics of LVNC and present updates, especially in the genetic pattern, diagnosis and treatment of the disease.

Vitamin D status and predictors of 25-hydroxyvitamin D levels in patients with heart failure living in a sunny region

Introduction

Aims: hypovitaminosis D has frequently been identified in patients with heart failure (HF). However, few studies have been conducted in regions with high solar incidence. Therefore, this study aimed to evaluate vitamin D status and predictors of 25-hydroxyvitamin D (25(OH)D) levels in patients with HF living in a sunny region (5 °- 6 °S). Methods: this cross-sectional study enrolled 70 patients with HF. Biodemographic, clinical, biochemical, dietary, and sun exposure data were collected, and 25(OH)D levels were measured. Results: the mean 25(OH)D level was 40.1 (12.4) ng/mL, and 24.3 % (95 % CI: 14.2-33.8) of patients with HF had hypovitaminosis D (25(OH)D < 30 ng/mL). Female patients (p = 0.001), those with ischemic etiology (p = 0.03) and those with high parathyroid hormone levels (> 67 pg/mL) (p = 0.034) were more likely to present hypovitaminosis D. Higher 25(OH)D levels were observed in men than in women (β = 7.78, p = 0.005) and in patients with HF in New York Heart Association (NHYA) functional class I when compared to those in class III/IV (β = 8.23, p = 0.032). Conclusions: the majority of patients with HF had sufficient 25(OH)D levels. Sex and functional classification were identified as independent predictors of 25(OH)D levels. These results highlight the need for increased monitoring of vitamin D status among female patients with heart failure and those with more severe symptoms.

Isoflavone Supplementation Does Not Potentiate the Effect of Combined Exercise Training on Resting and Ambulatory Blood Pressure in Non-Obese Postmenopausal Women: A Randomized Double-Blind Controlled Trial-A Pilot Study

Physical exercise and isoflavone supplementation are potential strategies to prevent and treat cardiovascular diseases in postmenopausal women. The aim of this study was to investigate whether there are additive effects of isoflavone supplementation when associated with combined aerobic and resistance exercise on resting and ambulatory blood pressure monitoring (ABPM) and in blood pressure variability (BPV). Thirty-one non-obese postmenopausal women were randomly allocated into two groups: placebo and exercise (Placebo n = 19); and isoflavone supplementation (100 mg/day) and exercise (isoflavone n = 19). ABPM and BPV were evaluated before and after 10 weeks of moderate combined (aerobic and resistance) exercise training. Generalized Estimating Equation (GEE) with Bonferroni correction and intention-to-treat analysis was used to compare the effects of interventions on resting BP, ABPM and BPV. Combined exercise training decreased resting systolic (SBP) and diastolic blood pressure (DBP) and reduced 24 h and awake ambulatory SBP, DBP and mean blood pressure over time, with no additional effects of isoflavone supplementation. No changes were observed in sleep period, or in BPV indexes (Standard Deviation of 24 h (SD), daytime and nighttime interval (SDdn) and average real variability (ARV) in both groups. We conclude that isoflavone supplementation does not potentiate the effects of combined training on resting and ambulatorial systolic and diastolic blood pressure in non-obese postmenopausal women.

Cuidados paliativos

Objetivos: identificar artigos nacionais e internacionais que abordem: i) os cuidados paliativos de idosos portadores de insuficiência cardíaca (IC); ii) as condutas médicas atuais para controle dos sintomas e condições clínicas, psicossociais e espirituais comumente apresentadas por idosos portadores desta condição clínica.Métodos: revisão narrativa através de busca por artigos do período de 2014 a 2019 nas bases de dados PubMed, Scielo, Lilacs e Scopus, utilizando os Descritores em Ciência e Saúde (DeCS): insuficiência cardíaca, idoso, muito idoso, cuidados paliativos, e os Medical Subject Headings (MeSH): heart failure, aged, elderly, palliative care.Síntese dos dados (Resultados): foram identificados 12 artigos de revisão acerca de cuidados paliativos de pacientes com insuficiência cardíaca, e somente dois artigos de revisão acerca de cuidados paliativos de idosos com insuficiência cardíaca.Conclusões: uma abordagem através de Avaliação Geriátrica Ampla (AGA), identificação de fragilidade e comorbidades, aliadas a habilidades específicas no manejo de IC são fundamentais para melhor desempenho dos cuidados paliativos desses pacientes. Além disso, há escassa disponibilidade de estudos originais acerca de cuidados paliativos de idosos portadores de IC.

Relationship between functional capacity, performance and symptoms in hospitalized patients with heart failure

OBJECTIVES

to evaluate the prevalence of symptoms in heart failure patients and to investigate the relationship between symptoms, functional capacity and performance.

METHODS

cross-sectional study, developed at a hospital specializing in cardiology. The sample (n=170) consisted of patients with heart failure, assessed by means of a sociodemographic form, New York Heart Association Functional Class, Edmonton Symptom Rating Scale and Karnofsky Physical Performance Scale. Analyzes were performed using Spearman's Correlation and Pearson's Chi-Square test.

RESULTS

dyspnea, fatigue and edema were the main symptoms that led to the search for health services. During hospitalization, the main symptoms were anxiety, sleep disturbance and sadness. Weak negative correlations were observed between functionality, functional class, and symptom overload.

CONCLUSIONS

the prevalence of symptoms was high and changed throughout the hospitalization period. Patients with poorer functional capacity and poorer performance had greater symptom overload.

Comparative Cardiotoxicity of Low Doses of Digoxin, Ouabain, and Oleandrin

The aim of this study was to evaluate the comparative effects of CGs on heart physiology. Twenty-eight Wistar rats were distributed into four groups (n = 7), control group received NaCl 0.9% every 24 h for 21 days; treated groups received respectively 50 μg/kg of digoxin (DIG), ouabain (OUA) and oleandrin (OLE) every 24 h for 21 days. Serial ECGs were performed, as well as serum levels of creatinine kinase (CK), its MB fraction, troponin I (cTnI), calcium (Ca²⁺) and lactic dehydrogenase (LDH). Heart tissue was processed for histology, scanning electron microscopy and Western blot analysis for cTnI, brain natriuretic peptide (BNP), sodium potassium pump alpha-1 and alpha-2. Ventricle samples were also analyzed for thiobarbituric acid reactive substances and antioxidant enzymes (SOD, GPX, and CAT). ECGs showed decrease in QT and progressive shortening of QRS. No arrhythmias were observed. No significant differences were associated with CGs treatment and serum levels of CK, CK-MB, and cTnI. Only oleandrin increased LDH levels. Histological analysis showed degenerative changes and only oleandrin promoted moderate focal necrosis of cardiomyocytes. Scanning microscopy also confirmed the greatest effect of oleandrin, with rupture and shortening of cardiac fibers. The expression of troponin I and alpha-1 isoform were not altered, however, the protein levels of BNP and alpha-2 were higher in the groups that received oleandrin and ouabain in relation to the digoxin group. All GCs affected the production of ROS, without causing lipid peroxidation, through the activation of different antioxidant pathways. It is concluded that the administration of digoxin, ouabain, and oleandrin at 50 µg/kg for 21 days caused cardiovascular damage that represent an important limitation into its future use in heart failure and antineoplastic therapy.

Epidemiology of heart failure

The heart failure syndrome has first been described as an emerging epidemic about 25 years ago. Today, because of a growing and ageing population, the total number of heart failure patients still continues to rise. However, the case mix of heart failure seems to be evolving. Incidence has stabilized and may even be decreasing in some populations, but alarming opposite trends have been observed in the relatively young, possibly related to an increase in obesity. In addition, a clear transition towards heart failure with a preserved ejection fraction has occurred. Although this transition is partially artificial, due to improved recognition of heart failure as a disorder affecting the entire left ventricular ejection fraction spectrum, links can be made with the growing burden of obesity‐related diseases and with the ageing of the population. Similarly, evidence suggests that the number of patients with heart failure may be on the rise in low‐income countries struggling under the double burden of communicable diseases and conditions associated with a Western‐type lifestyle. These findings, together with the observation that the mortality rate of heart failure is declining less rapidly than previously, indicate we have not reached the end of the epidemic yet. In this review, the evolving epidemiology of heart failure is put into perspective, to discern major trends and project future directions.

Effect of combined interval training on the cardiorespiratory fitness in heart failure patients: a systematic review and meta-analysis

BACKGROUND

The combination of interval training and resistance training has showed interesting results in chronic heart failure patients, corroborating the benefits of physiological adaptations of both protocols.

OBJECTIVE

To evaluate the effect of the combination of interval training and resistance training program when compared to interval training alone and/or without intervention group on cardiorespiratory fitness in patients with chronic heart failure.

METHODS

We search MEDLINE via PubMed, ScienceDirect, Sportdiscus, BIREME and Scielo, from their inception to December 2018. Were included both randomized and non-randomized controlled trials comparing the effect of combined training, interval training alone and/or WI group on VO2peak (expressed in ml/kg/min), in people with chronic heart failure patients. The meta-analysis was conducted via Review Manager v 5.3 software, using random effect model.

RESULTS

Ten articles were selected (nine randomized controlled trial), involving 401 participants. Six studies compared combined training with interval training and six studies compared combined training with the without intervention group. Eighty percent of the trials presented moderate risk of bias and twenty percent low risk of bias. Data showed significant difference and major increase in VO2peak in favor to combined training group compared to interval training group (SMD=0.25; CI=0.04-0.46) and without intervention group (SMD=0.46; CI=0.29-0.64), respectively.

CONCLUSION

The combination of interval training and resistance training showed more effective in increasing cardiorespiratory fitness in patients with heart failure than interval training alone and non-exercise therapy. However, further studies should be conducted to increase the understanding of this combined training method.

Predictors of one-year outcomes in chronic heart failure: the portrait of a middle income country

Background

Heart failure (HF) is a major public health problem with increasing prevalence worldwide. It is associated with high mortality and poor quality of life due to recurrent and costly hospital admissions. Several studies have been conducted to describe HF risk predictors in different races, countries and health systems. Nonetheless, understanding population-specific determinants of HF outcomes remains a great challenge.

We aim to evaluate predictors of 1-year survival of individuals with systolic heart failure from the GENIUS-HF cohort.

Methods

We enrolled 700 consecutive patients with systolic heart failure from the SPA outpatient clinic of the Heart Institute, a tertiary health-center in Sao Paulo, Brazil. Inclusion criteria were age between 18 and 80 years old with heart failure diagnosis of different etiologies and left ventricular ejection fraction ≤50% in the previous 2 years of enrollment on the cohort. We recorded baseline demographic and clinical characteristics and followed-up patients at 6 months intervals by telephone interview. Study data were collected and data quality assurance by the Research Electronic Data Capture tools. Time to death was studied using Cox proportional hazards models adjusted for demographic, clinical and socioeconomic variables and medication use.

Results

We screened 2314 consecutive patients for eligibility and enrolled 700 participants.

The overall mortality was 6.8% (47 patients); the composite outcome of death and hospitalization was 17.7% (123 patients) and 1% (7 patients) have been submitted to heart transplantation after one year of enrollment. After multivariate adjustment, baseline values of blood urea nitrogen (HR 1.017; CI 95% 1.008–1.027; p < 0.001), brain natriuretic peptide (HR 1.695; CI 95% 1.347–2.134; p < 0.001) and systolic blood pressure (HR 0.982;CI 95% 0.969–0.995; p = 0.008) were independently associated with death within 1 year. Kaplan Meier curves showed that ischemic patients have worse survival free of death and hospitalization compared to other etiologies.

Conclusions

High levels of BUN and BNP and low systolic blood pressure were independent predictors of one-year overall mortality in our sample.

Trial registration

Current Controlled Trials NTC02043431, retrospectively registered at in January 23, 2014.

Renal denervation in patients with heart failure secondary to Chagas' disease: A pilot randomized controlled trial

INTRODUCTION

Chagas disease is one of the most relevant endemic parasitic diseases in Latin America, affecting approximately 6 million people. Overt Chagas heart disease is an ominous condition, occurring in 20-30% of infected individuals, which has besides the persistent myocarditis a peculiar intracardiac ganglionic neuronal depletion and dysautonomy. This study aims to evaluate the safety and feasibility of renal denervation for patients with advanced symptomatic Chagas cardiomyopathy.

METHODS

Open-label prospective pilot study that randomized patients with Chagas heart disease to either renal denervation or conservative treatment (2:1 ratio). The primary endpoint was the incidence of major adverse events at 9 months, defined as a composite of all-cause death, myocardial infarction, stroke, need for renal artery invasive treatment, or worsening renal function.

RESULTS

A total of 17 patients were allocated for renal denervation (n = 11) or conservative treatment (n = 6). Included patients had severe symptomatic heart disease, with markedly depressed left ventricular function (average ejection fraction 26.7 ± 4.9%). For patients randomized to renal denervation, the procedure was performed successfully and uneventfully. After 9 months, the primary endpoint occurred in 36.4% of patients in the renal denervation group and 50.0% in the control arm (p = .6). After 9 months, clinical, laboratory, functional, echocardiographic, and quality of life parameters were similar between groups.

CONCLUSIONS

This pilot study suggests that renal denervation is safe and feasible in patients with Chagas cardiomyopathy, warranting future studies to better evaluate the clinical efficacy of the interventional strategy in improving the prognosis of this high-risk population.

Discharge guidance and telephone follow-up in the therapeutic adherence of heart failure: randomized clinical trial

OBJECTIVE

to evaluate the effectiveness of the behavioral intervention of discharge guidance and telephone follow-up in the therapeutic adherence, re-hospitalization and mortality of patients with heart failure.

METHOD

randomized clinical trial without blinding, including 201 patients diagnosed with heart failure admitted to the emergency room, who were randomized in Control Group and Intervention Group. Intervention was carried out with specific discharge guidance in the Intervention Group, who were contacted for solving doubts via phone calls after 7 and 30 days, and the adherence to treatment was evaluated after 90 days with the Morisky test, the Brief Medical Questionnaire and the non-drug adherence test in both groups. The Generalized Estimating Equations Model was used (p<0.05%).

RESULTS

One-hundred and one patients were randomly sorted in the Control Group and in the Intervention Group, their average age being 62.6±15.2. The Intervention Group had higher drug and non-drug therapeutic adherence compared to the Control Group (p<0.001) and there were lower re-hospitalization and death rates in the Intervention Group after 90 days.

CONCLUSION

discharge guidance with telephone follow-up was effective and resulted in greater therapeutic adherence, as well as in decrease of re-hospitalization and death rates in patients with heart failure. Clinical Trial Registration (REBEC): RBR- 37n859.

Global Longitudinal Strain Predicts Poor Functional Capacity in Patients with Systolic Heart Failure

Background

Left ventricular global longitudinal strain value (GLS) can predict functional capacity in patients with preserved left ventricular ejection fraction (LVEF) heart failure (HF) and to assess prognosis in reduced LVEF HF.

Objetive

Correlate GLS with parameters of Cardiopulmonary Exercise Test (CPET) and to assess if they could predict systolic HF patients that are more appropriated to be referred to heart transplantation according to CPET criteria.

Methods

Systolic HF patients with LVEF < 45%, NYHA functional class II and III, underwent prospectively CPET and echocardiography with strain analysis. LVEF and GLS were correlated with the following CPET variables: maxVO₂, VE/VCO₂ slope, heart rate reduction during the first minute of recovery (HRR) and time needed to reduce maxVO₂ in 50% after physical exercise (T_1/2VO₂). ROC curve analysis of GLS to predict VO₂ < 14 mL/kg/min and VE/VCO₂ slope > 35 (heart transplantation’s criteria) was performed.

Results

Twenty six patients were selected (age, 47 ± 12 years, 58% men, mean LVEF = 28 ± 8%). LVEF correlated only with maxVO₂ and T_1/2VO₂. GLS correlated to all CPET variables (maxVO₂: r = 0.671, p = 0.001; VE/VCO₂ slope: r = -0.513, p = 0.007; HRR: r = 0.466, p = 0.016, and T_1/2VO₂: r = -0.696, p = 0.001). GLS area under the ROC curve to predict heart transplantation’s criteria was 0.88 (sensitivity 75%, specificity 83%) for a cut-off value of -5.7%, p = 0.03.

Conclusion

GLS was significantly associated with all functional CPET parameters. It could classify HF patients according to the functional capacity and may stratify which patients have a poor prognosis and therefore to deserve more differentiated treatment, such as heart transplantation.

Heart Failure with Mid-Range Ejection Fraction - State of the Art

In 2016, the European Society of Cardiology (ESC) recognized heart failure (HF) with ejection fraction between 40 and 49% as a new HF phenotype, HF with mid-range ejection fraction (HFmrEF), with the main purpose of encouraging studies on this new category. In 2018, the Brazilian Society of Cardiology adhered to this classification and introduced HFmrEF in Brazil. This paper presents a narrative review of what the literature has described about HFmrEF. The prevalence of patients with HFmrEF ranged from 13 to 24% of patients with HF. Analyzing the clinical characteristics, HFmrEF shows intermediate characteristics or is either similar to HF with preserved ejection fraction (HFpEF) or to HF with reduced fraction (HFrEF). Regarding the prognosis, HFmrEF's all-cause mortality is similar to HFpEF's and lower than HFrEF's. Studies that analyzed cardiac mortality concluded that there was no significant difference between HFmrEF and HFrEF, both of which were lower than HFpEF. Despite the significant increase of publications on HFmrEF, there is a great scarcity of prospective studies and clinical trials that allow delineating specific therapies for this new phenotype. To better treat HFmrEF patients, it is fundamental that cardiologists and internists understand the differences and similarities of this new phenotype.

A normal sodium diet preserves serum sodium levels during treatment of acute decompensated heart failure: A prospective, blind and randomized trial

BACKGROUND

We tested the hypothesis that a normal sodium diet could be associated with preservation of serum sodium during treatment of acute decompensated heart failure (ADHF).

METHODS AND RESULTS

Forty-four patients hospitalized for ADHF were blindly randomized by using block method to a low sodium diet (LS: 3 g/day of dietary sodium chloride; n = 22, 59.5 ± 11.9 y.o., 50% males. LVEF = 30.0 ± 13.6%); and a normal sodium diet (NS: 7 g/day; n = 22, 56.4 ± 10.3 y.o., 68% males; LVEF = 27.8 ± 11.7%), and both groups were submitted to fluid restriction of 1.000 mL/day. At the 7th day of intervention 16 patients of LS group and 15 patients of NS group were assessed for difference in serum sodium. Both groups had equivalent decongestion, reflected by similar percent reduction of body weight (LS: -5.0 ± 4.7% vs NS: -4.5 ± 5.2%. p = 0.41). Reduction of the N terminal fragment of type B natriuretic peptide (NT-proBNP) was significant only in the NS (-1497.0 [-18843.0 - 1191.0]. p = 0.04). The LS group showed lower levels of serum sodium (135.4 ± 3.5 mmol/L) compared to the NS group (137.5 ± 1.9 mmol/L; p = 0.04). Four cases of hyponatremia were observed only in the LS group (22%). The NS group exhibited higher mean blood pressure values (79.4 ± 2.4 mmHg vs 75.5 ± 3.0 mmHg. p = 0.03), and lower heart rate (73.2 ± 1.6 bpm vs 75.5 ± 2.1 bpm. p = 0.02).

CONCLUSIONS

These results suggest that a normal sodium diet, when compared to a low sodium diet, is associated with similar degrees of decongestion, but with higher levels of natremia, blood pressure and lower neurohormonal activation during ADHF treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier no. NCT03722069.

Palliative care need in patients with advanced heart failure hospitalized in a tertiary hospital

OBJECTIVE

To evaluate the need for palliative care in patients with advanced Congestive Heart Failure (CHF) hospitalized in a cardiology ward.

METHOD

Application of the World Health Organization Palliative Needs tool (NECPAL) with the assistant physician, patient and/or caregiver for evaluation of indication of Palliative Care (PC).

RESULTS

82 patients with a diagnosis of class III/IV Heart Failure or ejection fraction less than or equal to 40% in echocardiography of the last 12 months were included: Mean age 68 ± 20 years, 51 male patients and 31 female patients. Forty-three patients (52.4%) were married or in consensual union and ten (12%) lived alone. The death of 46 patients (56.1%) in the subsequent 12 months would not surprise their physician, and forty-five patients (55%) had palliative care indication according to the NECPAL.

CONCLUSION

About half of patients hospitalized for class III/IV Heart Failure would have an indication of Palliative Care for the relief of suffering caused by the disease.

How long before hospital admission do the symptoms of heart failure decompensation arise?

ABSTRACT Objective: to identify the signs and symptoms of decompensation of heart failure (HF) and the duration of time to hospital admission. Method: this is a cross-sectional study with adult patients hospitalized for decompensated HF in a teaching hospital located in southern Brazil from July to October 2017. Data collection was performed through a structured questionnaire that included sociodemographic, clinical signs and symptoms of HF. In the data analysis, the following tests were applied: t-Student, Mann Whitney U-Test, Chi-Square Tests. Results: 94 patients, aged between 42 and 98 years old (mean of 71.2 years old) were included. The most prevalent signs and symptoms before emergency admission were dyspnea (79.8%), cough (29.8%), orthopnea (27.7%), edema (23.4%), and fatigue (22.3%). The median time from onset of signs and symptoms to arrival in the emergency room is fatigue and edema 7 days, orthopnea 5 days, cough 4 days and dyspnea 3 days. Conclusion: the set of classic signs and symptoms of decompensation of HF occurs around seven days before the emergency search and dyspnea is the worsening that leads the patient to a hospital emergency.

Non-pharmacological interventions for sleep and quality of life: a randomized pilot study

OBJECTIVE

to estimate the effects of non-pharmacological interventions to improve the quality of sleep and quality of life of patients with heart failure.

METHOD

pilot study of a randomized controlled trial with 32 individuals assigned to four groups. Sleep was assessed using the Pittsburgh Sleep Quality Inventory, while health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire, at the baseline and at the 12th and 24th weeks. The means of the outcomes according to intervention groups were compared using analysis of covariance; effect sizes were calculated per group.

RESULTS

all groups experienced improved quality of sleep and health-related quality of life at the end of the intervention (week 12) and at follow-up (week 24), though differences were not statistically significant (p between 0.22 and 0.40). The effects of the interventions at the 12th week ranged between -2.1 and -3.8 for the quality of sleep and between -0.8 and -1.7 for quality of life, with similar values at the 24th week.

CONCLUSION

the effects found in this study provide information for sample size calculations and statistical power for confirmatory studies. Brazilian Clinical Trials Registry - RBR 7jd2mm.

Six-minute walk test and incremental shuttle walk test in the evaluation of functional capacity in Chagas heart disease

Chagas heart disease (CHD) leads to a progressive functional impairment. Field tests, as the 6-min walk test (6MWT) and the incremental shuttle walk test (ISWT), may be inexpensive approaches in the evaluation of functional capacity of these patients. The present study was addressed to compare the 6MWT and the ISWT measures, and to determine the accuracy of these tests in the identification of functional impairment in patients with CHD. Thirty-five patients with CHD (47.1±8.2 years, NYHA I–III) were evaluated by echocardiography, cardiopulmonary exercise test (CPET), 6MWT, and ISWT. Correlations between the CPET (peak oxygen uptake [peak VO2] and the ratio between ventilation and the carbon dioxide production [VE/VCO2 slope]) and the field tests (walking distances) were also performed. The receiver operating characteristic (ROC) curve was selected to identify the best distances related to identify those patients with functional impairment. There was no difference between distances walked during the 6MWT and ISWT (P=0.694). The Bland-Altman analysis showed good agreement between the field tests. Both 6MWT and ISWT correlated with peak VO2 (r=0.577, P<0.001 and r=0.587, P<0.001, respectively) and ISWT correlated with VE/VCO2 slope (r=−0.339, P=0.003). The cutoff distances of 6MWT and ISWT to identify patients with peak VO2 less than 20 mL/kg/min were 520 m and 400 m, respectively, with no difference between the areas under ROC curves (P=0.276). Both the 6MWT and the ISWT demonstrated accuracy in identify functional impairment in patients with CHD, being useful tools for the risk stratification of these patients.

Efeitos do treinamento muscular inspiratório no controle autonômico: revisão sistemática

RESUMO A disfunção do sistema nervoso autônomo tem papel importante na fisiopatologia de diversas doenças. Uma possível maneira de melhorar o controle autonômico é o treinamento muscular inspiratório (TMI), sendo o objetivo deste estudo revisar sistematicamente a literatura disponível sobre os efeitos desta modalidade. Dois revisores buscaram ensaios clínicos controlados e randomizados nas bases de dados MEDLINE, PEDro, SciELO e LILACS, avaliando também sua qualidade metodológica (escala de PEDro). Foram encontrados 181 artigos e, após verificar os critérios de elegibilidade, foram incluídos quatro pesquisas que avaliaram o efeito do TMI sobre o controle autonômico de participantes com fatores de risco para doenças cardiovasculares, por meio da variabilidade da frequência cardíaca (VFC) e dos níveis plasmáticos de noradrenalina. O TMI melhorou o controle autonômico em três estudos, reduzindo a atividade nervosa simpática (níveis plasmáticos de noradrenalina; LF u.n. - VFC) e aumentando a atividade nervosa vagal (HF u.n. - VFC). Conclui-se que o TMI parece ser uma alternativa terapêutica para melhorar o controle autonômico.

Safety profile and efficacy of ivabradine in heart failure due to Chagas heart disease: a post hoc analysis of the SHIFT trial

AIMS

The SHIFT trial showed that ivabradine reduced heart rate (HR) and the risk of cardiovascular outcomes. Concerns remain over the efficacy and safety of ivabradine on heart failure (HF) due to Chagas disease (ChD). We therefore conducted a post hoc analysis of the SHIFT trial to investigate the effect of ivabradine in these patients.

METHODS AND RESULTS

SHIFT was a randomized, double-blind, placebo-controlled trial in symptomatic systolic stable HF, HR ≥ 70 b.p.m., and in sinus rhythm. The ChD HF subgroup included 38 patients, 20 on ivabradine, and 18 on placebo. The ChD HF subgroup showed high prevalence of bundle branch right block and, compared with the overall SHIFT population, lower systolic blood pressure; higher use of diuretics, cardiac glycosides, and antialdosterone agents; and lower use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker or target daily dose of beta-blocker. ChD HF presented a poor prognosis (all-cause mortality at 2 years was ~60%). The mean twice-daily dose of ivabradine was 6.26 ± 1.15 mg and placebo 6.43 ± 1.55 mg. Ivabradine reduced HR from 77.9 ± 3.8 to 62.3 ± 10.1 b.p.m. (P = 0.005) and improved functional class (P = 0.02). A trend towards reduction in all-cause death was observed in ivabradine arm vs. placebo (P = 0.07). Ivabradine was not associated with serious bradycardia, atrioventricular block, hypotension, or syncope.

CONCLUSIONS

ChD HF is an advanced form of HF with poor prognosis. Ivabradine was effective in reducing HR in these patients and improving functional class. Although our results are based on a very limited sample and should be interpreted with caution, they suggest that ivabradine may have a favourable benefit-risk profile in ChD HF patients.

Cost-Effectiveness of a Home Visit Program for Patients with Heart Failure in Brazil: Evidence from a Randomized Clinical Trial

OBJECTIVE

Estimate the cost-effectiveness of a nurse-led home visit (HV) intervention as compared with the standard HF management, within a randomized clinical trial in Brazil.

STUDY DESIGN

Cost-effectiveness study within a randomized trial.

METHODS

To assess the cost-effectiveness of four home visits and four telephone calls by nurses in the management of patients with HF within a randomized clinical trial (RCT: NCT01213875) in a perspective Public (PHS-Public Healthcare System) and private healthcare systems of Brazil during time frame of 24 weeks. The outcome was a composite endpoint hospital readmission rate (first visit to the emergency room (ER) and hospital readmission), or all-cause death and incremental cost-effectiveness ratio (ICER) of the study intervention to conventional management.

RESULTS

Home-based intervention was associated with a reduction in composite endpoint (RR 0.73; 95% confidence interval 0.54 - 0.99; P = 0.049), but at greater cost from the PHS perspective. The ICER at 24 weeks was R$585 per hospital readmission visit prevented. Within the private health insurance framework, home visits were associated with lower costs and lower readmission rates. Results were sensitive to the relative risk of the study intervention, admissions and intervention costs.

CONCLUSIONS

In Brazil, an intervention based on nurse-led home visits of patients with HF showed a favorable cost-effectiveness profile within the framework of the PHS and was dominant within the private healthcare system. Our analysis suggests that implementation of this program could not only benefit patients, but also provide a financial incentive to health administrators.

Aggressive fluid and sodium restriction in decompensated heart failure with preserved ejection fraction: Results from a randomized clinical trial

OBJECTIVES

Sodium and fluid restriction is commonly prescribed for heart failure patients. However, its role in the treatment of heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the effect of a diet with sodium and fluid restriction with an unrestricted diet in patients admitted for decompensated HFpEF.

METHODS

Patients were randomized to a diet with sodium (0.8 g/d) and fluid (800 mL/d) restriction (intervention group [IG]) or an unrestricted diet (control group [CG]) and followed for 7 d or hospital discharge. The primary outcome was weight loss. Secondary outcomes included clinical stability, perception of thirst, neurohormonal activation, nutrient intake, readmission, and mortality rate after 30 d.

RESULTS

Fifty-three patients were included (30, IG; 23, CG). The mean ejection fraction was 62% ± 8% for IG and 60% ± 7% for CG (P = 0.44). Weight loss was similar in both groups, being 1.6 ± 2.2 kg in the IG and 1.8 ± 2.1 kg in CG (P = 0.49) as well as the reduction in the congestion score (IG = 3.4 ± 3.5; CG = 3.8 ± 3.4; P = 0.70). The daily perception of thirst was higher in the IG (P = 0.03). Lower energy consumption was seen in the IG (P <0.001). No significant between-group differences at 30 d were found.

CONCLUSIONS

Aggressive sodium and fluid restriction does not provide symptomatic or prognosis benefits, but does produce greater perception of thirst, may impair the patient's food intake, and does not seem to have an important neurohormonal effect in patients admitted for decompensated HFpEF.

Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity: The CECCY Trial

BACKGROUND

Anthracycline (ANT) chemotherapy is associated with cardiotoxicity. Prevention with β-blockers remains controversial.

OBJECTIVES

This prospective, randomized, double-blind, placebo-controlled study sought to evaluate the role of carvedilol in preventing ANT cardiotoxicity.

METHODS

The authors randomized 200 patients with HER2-negative breast cancer tumor status and normal left ventricular ejection fraction (LVEF) referred for ANT (240 mg/m²) to receive carvedilol or placebo until chemotherapy completion. The primary endpoint was prevention of a ≥10% reduction in LVEF at 6 months. Secondary outcomes were effects of carvedilol on troponin I, B-type natriuretic peptide, and diastolic dysfunction.

RESULTS

Primary endpoint occurred in 14 patients (14.5%) in the carvedilol group and 13 patients (13.5%) in the placebo group (p = 1.0). No differences in changes of LVEF or B-type natriuretic peptide were noted between groups. A significant difference existed between groups in troponin I levels over time, with lower levels in the carvedilol group (p = 0.003). Additionally, a lower incidence of diastolic dysfunction was noted in the carvedilol group (p = 0.039). A nonsignificant trend toward a less-pronounced increase in LV end-diastolic diameter during the follow-up was noted in the carvedilol group (44.1 ± 3.64 mm to 45.2 ± 3.2 mm vs. 44.9 ± 3.6 mm to 46.4 ± 4.0 mm; p = 0.057).

CONCLUSIONS

In this largest clinical trial of β-blockers for prevention of cardiotoxicity under contemporary ANT dosage, the authors noted a 13.5% to 14.5% incidence of cardiotoxicity. In this scenario, carvedilol had no impact on the incidence of early onset of LVEF reduction. However, the use of carvedilol resulted in a significant reduction in troponin levels and diastolic dysfunction. (Carvedilol Effect in Preventing Chemotherapy-Induced Cardiotoxicity [CECCY]; NCT01724450).

Effect of an orientation group for patients with chronic heart failure: randomized controlled trial

OBJECTIVE

To evaluate the effect of the orientation group on therapeutic adherence and self-care among patients with chronic heart failure.

METHOD

Randomized controlled trial with 27 patients with chronic heart failure. The intervention group received nursing consultations and participated in group meetings with the multi-professional team. The control group only received nursing consultations in a period of four months. Questionnaires validated for use in Brazil were applied in the beginning and in the end of the study to assess self-care outcomes and adherence to treatment. Categorical variables were expressed through frequency and percentage distributions and the continuous variables through mean and standard deviation. The comparison between the initial and final scores of the intervention and control groups was done through the Student's t-test.

RESULTS

The mean adherence in the intervention group was 13.9 ± 3.6 before the study and 4.8 ± 2.3 after the study. In the control group it was 14.2 ± 3.4 before the study and 14.7 ± 3.5 after the study. The self-care confidence score was lower after the intervention (p=0.01).

CONCLUSION

The orientation group does not improve adherence to treatment and self-care management and maintenance and it may reduce confidence in self-care. Registry REBEC RBR-7r9f2m.

Bezold-Jarisch reflex in a patient undergoing endoscopic sympathectomy for management of refractory angina pectoris: a case report

Background and objectives

Ischemic cardiomyopathy is characterized by imbalance between supply and demand of myocardial oxygen. Endoscopic transthoracic sympathectomy is a therapeutic option indicated in refractory cases. However, the patient's position on the operating table may favor ischemic coronary events triggering the Bezold-Jarisch reflex.

Case report

A female patient, 47 years old, with refractory ischemic cardiomyopathy, admitted to the operating room for endoscopic transthoracic sympathectomy, developed the Bezold-Jarisch reflex with severe bradycardia and hypotension after placement in semi-sitting position to the procedure.

Conclusion

Bradyarrhythmia, hypotension, and asystole are complications potentially associated with patient placement in a semi-sitting position, particularly in cases with previous ischemic heart disease.

Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial

AIMS

Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC-1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals.

METHODS

The ReBIC-1 trial is currently enrolling HF patients in NYHA functional class I-II, left ventricular ejection fraction ≤45%, without a HF-related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double-blinded protocol. The trial has two co-primary outcomes: (1) dyspnea assessment using a visual-analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow-up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre-defined sub-group analysis based on NT-proBNP levels at baseline is planned.

PERSPECTIVE

Evidence-based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC-1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.

Chronic Chagas Heart Disease Management: From Etiology to Cardiomyopathy Treatment

Trypanosoma cruzi (T. cruzi) infection is endemic in Latin America and is becoming a worldwide health burden. It may lead to heterogeneous phenotypes. Early diagnosis of T. cruzi infection is crucial. Several biomarkers have been reported in Chagas heart disease (ChHD), but most are nonspecific for T. cruzi infection. Prognosis of ChHD patients is worse compared with other etiologies, with sudden cardiac death as an important mode of death. Most ChHD patients display diffuse myocarditis with fibrosis and hypertrophy. The remodeling process seems to be associated with etiopathogenic mechanisms and neurohormonal activation. Pharmacological treatment and antiarrhythmic therapy for ChHD is mostly based on results for other etiologies. Heart transplantation is an established, valuable therapeutic option in refractory ChHD. Implantable cardioverter-defibrillators are indicated for prevention of secondary sudden cardiac death. Specific etiological treatments should be revisited and reserved for select patients. Understanding and management of ChHD need improvement, including development of randomized trials.

Angiotensin-Converting Enzyme ID Polymorphism in Patients with Heart Failure Secondary to Chagas Disease

Background

Changes in the angiotensin-converting enzyme (ACE) gene may contribute to the increase in blood pressure and consequently to the onset of heart failure (HF). The role of polymorphism is very controversial, and its identification in patients with HF secondary to Chagas disease in the Brazilian population is required.

Objective

To determine ACE polymorphism in patients with HF secondary to Chagas disease and patients with Chagas disease without systolic dysfunction, and to evaluate the relationship of the ACE polymorphism with different clinical variables.

Methods

This was a comparative clinical study with 193 participants, 103 of them with HF secondary to Chagas disease and 90 with Chagas disease without systolic dysfunction. All patients attended the outpatient department of the General Hospital of the Federal University of Goias general hospital. Alleles I and D of ACE polymorphism were identified by polymerase chain reaction of the respective intron 16 fragments in the ACE gene and visualized by electrophoresis.

Results

In the group of HF patients, 63% were male, whereas 53.6% of patients with Chagas disease without systolic dysfunction were female (p = 0,001). The time from diagnosis varied from 1 to 50 years. Distribution of DD, ID and II genotypes was similar between the two groups, without statistical significance (p = 0,692). There was no difference in clinical characteristics or I/D genotypes between the groups. Age was significantly different between the groups (p = 0,001), and mean age of patients with HF was 62.5 years.

Conclusion

No differences were observed in the distribution of (Insertion/Deletion) genotype frequencies of ACE polymorphism between the studied groups. The use of this genetic biomarker was not useful in detecting a possible relationship between ACE polymorphism and clinical manifestations in HF secondary to Chagas disease.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO₂); carbon dioxide production (VCO₂); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.^1-6

The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases.

Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals.

Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

Self-care in heart failure patients

Objective:

to describe self-care behavior and its associated factors in a sample of heart failure Brazilian patients.

Method:

descriptive cross-sectional study with non-probabilistic sample of 116 ambulatory patients undergoing heart failure treatment. Self-care was evaluated using the Self-Care of Heart Failure Index, (scores ≥70 points=appropriate self-care). Association tests were applied, considering a descriptive level of 0.05.

Results:

the mean age of participants was 57.7 (SD =11.3) years; 54.3% were male; the mean schooling was 5.5 (SD = 4.0) years; and 74.1% had functional class II-III. The mean scores on the subscales of the Self-Care of Heart Failure Index indicated inappropriate self-care (self-care maintenance: 53.2 (SD =14.3), selfcare management: 50.0 (SD = 20.3) and self-care confidence: 52.6 (SD=22.7)) and it was found low frequencies of participants with appropriate self-care (self-care maintenance, 6.9%), self-care management (14.7%) and self-care confidence (19%). Higher scores of the Self-Care of Heart Failure Index were associated with: reduced left ventricular ejection fraction (p=0.001), longer time of experience with the disease (p=0.05) and joint monitoring by physician and nurse (p=0.007).

Conclusion:

investments are needed to improve the self-care behavior and the nursing can play a relevant role in this improvement.

Impacto do monitoramento telefônico em pacientes com insuficiência cardíaca: ensaio clínico randomizado

Resumo Objetivo Analisar o autocuidado e o conhecimento em pacientes com insuficiência cardíaca monitorados por contato telefônico e analisar a correlação do conhecimento com o autocuidado. Métodos Ensaio clínico randomizado, realizado em uma clínica especializada, no período de abril de 2015 a dezembro de 2015. Foram monitorados e randomizados 36 pacientes no Grupo Controle (17) ou no Grupo Intervenção (19). Ambos os grupos participaram do monitoramento convencional, compreendendo três atendimentos (Basal; 2° mês; 4° mês); no Grupo Intervenção houve associação do monitoramento telefônico por meio de um guia padronizado. Foram utilizados os Questionários de Conhecimento e de Autocuidado para avaliação dos desfechos primários e secundários. Resultados Houve diferença no conhecimento (12,7±1,7 vs. 10,8±2,2; p=0,009) e autocuidado (25,4±6,6 vs. 29,5±4,8; p=0,04) no 4° mês; correlação negativa entre os escores do conhecimento e autocuidado no 2° mês (r=-0,48; p=0,03). Conclusão O monitoramento convencional combinado ao monitoramento telefônico mostra-se eficaz no 4° mês com a melhoria do conhecimento e autocuidado de pacientes com insuficiência cardíaca e correlação significativa desses desfechos no 2° mês.