Antonio Carlos Pereira-Barretto

Serial measure of cardiac troponin T levels for prediction of clinical events in decompensated heart failure

BACKGROUND This study determined whether serial determinations of cardiac troponin T (cTnT) in decompensated heart failure (HF) are predictive of clinical events (death, need for readmission for new episode of HF decompensation, or both) during 1 year of follow-up. METHODS AND RESULTS Sixty-two patients with decompensated HF were enrolled in this cohort. The first measurement of cTnT (cTnT1) was from a blood sample drawn within 4 days of hospital admission; the second measurement (cTnT2) was on blood obtained 7 days later. Forty-nine clinical events (16 deaths, 10 readmissions, 23 combined readmission and deaths) occurred during the follow-up. The independent predictors of clinical events were: cTnT1>.020 ng/mL (P<.050), cTnT2>.020 ng/mL (P<.050), and serum sodium<135 mEq/L (P<.050). Based on levels of cTnT1 and cTnT2>.020 ng/mL (+) or </=0.020 ng/mL(-), patients were divided into 2 groups: group 1 (cTnT1-, cTnT2- or cTnT1+, cTnT2-), group 2 (cTnT1-, cTnT2+ or cTnT1+, cTnT2+). Group 2 patients had higher rates of death (45.0% versus 71.4%, P<.050), hospital readmission (35.0% versus 61.9%, P<.050), and clinical events (55.0% versus 90.5%, P<.010) than group 1 patients. CONCLUSIONS Persistently increased cTnT levels (>.020 ng/mL) are predictive of higher rates of death and hospital readmission for decompensated HF.

Reverse Cardiac Remodeling: A Marker of Better Prognosis in Heart Failure

In heart failure syndrome, myocardial dysfunction causes an increase in neurohormonal activity, which is an adaptive and compensatory mechanism in response to the reduction in cardiac output. Neurohormonal activity is initially stimulated in an attempt to maintain compensation; however, when it remains increased, it contributes to the intensification of clinical manifestations and myocardial damage. Cardiac remodeling comprises changes in ventricular volume as well as the thickness and shape of the myocardial wall. With optimized treatment, such remodeling can be reversed, causing gradual improvement in cardiac function and consequently improved prognosis.

Papel dos níveis de BNP no prognóstico da insuficiência cardíaca avançada descompensada

BACKGROUND Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

Escore para avaliação do estado nutricional: seu valor na estratificação prognóstica de portadores de cardiomiopatia dilatada e insuficiência cardíaca avançada

OBJECTIVE Develop a method for the evaluation of patients nutritional status through a score that expresses universal nutritional status, as well as investigate if that score would be efficient for the prognostic stratification of advanced heart failure (HF) pts. METHODS The score was reached by the selection of evaluation methods that would quantify nutritional status: ideal body weight percentage, thickness of tricipital skinfold, percentiles for arm muscular mass circumference, albumin serum level, lymphocyte total count. In order to be validated, the score was applied to a group of 95 pts. Pts were under 65 years old no evidence of consumptive diseases. The score was analyzed to confirm whether it would keep correlation with HF clinical data and whether it would stratify its prognostic. RESULTS Nutritional status suggesting moderate or severe malnutrition could be observed in 31/95 (32.6%). No correlation was found between nutritional score values and the duration of symptoms, or the level of ventricular dysfunction. Pts with high nutritional score showed a trend towards higher mortality rate (p=0.0606). CONCLUSION Those data suggest malnutrition is reported by 1/3 of pts with advanced HF. A score comprising 5 parameters for nutritional status showed good correlation with the clinical, global evaluation of pts with HF. A score over 8 identified pts with higher probability of death as outcome, confirming that pts under higher malnutrition exhibit worse evolution.OBJETIVO: Desenvolver metodo de avaliacao do estado nutricional do paciente atraves de escore que expresse o estado nutricional de maneira universal e verificar se esse escore seria eficaz na estratificacao prognostica de pacientes com insuficiencia cardiaca (IC) avancada. METODOS: Para compor o escore foram selecionados metodos de avaliacao que procurassem quantificar forma de medida do estado nutricional: a porcentagem ideal do peso, a espessura da prega tricipital, os percentis da circunferencia da massa muscular do braco, os niveis sericos de albumina, a contagem global de linfocitos. Para valida-lo, aplicou-se o escore num grupo de 95 pacientes com idade inferior a 65 anos, sem evidencias de doencas consumptivas e analisou-se se esse escore manteria correlacao com os dados clinicos da IC e permitiria estratificar o prognostico. RESULTADOS: A situacao nutricional esteve alterada nos pacientes e escore elevado sugerindo desnutricao moderada ou intensa foi observado em 31/95 (32,6%) dos casos. Nao houve correlacao entre os valores do escore nutricional, duracao dos sintomas e grau de disfuncao ventricular. Os pacientes com escore nutricional elevado apresentaram tendencia de maior mortalidade (p=0,0606). CONCLUSOES: Os dados sugerem que a desnutricao atinge cerca de 1/3 dos pacientes com IC avancada. Um escore que englobou cinco parâmetros de avaliacao nutricional teve boa correlacao com a avaliacao clinica e permitiu avaliar globalmente a desnutricao de portadores de IC. Escore superior a 8 identificou pacientes com maior probabilidade de morrer, confirmando que pacientes mais desnutridos tem pior evolucao.

Temporal variation in the prognosis and treatment of advanced heart failure - before and after 2000.

Background The treatment of heart failure has evolved in recent decades suggesting that survival is increasing. Objective To verify whether there has been improvement in the survival of patients with advanced heart failure. Methods We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis. Results The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7). Conclusions Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.

Relationship between depression, BNP levels and ventricular impairment in heart failure

FUNDAMENTO: A depressao e uma comorbidade frequente na insuficiencia cardiaca (IC), mas os mecanismos relacionados a pior evolucao de pacientes deprimidos com IC ainda nao estao esclarecidos. OBJETIVO: Avaliar o papel da depressao grave na evolucao dos pacientes com IC descompensada. METODOS: Estudamos consecutivamente 43 pacientes com IC avancada e FE < 40,0%, hospitalizados para compensacao cardiaca. Os pacientes, apos historia e exame fisico, foram submetidos a exames laboratoriais, incluindo a dosagem de BNP. Apos o diagnostico de depressao, aplicou-se a escala de Hamilton-D. Depressao grave foi definida por escore igual ou maior que 18. As variaveis clinico-laboratoriais, segundo a presenca ou nao de depressao grave, foram analisadas pela regressao logistica. A curva ROC definiu o ponto de corte para o BNP. RESULTADOS: Depressao grave ou muito grave foi identificada em 24 (55,8%) pacientes. Os pacientes deprimidos graves nao diferiram dos nao deprimidos quanto a idade, sexo e funcao renal, mas apresentaram menor comprometimento cardiaco (FE 23,4 ± 7,2% vs 19,5 ± 5,2%; p = 0,046) e valores mais elevados do BNP (2.582,8 ± 1.596,6 pg/ml vs 1.206,6 ± 587,0 pg/ml; p < 0,001). Entretanto, os pacientes com BNP maior que 1.100 pg/ml tiveram 12,0 (odds ratio [IC 95%] = 2,61 - 55,26) vezes mais chance de desenvolverem quadros de depressao grave. CONCLUSAO: Os pacientes com depressao grave apresentaram maior grau de estimulacao neuro-hormonal, apesar do grau de disfuncao ventricular ser menor. As alteracoes fisiopatologicas relacionadas a depressao, aumentando a estimulacao neuro-hormonal e as citocinas, provavelmente contribuiram para essa maior manifestacao clinica, mesmo em presenca de menor dano cardiaco.BACKGROUND Depression is a common comorbidity in heart failure (HF); however, the mechanisms related to a poorer outcome of depressed patients with HF remain unclear. OBJECTIVE To evaluate the role of severe depression in the outcome of patients with decompensated HF. METHODS A total of 43 patients with advanced HF, EF < 40.0%, and hospitalized for cardiac compensation were consecutively studied. After history taking and physical examination, the patients underwent laboratory tests including BNP determination. After the diagnosis of depression was made, the Hamilton-D scale was applied. Severe depression was defined by a score equal to or greater than 18. The clinical and laboratory variables according to the presence or absence of severe depression were analyzed using logistic regression. The ROC curve defined the cut-off point for BNP. RESULTS Severe or very severe depression was identified in 24 (55.8%) patients. Severely depressed patients did not differ from non-depressed patients as regards age, gender and renal function, but showed less cardiac impairment (EF 23.4 ± 7.2% vs 19.5 ± 5.2%; p = 0.046) and higher BNP levels (2,582.8 ± 1,596.6 pg/ml vs 1,206.6 ± 587.0 pg/ml; p < 0.001). However, patients with BNP levels higher than 1,100 pg/ml had a 12.0-fold higher chance (odds ratio [95% CI] = 2.61 - 55.26) of developing severe depression. CONCLUSION Patients with severe depression showed a higher degree of neurohormonal stimulation despite their lower degree of ventricular dysfunction. The pathophysiological changes related to depression, leading to increased neurohormonal stimulation and cytokines, probably contributed to this more intense clinical manifestation even in the presence of less cardiac damage.

Economy class syndrome after long duration bus travel

A 65 year-old man with heart failure due to hypertensive and ischemic heart disease was admitted to the hospital with dyspnea, bloody sputum and pleuritic chest pain after a 52-hour bus trip. Clinical and laboratory evaluation included chest helical tomography that demonstrated a filling defect of the right main branch of the pulmonary artery and a regular peripheral opacity of triangular shape in the inferior lobe of the lower lung. The diagnosis of pulmonary thromboembolism was made and therapy with heparin, followed by warfarin was introduced. The patient was discharged from the hospital. The diagnosis of pulmonary embolism should be considered in patients with complaints like this patient after long-distance bus travel.

Cardiac troponin T for risk stratification in decompensated chronic heart failure

FUNDAMENTO: As troponinas cardiacas sao marcadores altamente sensiveis e especificos de lesao miocardica. Esses marcadores foram detectados na insuficiencia cardiaca (IC) e estao associadas com mau prognostico. OBJETIVO: Avaliar a relacao da troponina T (cTnT) e suas faixas de valores com o prognostico na IC descompensada. METODOS: Estudaram-se 70 pacientes com piora da IC cronica que necessitaram de hospitalizacao. Na admissao, o modelo de Cox foi utilizado para avaliar as variaveis capazes de predizer o desfecho composto por morte ou re-hospitalizacao em razao de piora da IC durante um ano. RESULTADOS: Durante o seguimento, ocorreram 44 mortes, 36 re-hospitalizacoes por IC e 56 desfechos compostos. Na analise multivariada, os preditores de eventos clinicos foram: cTnT (cTnT > 0,100 ng/ml; hazard ratio (HR) 3,95 intervalo de confianca (IC) 95%: 1,64-9,49, p = 0,002), diâmetro diastolico final do ventriculo esquerdo (DDVE >70 mm; HR 1,92, IC95%: 1,06-3,47, p = 0,031) e sodio serico (Na 0,020 e 0,100 ng/ml, n = 12). As probabilidades de sobrevida e sobrevida livre de eventos foram: 54,2%, 31,5%, 16,7% (p = 0,020), e 36,4%, 11,5%, 8,3% (p = 0,005), respectivamente. CONCLUSAO: A elevacao da cTnT esta associada com mau prognostico na IC descompensada, e o grau dessa elevacao pode facilitar a estratificacao de risco.BACKGROUND The cardiac troponins are highly sensitive and specific markers of myocardial injury. They have been detected in heart failure (HF) and are associated with a bad prognosis. OBJECTIVE To evaluate the association of cardiac troponin T (cTnT) and its ranges with prognosis in decompensated HF. METHODS A total of 70 patients with chronic HF worsening that needed hospitalization were studied. Cox model was used to evaluate the variables at admission capable of predicting the combined outcome that consisted of death or re-hospitalization due to HF worsening during a 1-year follow-up. RESULTS During the follow-up, there were 44 deaths, 36 re-hospitalizations due to HF and 56 combined outcomes. At the multivariate analysis, the predictors of clinical events were the cTnT (cTnT > or = 0.100 ng/mL; hazard ratio [HR] 3.95 95% confidence interval [CI]: 1.64-9.49, p = 0.002), left ventricular end diastolic diameter (LVDD > or = 70 mm; HR 1.92, 95%CI: 1.06-3.47, p = 0.031) and serum sodium (Na < 135 mEq/L; HR 1.79, 95%CI: 1.02-3.15, p = 0.044). To evaluate the association between the cTnT increase and the prognosis in decompensated HF, the patients were stratified in three groups: low-cTnT (cTnT <0.020 ng/ml, n = 22), intermediate-cTnT (cTnT > 0.020 and < 0.100 ng/ml, n = 36), and high-cTnT (cTnT > or = 0.100 ng/ml, n = 12).The probabilities of survival and event-free survival were 54.2%, 31.5%, 16.7% (p = 0.020) and 36.4%, 11.5%, 8.3% (p = 0.005), respectively. CONCLUSION The increase in cTnT is associated with a bad prognosis in decompensated HF and the degree of this increase can help the risk stratification.

Troponina cardíaca T para estratificação de risco na insuficiência cardíaca crônica descompensada

FUNDAMENTO: As troponinas cardiacas sao marcadores altamente sensiveis e especificos de lesao miocardica. Esses marcadores foram detectados na insuficiencia cardiaca (IC) e estao associadas com mau prognostico. OBJETIVO: Avaliar a relacao da troponina T (cTnT) e suas faixas de valores com o prognostico na IC descompensada. METODOS: Estudaram-se 70 pacientes com piora da IC cronica que necessitaram de hospitalizacao. Na admissao, o modelo de Cox foi utilizado para avaliar as variaveis capazes de predizer o desfecho composto por morte ou re-hospitalizacao em razao de piora da IC durante um ano. RESULTADOS: Durante o seguimento, ocorreram 44 mortes, 36 re-hospitalizacoes por IC e 56 desfechos compostos. Na analise multivariada, os preditores de eventos clinicos foram: cTnT (cTnT > 0,100 ng/ml; hazard ratio (HR) 3,95 intervalo de confianca (IC) 95%: 1,64-9,49, p = 0,002), diâmetro diastolico final do ventriculo esquerdo (DDVE >70 mm; HR 1,92, IC95%: 1,06-3,47, p = 0,031) e sodio serico (Na 0,020 e 0,100 ng/ml, n = 12). As probabilidades de sobrevida e sobrevida livre de eventos foram: 54,2%, 31,5%, 16,7% (p = 0,020), e 36,4%, 11,5%, 8,3% (p = 0,005), respectivamente. CONCLUSAO: A elevacao da cTnT esta associada com mau prognostico na IC descompensada, e o grau dessa elevacao pode facilitar a estratificacao de risco.BACKGROUND The cardiac troponins are highly sensitive and specific markers of myocardial injury. They have been detected in heart failure (HF) and are associated with a bad prognosis. OBJECTIVE To evaluate the association of cardiac troponin T (cTnT) and its ranges with prognosis in decompensated HF. METHODS A total of 70 patients with chronic HF worsening that needed hospitalization were studied. Cox model was used to evaluate the variables at admission capable of predicting the combined outcome that consisted of death or re-hospitalization due to HF worsening during a 1-year follow-up. RESULTS During the follow-up, there were 44 deaths, 36 re-hospitalizations due to HF and 56 combined outcomes. At the multivariate analysis, the predictors of clinical events were the cTnT (cTnT > or = 0.100 ng/mL; hazard ratio [HR] 3.95 95% confidence interval [CI]: 1.64-9.49, p = 0.002), left ventricular end diastolic diameter (LVDD > or = 70 mm; HR 1.92, 95%CI: 1.06-3.47, p = 0.031) and serum sodium (Na < 135 mEq/L; HR 1.79, 95%CI: 1.02-3.15, p = 0.044). To evaluate the association between the cTnT increase and the prognosis in decompensated HF, the patients were stratified in three groups: low-cTnT (cTnT <0.020 ng/ml, n = 22), intermediate-cTnT (cTnT > 0.020 and < 0.100 ng/ml, n = 36), and high-cTnT (cTnT > or = 0.100 ng/ml, n = 12).The probabilities of survival and event-free survival were 54.2%, 31.5%, 16.7% (p = 0.020) and 36.4%, 11.5%, 8.3% (p = 0.005), respectively. CONCLUSION The increase in cTnT is associated with a bad prognosis in decompensated HF and the degree of this increase can help the risk stratification.

Serum NT-proBNP levels are a prognostic predictor in patients with advanced heart failure

OBJECTIVE: To verify if the determination of NT-proBNP values would help predict the prognosis in advanced heart failure (HF) patients. METHODS: One hundred and five subjects with average age of 52.4 years were evaluated, 66.6% of them males. Thirty-three (32.0%) subjects were outpatients and 70 (67.9%) were inpatients (functional class III/IV) admitted to the hospital for cardiac compensation. All patients had left ventricular systolic dysfunction and a mean ejection fraction of 0.29. The NT-proBNP levels were measured in all patients and they were followed-up over a period from 2 to 90 days (average 77 days). A ROC curve was drawn to determine the best cut-off point, as well as the corresponding Kaplan-Meyer survival curves. RESULTS: During the follow-up period, 22 patients died. The average NT-proBNP value of the patients who remained alive was 6,443.67±6,071.62 pg/ml, whereas that of those who died was 14,609.66±12,165.15 pg/ml (p=0.001). The ROC curve identified a cut-off point at 6,000 pg/ml with 77.3% sensitivity (area under the curve: 0.74). The survival curve for values below and above 6,000 pg/ml was significantly different (p=0.002): patients with values below 6,000 pg/ml had a 90.2% 90-day survival, and those patients with values above, a 66% survival. CONCLUSION: Patients with advanced HF, especially those admitted to the hospital for cardiac compensation, had much higher NT-proBNP values, with a two-fold increase among those who died during the follow-up period. Values above 6,000 pg/ml identify the patients most likely to die within 90 days after hospital discharge.OBJECTIVE To verify if the determination of NT-proBNP values would help predict the prognosis in advanced heart failure (HF) patients. METHODS One hundred and five subjects with average age of 52.4 years were evaluated, 66.6% of them males. Thirty-three (32.0%) subjects were outpatients and 70 (67.9%) were inpatients (functional class III/IV) admitted to the hospital for cardiac compensation. All patients had left ventricular systolic dysfunction and a mean ejection fraction of 0.29. The NT-proBNP levels were measured in all patients and they were followed-up over a period from 2 to 90 days (average 77 days). A ROC curve was drawn to determine the best cut-off point, as well as the corresponding Kaplan-Meyer survival curves. RESULTS During the follow-up period, 22 patients died. The average NT-proBNP value of the patients who remained alive was 6,443.67+/-6,071.62 pg/ml, whereas that of those who died was 14,609.66+/-12,165.15 pg/ml (p=0.001). The ROC curve identified a cut-off point at 6,000 pg/ml with 77.3% sensitivity (area under the curve: 0.74). The survival curve for values below and above 6,000 pg/ml was significantly different (p=0.002): patients with values below 6,000 pg/ml had a 90.2% 90-day survival, and those patients with values above, a 66% survival. CONCLUSION Patients with advanced HF, especially those admitted to the hospital for cardiac compensation, had much higher NT-proBNP values, with a two-fold increase among those who died during the follow-up period. Values above 6,000 pg/ml identify the patients most likely to die within 90 days after hospital discharge.