Antonio José Lagoeiro Jorge

The Prevalence of Stages of Heart Failure in Primary Care: A Population-Based Study

BACKGROUND Planning strategies to prevent heart failure (HF) in developing countries require epidemiologic data in primary care. The purpose of this study was to estimate the prevalence of HF stages and their phenotypes, HF with preserved ejection fraction (HFPEF), and HF with reduced EF (HFREF) and to determine B-type natriuretic peptide (BNP) levels to identify HF in the adult population. METHODS AND RESULTS This is a cross-sectional study including 633 individuals, aged ≥45 years, who were randomly selected and registered in a primary care program of a medium-sized city in Brazil. All participants were underwent clinical evaluations, BNP measurements, electrocardiograms, and tissue Doppler echocardiography in a single day. The participants were classified as stage 0 (healthy, 11.7%), stage A (risk factors, 36.6%), stage B (structural abnormalities, 42.7%), or stage C (symptomatic HF, 9.3%). Among patients with HF, 59% presented with HFPEF and 41% presented with HFREF. The mean BNP levels were 20 pg/mL(-1) in stage 0, 20 pg/mL(-1) in stage A, 24 pg/mL(-1) in stage B, 93 pg/mL(-1) in HFPEF, and 266 pg/mL(-1) in HFREF. The cutoff BNP level with optimal sensitivity (92%) and specificity (91%) to identify HF was 42 pg/mL(-1). CONCLUSION The present study demonstrated a high prevalence of individuals at risk for HF and the predominance of HFPEF in a primary care setting. The clinical examination, along with BNP and tissue Doppler echocardiography, may facilitate early detection of stages A and B HF and allow implementation of interventions aimed at preventing progression to symptomatic HF.

Insuficiência cardíaca com fração de ejeção normal: novos critérios diagnósticos e avanços fisiopatológicos

Heart failure (HF) is a highly prevalent complex cardiovascular syndrome, and its clinical presentation is usually associated with ventricular dilatation, decreased contractility and reduced left ventricular ejection fraction (EF). However, in the past two decades studies have demonstrated that many patients with signs and symptoms of HF have normal EF (higher than 50%). The great challenge for doctors lies in the identification of patients presenting heart failure with normal ejection fraction (HFNEF) and this challenge seems to be mainly related to the high complexity of the syndrome and to the lack of a standardized method to confirm or exclude the diagnosis that could be used in the daily clinical practice. Unlike in heart failure with reduced ejection fraction (HFREF) in which one single parameter - EF lower than 50%, is sufficient to confirm the diagnosis of the syndrome, in HFNEF different diastolic indexes have been used to characterize the presence or absence of diastolic dysfunction (DD). The purpose of this review is to show new concepts related to the diastolic function that will help understand the cardiovascular pathophysiology of HFNEF, and to discuss the new guideline of the European Society of Cardiology for the diagnosis and exclusion of HFNEF based on cardiac function indices obtained using tissue Doppler imaging (TDI) and natriuretic peptide determination.La insuficiencia cardiaca (IC) es un complejo sindrome cardiovascular con elevada prevalencia, y su cuadro clinico se asocia frecuentemente a la dilatacion del ventriculo, la disminucion de la contractilidad y la reducida fraccion de eyeccion del ventriculo izquierdo (FE). Sin embargo, en las ultimas dos decadas, estudios han evidenciado que muchos pacientes con sintomas y seA±ales de IC presentan FE normal (mayor que el 50%). La gran dificultad de los medicos estaria en la identificacion de esos pacientes que presentan insuficiencia cardiaca con fraccion de eyeccion normal (ICFEN). Esta dificultad parece estar relacionada principalmente a alta complejidad del sindrome y la falta de un metodo estandar para que se confirme o excluya el diagnostico que pudiera utilizarse rutinariamente en la practica clinica. Diferentemente de la insuficiencia cardiaca con fraccion de eyeccion reducida (ICFER), en la que un unico parametro - la FE menor que el 50%- confirma el diagnostico del sindrome, en la ICFEN diferentes indices diastolicos se han empleado para que se caracterice la presencia o no de la disfuncion diastolica (DD). Esta revision tiene el proposito de revelar nuevos conceptos relacionados a la funcion diastolica que auxiliaran la comprension de la fisiopatologia cardiovascular presente en la ICFEN. El presente trabajo tiene tambien por objeto que se discuta la nueva directriz de la Sociedad Europea de Cardiologia para el diagnostico y exclusion de la ICFEN, basada en los indices de funcion cardiaca obtenidos por el ecocardiograma con Doppler tisular (EDT) y en la dosificacion del peptido natriuretico.

Tratamento da insuficiência cardíaca com fração de ejeção normal

Different from heart failure with reduced ejection fraction (HFREF), for which large studies have demonstrated the effectiveness of drug treatment to improve morbidity and mortality, no treatment study has shown definitive results in patients with heart failure with normal ejection fraction (HFNEF). HFNEF is more prevalent in women and the elderly and it is associated with multiple comorbidities. Although the optimum treatment has yet to be defined, the control of arterial hypertension and decreased fluid overload are important measures to control the syndrome. In Brazil, the recommendations for the treatment of HF are based on the Review of the II Directives of the Brazilian Society of Cardiology for the diagnosis and treatment of Heart Failure - 2002. However, none of the recommendations is specific for patients with HFNEF, as they are based on general measures proposed by specialists. This review aims at demonstrating the scientific evidence from recent clinical trials in HFNEF and future perspectives in terms of new medications.

Systems Biology Applied to Heart Failure With Normal Ejection Fraction

Heart failure with normal ejection fraction (HFNEF) is currently the most prevalent clinical phenotype of heart failure. However, the treatments available have shown no reduction in mortality so far. Advances in the omics sciences and techniques of high data processing used in molecular biology have enabled the development of an integrating approach to HFNEF based on systems biology. This study aimed at presenting a systems-biology-based HFNEF model using the bottom-up and top-down approaches. A literature search was conducted for studies published between 1991 and 2013 regarding HFNEF pathophysiology, its biomarkers and systems biology. A conceptual model was developed using bottom-up and top-down approaches of systems biology. The use of systems-biology approaches for HFNEF, a complex clinical syndrome, can be useful to better understand its pathophysiology and to discover new therapeutic targets.

Entendendo a disfunção diastólica assintomática na prática clínica

1 . Cardiac dysfunction, either systolic or asymptomatic diastolic, has a high prevalence in the adult population older than 45 years, and is a phase during which the patient can progress to the clinical form of HF; this transition brings a five-fold increase in mortality 2 . Identifying patients with asymptomatic cardiac dysfunction may allow the implementation of nonpharmacological or pharmacological interventions aiming at reversing heart functional and structural abnormalities, thus delaying the onset of symptomatic HF. The concept that HF has progressive stages and is therefore a preventable condition was proposed by the American College of Cardiology (ACC) and the American Heart Association (AHA) 3 and was incorporated by the Chronic HF Guidelines of the Brazilian Society of Cardiology 4 . HF with normal ejection fraction (HFNEF) is now a new epidemic that affects elderly hypertensive patients and represents more than 50% of patients hospitalized for HF. The onset of HFNEF is preceded by diastolic abnormalities such as slowing in relaxation and alterations in the filling pressures and structure of the left ventricle (LV) - left ventricular hypertrophy (LVH), and increased left atrial volume (LAV). Thus, it is important to detect these abnormalities in a preclinical phase 2 . Asymptomatic systolic dysfunction is easily recognized by clinicians using a cardiac imaging method, for the presence of left ventricular ejection fraction (LVEF) < 50%. The characterization of asymptomatic diastolic dysfunction (DD) is made by a triad consisting of absence of HF symptoms, evidence of DD and LVEF ≥ 50%, and its presence is a marker for the onset of symptomatic HF and reduced life expectancy 5 .

Heart failure with normal ejection fraction: new diagnostic criteria and pathophysiological advances.

Heart failure (HF) is a highly prevalent complex cardiovascular syndrome, and its clinical presentation is usually associated with ventricular dilatation, decreased contractility and reduced left ventricular ejection fraction (EF). However, in the past two decades studies have demonstrated that many patients with signs and symptoms of HF have normal EF (higher than 50%). The great challenge for doctors lies in the identification of patients presenting heart failure with normal ejection fraction (HFNEF) and this challenge seems to be mainly related to the high complexity of the syndrome and to the lack of a standardized method to confirm or exclude the diagnosis that could be used in the daily clinical practice. Unlike in heart failure with reduced ejection fraction (HFREF) in which one single parameter - EF lower than 50%, is sufficient to confirm the diagnosis of the syndrome, in HFNEF different diastolic indexes have been used to characterize the presence or absence of diastolic dysfunction (DD). The purpose of this review is to show new concepts related to the diastolic function that will help understand the cardiovascular pathophysiology of HFNEF, and to discuss the new guideline of the European Society of Cardiology for the diagnosis and exclusion of HFNEF based on cardiac function indices obtained using tissue Doppler imaging (TDI) and natriuretic peptide determination.La insuficiencia cardiaca (IC) es un complejo sindrome cardiovascular con elevada prevalencia, y su cuadro clinico se asocia frecuentemente a la dilatacion del ventriculo, la disminucion de la contractilidad y la reducida fraccion de eyeccion del ventriculo izquierdo (FE). Sin embargo, en las ultimas dos decadas, estudios han evidenciado que muchos pacientes con sintomas y seA±ales de IC presentan FE normal (mayor que el 50%). La gran dificultad de los medicos estaria en la identificacion de esos pacientes que presentan insuficiencia cardiaca con fraccion de eyeccion normal (ICFEN). Esta dificultad parece estar relacionada principalmente a alta complejidad del sindrome y la falta de un metodo estandar para que se confirme o excluya el diagnostico que pudiera utilizarse rutinariamente en la practica clinica. Diferentemente de la insuficiencia cardiaca con fraccion de eyeccion reducida (ICFER), en la que un unico parametro - la FE menor que el 50%- confirma el diagnostico del sindrome, en la ICFEN diferentes indices diastolicos se han empleado para que se caracterice la presencia o no de la disfuncion diastolica (DD). Esta revision tiene el proposito de revelar nuevos conceptos relacionados a la funcion diastolica que auxiliaran la comprension de la fisiopatologia cardiovascular presente en la ICFEN. El presente trabajo tiene tambien por objeto que se discuta la nueva directriz de la Sociedad Europea de Cardiologia para el diagnostico y exclusion de la ICFEN, basada en los indices de funcion cardiaca obtenidos por el ecocardiograma con Doppler tisular (EDT) y en la dosificacion del peptido natriuretico.

Compliance with the Prescription of Antihypertensive Medications and Blood Pressure Control in Primary Care

Background: Hypertension is the most prevalent risk factor for cardiovascular disease, and its proper control can prevent the high morbidity and mortality associated with this disease. Objective: To assess the degree of compliance of antihypertensive prescriptions with the VI Brazilian Guidelines on Hypertension and the blood pressure control rate in primary care. Methods: Cross-sectional study conducted between August 2011 and November 2012, including 332 adults ≥ 45 years registered in the Family Doctor Program in Niteroi and selected randomly. The analysis included the prescribed antihypertensive classes, doses, and frequencies, as well as the blood pressure (BP) of the individuals. Results: The rate of prescription compliance was 80%. Diuretics were the most prescribed medications, and dual therapy was the most used treatment. The most common non-compliances were underdosing and underfrequencies. The BP goal in all cases was < 140/90 mmHg, except for diabetic patients, in whom the goal was set at < 130/80 mmHg. Control rates according to these goals were 44.9% and 38.6%, respectively. There was no correlation between prescription compliance and BP control. Conclusions: The degree of compliance was considered satisfactory. The achievement of the targets was consistent with national and international studies, suggesting that the family health model is effective in BP management, although it still needs improvement. Fundamento: A hipertensão arterial é o fator de risco mais prevalente para a doença cardiovascular e seu controle adequado pode prevenir a elevada morbi-mortalidade associada a esta doença. Objetivo: Avaliar o grau de conformidade das prescrições de anti-hipertensivos com as VI Diretrizes Brasileiras de Hipertensão e a taxa de controle pressórico na atenção básica. Métodos: Estudo transversal conduzido entre agosto de 2011 e novembro de 2012, incluindo 332 adultos ≥ 45 anos cadastrados no Programa Médico de Família de Niterói e selecionados aleatoriamente. Foram analisadas as classes de anti-hipertensivos prescritos, suas doses e frequências, bem como a pressão arterial (PA) dos indivíduos. Resultados: A taxa de conformidade das prescrições foi de 80%. Diuréticos foram as medicações mais prescritas e a terapia dupla foi o tratamento mais utilizado. As não conformidades mais comuns foram subdoses e subfrequências. A meta de PA para todos os casos foi < 140/90 mmHg, exceto para diabéticos, que foi < 130/80 mmHg. As taxas de controle de acordo com essas metas foram de 44,9% e 38,6%, respectivamente. Não houve correlação entre conformidade da prescrição e controle pressórico. Conclusões: O grau de conformidade foi considerado satisfatório. O alcance das metas foi compatível com estudos nacionais e internacionais, sugerindo que o modelo de saúde da família é efetivo no manejo da PA, embora ainda necessite aprimoramento. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0).

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care

Background Obstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women. Objective To study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied. Methods Observational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05). Results Of the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III. Conclusion BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.

Insuficiencia cardiaca con fracción de eyección normal: nuevos criterios diagnósticos y avances fisiopatológicos

Heart failure (HF) is a highly prevalent complex cardiovascular syndrome, and its clinical presentation is usually associated with ventricular dilatation, decreased contractility and reduced left ventricular ejection fraction (EF). However, in the past two decades studies have demonstrated that many patients with signs and symptoms of HF have normal EF (higher than 50%). The great challenge for doctors lies in the identification of patients presenting heart failure with normal ejection fraction (HFNEF) and this challenge seems to be mainly related to the high complexity of the syndrome and to the lack of a standardized method to confirm or exclude the diagnosis that could be used in the daily clinical practice. Unlike in heart failure with reduced ejection fraction (HFREF) in which one single parameter - EF lower than 50%, is sufficient to confirm the diagnosis of the syndrome, in HFNEF different diastolic indexes have been used to characterize the presence or absence of diastolic dysfunction (DD). The purpose of this review is to show new concepts related to the diastolic function that will help understand the cardiovascular pathophysiology of HFNEF, and to discuss the new guideline of the European Society of Cardiology for the diagnosis and exclusion of HFNEF based on cardiac function indices obtained using tissue Doppler imaging (TDI) and natriuretic peptide determination.La insuficiencia cardiaca (IC) es un complejo sindrome cardiovascular con elevada prevalencia, y su cuadro clinico se asocia frecuentemente a la dilatacion del ventriculo, la disminucion de la contractilidad y la reducida fraccion de eyeccion del ventriculo izquierdo (FE). Sin embargo, en las ultimas dos decadas, estudios han evidenciado que muchos pacientes con sintomas y seA±ales de IC presentan FE normal (mayor que el 50%). La gran dificultad de los medicos estaria en la identificacion de esos pacientes que presentan insuficiencia cardiaca con fraccion de eyeccion normal (ICFEN). Esta dificultad parece estar relacionada principalmente a alta complejidad del sindrome y la falta de un metodo estandar para que se confirme o excluya el diagnostico que pudiera utilizarse rutinariamente en la practica clinica. Diferentemente de la insuficiencia cardiaca con fraccion de eyeccion reducida (ICFER), en la que un unico parametro - la FE menor que el 50%- confirma el diagnostico del sindrome, en la ICFEN diferentes indices diastolicos se han empleado para que se caracterice la presencia o no de la disfuncion diastolica (DD). Esta revision tiene el proposito de revelar nuevos conceptos relacionados a la funcion diastolica que auxiliaran la comprension de la fisiopatologia cardiovascular presente en la ICFEN. El presente trabajo tiene tambien por objeto que se discuta la nueva directriz de la Sociedad Europea de Cardiologia para el diagnostico y exclusion de la ICFEN, basada en los indices de funcion cardiaca obtenidos por el ecocardiograma con Doppler tisular (EDT) y en la dosificacion del peptido natriuretico.

Vitamin D Deficiency and Cardiovascular Diseases

Vitamin D is considered a steroid hormone with a broad spectrum of action in the human body. Its action arises from the binding of its active metabolite (1α,25dihydroxyvitamin D) to its receptor (VDR), which is present throughout the body, including vascular smooth muscle cells and cardiomyocytes. Initially, vitamin D deficiency was related only to changes in the musculoskeletal system, but in recent years, researchers have demonstrated its relationship with several pathologies related to other systems, such as cardiovascular diseases. The objective of this study is to review vitamin D’s pathophysiology, describe its relationship with cardiovascular diseases based on the most recent publications, and highlight the results of vitamin supplementation in the prevention of such pathologies.