s Henrique Del Carlo

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.

Re-hospitalizações e morte por insuficiência cardíaca: índices ainda alarmantes

BACKGROUND Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS We followed the progress of 263 patients with a mean EF of 27.1%, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9+/-15.2 years, most were men, and 63.1% required inotropic drugs for cardiac compensation in the acute phase. RESULTS Average hospital stay was 25.1+/-16.7 days. During hospitalization, 23 (8.8%) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2%) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5+/-18.0 days. Over the first year of follow-up, 62 (25.8%) patients died. CONCLUSIONS HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5% of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

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.

Microneurography and venous occlusion plethysmography in heart failure: correlation with prognosis

BACKGROUND Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.FUNDAMENTO: Microneurografia e pletismografia de oclusao venosa podem ser considerados metodos de avaliacao da atividade simpatica. OBJETIVO: Avaliar a intensidade da atividade simpatica atraves da microneurografia e da pletismografia de oclusao venosa em pacientes com insuficiencia cardiaca, e correlacionar essa intensidade com prognostico. METODOS: 52 pacientes com insuficiencia cardiaca (FE 53,5 impulsos/min para ANSM (S=90,55. E=73,68%) e 1,81 ml/min/100gr (P<0,001). Analise de regressao logistica: quanto maior a ANSM e menor o FSM, maior e a probabilidade de morte. CONCLUSAO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognosticos na insuficiencia cardiaca avancada.

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.

Microneurografia e pletismografia de oclusão venosa na insuficiência cardíaca: correlação com prognóstico

BACKGROUND Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.FUNDAMENTO: Microneurografia e pletismografia de oclusao venosa podem ser considerados metodos de avaliacao da atividade simpatica. OBJETIVO: Avaliar a intensidade da atividade simpatica atraves da microneurografia e da pletismografia de oclusao venosa em pacientes com insuficiencia cardiaca, e correlacionar essa intensidade com prognostico. METODOS: 52 pacientes com insuficiencia cardiaca (FE 53,5 impulsos/min para ANSM (S=90,55. E=73,68%) e 1,81 ml/min/100gr (P<0,001). Analise de regressao logistica: quanto maior a ANSM e menor o FSM, maior e a probabilidade de morte. CONCLUSAO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognosticos na insuficiencia cardiaca avancada.

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.

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.