Elieusa e Silva Sampaio

Silent Cerebral Infarctions with Reduced, Mid-Range and Preserved Ejection Fraction in Patients with Heart Failure

Heart failure predisposes to an increased risk of silent cerebral infarction, and data related to left ventricular ejection fraction are still limited. Our objective was to describe the clinical and echocardiographic characteristics and factors associated with silent cerebral infarction in patients with heart failure, according to the left ventricular ejection fraction groups. A prospective cohort was performed at a referral hospital in Cardiology between December 2015 and July 2017. The left ventricular ejection fraction groups were: reduced (≤ 40%), mid-range (41-49%) and preserved (≥ 50%). All patients underwent cranial tomography, transthoracic and transesophageal echocardiography. Seventy-five patients were studied. Silent cerebral infarction was observed in 14.7% of the study population (45.5% lacunar and 54.5% territorial) and was more frequent in patients in the reduced left ventricular ejection fraction group (29%) compared with the mid-range one (15.4%, p = 0.005). There were no cases of silent cerebral infarction in the group of preserved left ventricular ejection fraction. In the univariate analysis, an association was identified between silent cerebral infarction and reduced (OR = 8.59; 95%CI: 1.71 - 43.27; p = 0.009) and preserved (OR = 0.05; 95%CI: 0.003-0.817, p = 0.003) left ventricular ejection fraction and diabetes mellitus (OR = 4.28, 95%CI: 1.14-16.15, p = 0.031). In patients with heart failure and without a clinical diagnosis of stroke, reduced and mid-range left ventricular ejection fractions contributed to the occurrence of territorial and lacunar silent cerebral infarction, respectively. The lower the left ventricular ejection fraction, the higher the prevalence of silent cerebral infarction.

Occurrence of Stroke and Reduced Ejection Fraction in Patients with Chagas Disease

5. da Matta JA, Aras R Jr, de Macedo CR, da Cruz CG, Netto EM. Stroke correlates in Chagasic and non-Chagasic cardiomyopathies. PLoS One. 2012;7(4):e35116. doi: 10.1371/journal.pone.0035116. References DOI: 10.5935/abc.20180029 To the Editor Chagas disease (CD) is a well-defined risk factor for stroke.1 But the prognostic significance of stroke prevalence in left ventricular ejection fraction (LVEF) reduced compared to preserved LVEF in patients with heart failure and with CD, is still poorly known.2 There are studies that demonstrate the association of stroke with CD and reduced LVEF3 and there are studies that refute this association.4 In a cross-sectional study involving 85 chagasic patients with a mean age of 61.8 ± 9.3 years, 71.8% with heart failure and 96.5% of black race, patients were compared with LVEF ≤ 40% and LVEF > 40% to evaluate stroke occurrence in patients with CD and reduced LVEF. It was shown that LVEF ≤ 40% (OR 4.37: 1.65-11.63; p = 0.003) was an independent predictor for stroke compared to patients with preserved LVEF. There was also a high prevalence (50%) of CVA, which was obtained by cranial tomography, a number close to a cohort of 41.6% in the same town.5 There were no hemorrhagic strokes and there was also no significant relationship between fibrillation atrial and stroke, this data can be explained by the use of oral anticoagulants in these patients. In addition, 54.8% of silent vascular accidents were detected in patients who had no history of stroke. The high prevalence of stroke in this study with chagasic patients may have occurred because all patients were evaluated with cranial tomography, contrary to other studies, which generally use clinical and/or radiological findings as diagnostic criteria for stroke1,4 and do not usually evaluate silent cerebral infarction.4 Data suggest that reduced LVEF is associated with stroke, confirmed by cranial tomography and may be an independent predictor of embolic events in this population.

Incidence of Atrial High-Rate Episodes in Chagas Disease Patients

2. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2(5):474-80. 3. Camm AJ, Simantirakis E, Goette A, Lip GY, Vardas P, Melanie C, et al. Atrial high-rate episodes and stroke prevention. Europace. 2017;19 (2):169-79.

Therapeutic Adherence and Functional Capacity in Heart Failure

Dear Editor, Heart failure (HF) has become a major public health problem, as it is the final pathway of most heart diseases1. One of the main factors that lead to decompensation in HF is poor patient adherence to treatment2. Educational intervention programs for the management of chronic disease and clinical monitoring of HF are associated with better adherence to treatment3,4. It was observed, in a non-controlled clinical trial with 25 patients in a HF outpatient clinic, that the educational intervention improved the following indicators: renal function assessment with improved estimated glomerular filtration rate (eGFR; median: V0 = 61 vs. V1 = 68) and B-type natriuretic peptide (BNP), treatment adherence score and functional capacity at the six-minute walk test (6MWT). The treatment adherence questionnaire assessed the following: correct use of medications, daily weight, salt and fluid restriction, alcohol intake and attendance at appointments and tests. The adherence score can range from zero to 10 points4. At the adherence assessment, an improvement was observed comparing the pre (V0) and post (V1) intervention periods, with a median of V0 = 5.0 vs. V1 = 6.1 (p = 0.006). It was demonstrated that in V0, the patients considered non-adherent sought the emergency service in the last 30 days more often than those considered adherent (p = 0.013) and in V1, 100% of patients reported not having sought the emergency service during the period. After the educational intervention, patients with systolic HF with low left ventricular ejection fraction (LVEF ≤ 40%) showed improved adherence score (p = 0.006) and clinical improvement with a decrease in functional class (FC) and weight (p = 0.022). As for the 6MWT, the patients that showed better performance in the test were those considered adherent to treatment, with FC III, time of HF = 12-16 years, LVEF of 24 to 29%, and hypertensive etiology. Clinical and renal function improvement was observed in outpatients with heart failure submitted to educational intervention that showed greater adherence to optimized therapy.