Euler Brancalhão

Predictors of low cardiac output in decompensated severe heart failure.

OBJECTIVE: To identify predictors of low cardiac output and mortality in decompensated heart failure. INTRODUCTION: Introduction: Patients with decompensated heart failure have a high mortality rate, especially those patients with low cardiac output. However, this clinical presentation is uncommon, and its management is controversial. METHODS: We studied a cohort of 452 patients hospitalized with decompensated heart failure with an ejection fraction of <0.45. Patients underwent clinical‐hemodynamic assessment and Chagas disease immunoenzymatic assay. Low cardiac output was defined according to L and C clinical‐hemodynamic profiles. Multivariate analyses assessed clinical outcomes. P<0.05 was considered significant. RESULTS: The mean age was 60.1 years; 245 (54.2%) patients were >60 years, and 64.6% were men. Low cardiac output was present in 281 (63%) patients on admission. Chagas disease was the cause of heart failure in 92 (20.4%) patients who had higher B type natriuretic peptide levels (1,978.38 vs. 1,697.64 pg/mL; P = 0.015). Predictors of low cardiac output were Chagas disease (RR: 3.655, P<0.001), lower ejection fraction (RR: 2.414, P<0.001), hyponatremia (RR: 1.618, P = 0.036), and renal dysfunction (RR: 1.916, P = 0.007). Elderly patients were inversely associated with low cardiac output (RR: 0.436, P = 0.001). Predictors of mortality were Chagas disease (RR: 2.286, P<0.001), ischemic etiology (RR: 1.449, P = 0.035), and low cardiac output (RR: 1.419, P = 0.047). CONCLUSIONS: In severe decompensated heart failure, predictors of low cardiac output are Chagas disease, lower ejection fraction, hyponatremia, and renal dysfunction. Additionally, Chagas disease patients have higher B type natriuretic peptide levels and a worse prognosis independent of lower ejection fraction.

Chagas cardiomyopathy: prognosis in clinical and hemodynamic profile C

BACKGROUND patients with heart failure (HF) who are admitted showing poor perfusion and congestion (clinical-hemodynamic profile C) are the group that evolves with the worst prognosis in decompensated heart failure. However, there is little information in literature on the etiology of cardiopathy influences the outcome of patients in advanced stage. OBJECTIVE to assess the outcome of patients admitted with clinical and hemodynamic profile C and verify the role of the etiology in this phase. METHODS a cohort study was performed including patients with left ventricle ejection fraction (LVEF) < 45.0%, functional class IV and hospitalization presenting clinical-hemodynamic profile C. The group was divided into patients with chagasic (Ch) and non chagasic (NCh) cardiomyopathy. Statistical analysis used Student t test, Fisher exact test, chi-square and SPSS tests. The significance of p < 0.05 was considered. RESULTS one hundred patients, with mean age 57.6 ± 15.1 years and mean LVEF of 23.8 ± 8.5%, were included. Among the patients studied, 33.0% were chagasic and, in comparison with NCh, had lower systolic blood pressure (Ch 89.3 ± 17.1 mmHg versus NCh 98.8 ± 21.7 mmHg, p = 0.03 ) and lowest average age - Ch 52.9 ± 14.5 years versus NCh 59.8 ± 14.9 years, p = 0.03). During follow-up of 25 months, mortality was 66.7% for Ch and 37.3% in NCh (p = 0.019). The Chagas disease etiology was an independent marker of poor prognosis in multivariate analysis with risk ratio of 2.75 (HF 95.0%, from 1.35 to 5.63). CONCLUSION in patients with advanced HF, Chagas disease is an important predictor of the worst prognosis.FUNDAMENTO: Os pacientes com insuficiencia cardiaca (IC) que sao internados apresentando ma perfusao e congestao (perfil clinico-hemodinâmico C) constituem o grupo que evolui com pior prognostico na IC descompensada. Entretanto, ha pouca informacao na literatura se a etiologia da cardiopatia influencia na evolucao dos pacientes na fase avancada. OBJETIVO: Avaliar a evolucao dos pacientes que se internaram com perfil clinico-hemodinâmico C e verificar o papel da etiologia nesta fase. METODOS: Um estudo de coorte foi realizado incluindo pacientes com fracao de ejecao do ventriculo esquerdo (FEVE) < 45,0%, classe funcional IV e internacao hospitalar apresentando perfil clinico-hemodinâmico C. O grupo foi dividido em pacientes portadores de cardiomiopatia chagasica (Ch) e nao chagasica (NCh). Para analise estatistica foram utilizados os testes t de Student, exato de Fisher, qui-quadrado e o programa SPSS. O significante de p < 0,05 foi considerado. RESULTADOS: Cem pacientes, com idade media de 57,6 ± 15,1 anos e FEVE media de 23,8 ± 8,5%, foram incluidos. Dentre os pacientes estudados, 33,0% eram chagasicos e, na comparacao com os NCh, apresentaram menor pressao arterial sistolica (Ch 89,3 ± 17,1 mmHg versus NCh 98,8 ± 21,7 mmHg; p = 0,03) e menor idade media - Ch 52,9 ± 14,5 anos versus NCh 59,8 ± 14,9 anos; p = 0,03). Durante o acompanhamento de 25 meses, a mortalidade foi de 66,7% nos Ch e de 37,3% nos NCh (p = 0,019). A etiologia chagasica foi um marcador independente de mau prognostico na analise multivariada com razao de risco de 2,75 (IC 95,0%; 1,35 - 5,63). CONCLUSAO: Nos pacientes com IC avancada, a etiologia chagasica e um importante preditor de pior prognostico.

Cardiomiopatia chagásica: prognóstico no perfil clínico-hemodinâmico C

BACKGROUND patients with heart failure (HF) who are admitted showing poor perfusion and congestion (clinical-hemodynamic profile C) are the group that evolves with the worst prognosis in decompensated heart failure. However, there is little information in literature on the etiology of cardiopathy influences the outcome of patients in advanced stage. OBJECTIVE to assess the outcome of patients admitted with clinical and hemodynamic profile C and verify the role of the etiology in this phase. METHODS a cohort study was performed including patients with left ventricle ejection fraction (LVEF) < 45.0%, functional class IV and hospitalization presenting clinical-hemodynamic profile C. The group was divided into patients with chagasic (Ch) and non chagasic (NCh) cardiomyopathy. Statistical analysis used Student t test, Fisher exact test, chi-square and SPSS tests. The significance of p < 0.05 was considered. RESULTS one hundred patients, with mean age 57.6 ± 15.1 years and mean LVEF of 23.8 ± 8.5%, were included. Among the patients studied, 33.0% were chagasic and, in comparison with NCh, had lower systolic blood pressure (Ch 89.3 ± 17.1 mmHg versus NCh 98.8 ± 21.7 mmHg, p = 0.03 ) and lowest average age - Ch 52.9 ± 14.5 years versus NCh 59.8 ± 14.9 years, p = 0.03). During follow-up of 25 months, mortality was 66.7% for Ch and 37.3% in NCh (p = 0.019). The Chagas disease etiology was an independent marker of poor prognosis in multivariate analysis with risk ratio of 2.75 (HF 95.0%, from 1.35 to 5.63). CONCLUSION in patients with advanced HF, Chagas disease is an important predictor of the worst prognosis.FUNDAMENTO: Os pacientes com insuficiencia cardiaca (IC) que sao internados apresentando ma perfusao e congestao (perfil clinico-hemodinâmico C) constituem o grupo que evolui com pior prognostico na IC descompensada. Entretanto, ha pouca informacao na literatura se a etiologia da cardiopatia influencia na evolucao dos pacientes na fase avancada. OBJETIVO: Avaliar a evolucao dos pacientes que se internaram com perfil clinico-hemodinâmico C e verificar o papel da etiologia nesta fase. METODOS: Um estudo de coorte foi realizado incluindo pacientes com fracao de ejecao do ventriculo esquerdo (FEVE) < 45,0%, classe funcional IV e internacao hospitalar apresentando perfil clinico-hemodinâmico C. O grupo foi dividido em pacientes portadores de cardiomiopatia chagasica (Ch) e nao chagasica (NCh). Para analise estatistica foram utilizados os testes t de Student, exato de Fisher, qui-quadrado e o programa SPSS. O significante de p < 0,05 foi considerado. RESULTADOS: Cem pacientes, com idade media de 57,6 ± 15,1 anos e FEVE media de 23,8 ± 8,5%, foram incluidos. Dentre os pacientes estudados, 33,0% eram chagasicos e, na comparacao com os NCh, apresentaram menor pressao arterial sistolica (Ch 89,3 ± 17,1 mmHg versus NCh 98,8 ± 21,7 mmHg; p = 0,03) e menor idade media - Ch 52,9 ± 14,5 anos versus NCh 59,8 ± 14,9 anos; p = 0,03). Durante o acompanhamento de 25 meses, a mortalidade foi de 66,7% nos Ch e de 37,3% nos NCh (p = 0,019). A etiologia chagasica foi um marcador independente de mau prognostico na analise multivariada com razao de risco de 2,75 (IC 95,0%; 1,35 - 5,63). CONCLUSAO: Nos pacientes com IC avancada, a etiologia chagasica e um importante preditor de pior prognostico.

Uso da monitorização hemodinâmica contínua não invasiva na insuficiência cardíaca descompensada

Background: The clinical and hemodynamic assessment at the bedside and the use of pulmonary artery catheter for the estimation of hemodynamic data have been used in decompensated heart failure. However, there are no data on the use of continuous noninvasive hemodynamic monitoring. Objective: To compare the data obtained through noninvasive hemodynamic monitoring with invasive ones in patients with decompensated heart failure and refractory to treatment. Methods: The non-invasive hemodynamic measurements were obtained through continuous monitoring of systemic blood pressure by the pulse wave model (Modelflow) and compared with measurements obtained by the passage of a pulmonary artery catheter, simultaneously. Results: A total of 56 measurements were performed in 14 patients studied on different days and time periods. The correlation index between systolic blood pressure measurements was r = 0.26 (95% CI = 0.00 to 0.49, p = 0.0492) and diastolic ones, r = 0.50 (95% CI = 0.27 to 0.67, p <0.0001). The correlation was r = 0.55 (95% CI = 0.34 to 0.71, p <0.0001) for cardiac index and r = 0.32 (95% CI = 0.06 to 0 53, p = 0.0178) for systemic vascular resistance. Conclusion: There was a correlation between the hemodynamic measurements when compared to noninvasive pulmonary artery catheter measurements. The continuous noninvasive hemodynamic monitoring may be useful for hospitalized patients with decompensated heart failure. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Constrictive pericarditis with extensive calcification.

Pacientes con signos y sintomas de insuficiencia cardiaca derecha, de etiologia desconocida, trasladados para recibir tratamiento en un hospital de referencia en la region este de Sao Paulo, con diagnostico de pericarditis constrictiva calcificada, tratada quirurgicamente. Esta patologia se caracteriza por un proceso de calcificacion irreversible del pericardio, y el tratamiento quirurgico es la alternativa para el control de los sintomas y la mejora de la calidad de vida de los pacientes. Este caso llamo la atencion por la extension de la calcificacion y por su local de distribucion, alcanzando el tabique interventricular, lo que dificulto el diagnostico por el aspecto inusual de las imagenes, dejando dudas sobre si no habria otra enfermedad asociada.

É necessário suspender o betabloqueador na insuficiência cardíaca descompensada com baixo débito

Correspondencia: Marcelo Villaca Lima • Rua Ribeiro de Barros, 55/51, Vila Anglo Brasileira, 05027-020, Sao Paulo, SP Brasil E-mail: villacalima@cardiol.br Articulo recibido en 15/12/09; revisado recibido en 05/04/10; aceptado en 26/04/10. Resumen Fundamento: Hay evidencias de que la suspension del betabloqueante (BB) en la descompensacion cardiaca puede aumentar la mortalidad. La dobutamina (dobuta) es el inotropico mas utilizado en la descompensacion, mientras tanto, BB y dobuta actuan en el mismo receptor con acciones antagonicas, y el uso concomitante de los dos farmacos podria dificultar la compensacion.BACKGROUND there is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE to evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS we studied 44 patients with LVEF < 45% and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS mean LVEF 23.8 ± 6.6%. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.

Is it necessary to suspend betablockers in decompensated heart failure with low output

Correspondencia: Marcelo Villaca Lima • Rua Ribeiro de Barros, 55/51, Vila Anglo Brasileira, 05027-020, Sao Paulo, SP Brasil E-mail: villacalima@cardiol.br Articulo recibido en 15/12/09; revisado recibido en 05/04/10; aceptado en 26/04/10. Resumen Fundamento: Hay evidencias de que la suspension del betabloqueante (BB) en la descompensacion cardiaca puede aumentar la mortalidad. La dobutamina (dobuta) es el inotropico mas utilizado en la descompensacion, mientras tanto, BB y dobuta actuan en el mismo receptor con acciones antagonicas, y el uso concomitante de los dos farmacos podria dificultar la compensacion.BACKGROUND there is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE to evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS we studied 44 patients with LVEF < 45% and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS mean LVEF 23.8 ± 6.6%. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.

Short-term add-on therapy with angiotensin receptor blocker for end-stage inotrope-dependent heart failure patients: B-type natriuretic peptide reduction in a randomized clinical trial

OBJECTIVE: We aimed to evaluate angiotensin receptor blocker add-on therapy in patients with low cardiac output during decompensated heart failure. METHODS: We selected patients with decompensated heart failure, low cardiac output, dobutamine dependence, and an ejection fraction <0.45 who were receiving an angiotensin-converting enzyme inhibitor. The patients were randomized to losartan or placebo and underwent invasive hemodynamic and B-type natriuretic peptide measurements at baseline and on the seventh day after intervention. ClinicalTrials.gov: NCT01857999. RESULTS: We studied 10 patients in the losartan group and 11 patients in the placebo group. The patient characteristics were as follows: age 52.7 years, ejection fraction 21.3%, dobutamine infusion 8.5 mcg/kg.min, indexed systemic vascular resistance 1918.0 dynes.sec/cm5.m2, cardiac index 2.8 L/min.m2, and B-type natriuretic peptide 1,403 pg/mL. After 7 days of intervention, there was a 37.4% reduction in the B-type natriuretic peptide levels in the losartan group compared with an 11.9% increase in the placebo group (mean difference, -49.1%; 95% confidence interval: -88.1 to -9.8%, p = 0.018). No significant difference was observed in the hemodynamic measurements. CONCLUSION: Short-term add-on therapy with losartan reduced B-type natriuretic peptide levels in patients hospitalized for decompensated severe heart failure and low cardiac output with inotrope dependence.

Pericarditis constrictiva con calcificación extensa

Pacientes con signos y sintomas de insuficiencia cardiaca derecha, de etiologia desconocida, trasladados para recibir tratamiento en un hospital de referencia en la region este de Sao Paulo, con diagnostico de pericarditis constrictiva calcificada, tratada quirurgicamente. Esta patologia se caracteriza por un proceso de calcificacion irreversible del pericardio, y el tratamiento quirurgico es la alternativa para el control de los sintomas y la mejora de la calidad de vida de los pacientes. Este caso llamo la atencion por la extension de la calcificacion y por su local de distribucion, alcanzando el tabique interventricular, lo que dificulto el diagnostico por el aspecto inusual de las imagenes, dejando dudas sobre si no habria otra enfermedad asociada.

Pericardite constritiva com calcificação extensa

Pacientes con signos y sintomas de insuficiencia cardiaca derecha, de etiologia desconocida, trasladados para recibir tratamiento en un hospital de referencia en la region este de Sao Paulo, con diagnostico de pericarditis constrictiva calcificada, tratada quirurgicamente. Esta patologia se caracteriza por un proceso de calcificacion irreversible del pericardio, y el tratamiento quirurgico es la alternativa para el control de los sintomas y la mejora de la calidad de vida de los pacientes. Este caso llamo la atencion por la extension de la calcificacion y por su local de distribucion, alcanzando el tabique interventricular, lo que dificulto el diagnostico por el aspecto inusual de las imagenes, dejando dudas sobre si no habria otra enfermedad asociada.