Humberto Villacorta

The Role of B-Type Natriuretic Peptide in the Diagnosis of Congestive Heart Failure in Patients Presenting to an Emergency Department with Dyspnea

OBJECTIVE To determine the utility of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure (CHF) in patients presenting with dyspnea to an emergency department (ED). METHODS Seventy patients presenting with dyspnea to an ED from April to July 2001 were included in the study. Mean age was 72+/-16 years and 33 (47%) were male. BNP was measured in all patients at the moment of admission to the ED. Emergency-care physicians, blinded to BNP values, were required to assign a probable initial diagnosis. A cardiologist retrospectively reviewed the data (blinded to BNP measurements) and assigned a definite diagnosis, which was considered the gold standard for assessing the diagnostic performance of BNP. RESULTS The mean BNP concentration was higher in patients with CHF (n=36) than in those with other diagnoses (990+/-550 vs 80+/-67 pg/mL, p<0.0001). Patients with systolic dysfunction had higher BNP levels than those with preserved systolic function (1,180+/-641 vs 753+/-437 pg/mL, p=0.03). At a blood concentration of 200 pg/mL, BNP showed a sensitivity of 100%, specificity of 97.1%, positive predictive value of 97.3%, and negative predictive value of 100%. The application of BNP could have potentially corrected all 16 cases in which the diagnosis was missed by the emergency department physician. CONCLUSION BNP measurement is a useful tool in the diagnosis of CHF in patients presenting to the ED with dyspnea.

Anemia como fator prognóstico em uma população hospitalizada por insuficiência cardíaca descompensada

De julho a setembro de 2001, 204 pacientes foram incluidosem um registro hospitalar multicentrico de insuficiencia cardiaca(Estudo EPICA–Niteroi). Os 142 que tinham dados sobre hematocri-to e hemoglobina coletados na admissao hospitalar compuseramesta analise retrospectiva. A idade media foi de 69,5±13,3 anos e72 (50,7%) eram do sexo masculino. Considerou-se como anemiauma hemoglobina < 13,5 g/dL para os homens e < 12 g/dL para asmulheres. Avaliou-se atraves de analise uni e multivariada por regressaologistica a relacao da anemia com a mortalidade hospitalar.

C-reactive protein: an inflammatory marker with prognostic value in patients with decompensated heart failure

BACKGROUND Inflammation has been implicated in the pathophysiology of a series of cardiovascular diseases. C-reactive protein (CRP) is a marker of inflammation easily obtained in the emergency room. OBJECTIVE To study the prognostic value of CRP in patients admitted for acute decompensated heart failure (ADHF). METHODS A prospective cohort of 119 patients with ADHF treated in the emergency room. Mean age was 74+/-11 years and 76 (64%) of patients were male. All were New York Heart Association Functional Class III or IV. CRP was measured by nephelometry at admission. Patients were followed after hospital discharge for an average of 12+/-9.7 months and cardiovascular mortality was the outcome analyzed. RESULTS There were 44 (36.9%) deaths, all from cardiovascular causes. Individuals with CRP > 3 mg/dl had higher mortality than those below this level (p=0.018). In the multivariate analysis using Cox proportional model, CRP proved to be the most important independent prognostic factor (odds ratio 0.0916 [95% CI = 0.0341 - 0.1490] for each one-unit increment in CRP). CONCLUSION CRP is an independent cardiovascular mortality predictor in patients with ADHF, indicating that inflammation represents an important component in the pathophysiology of the disease.

Insuficiência Cardíaca com Função Sistólica Preservada

numa populacao de idosos foi feita por Topol e cols., em 1985.As evidencias cientificas sobre o impacto do tratamento medica-mentoso da insuficiencia cardiaca com funcao sistolica preserva-da sobre a qualidade de vida, alivio sintomatico ou mortalidadesao escassas e, no momento atual, seis ensaios clinicos multi-centricos estao em curso, avaliando os efeitos sobre a morbi-mortalidade, dos inibidores da ECA e ou ARA-II nesta sindrome

EVOLUCAO INTRA-HOSPITALAR E SEGUIMENTO POS-ALTA DE PACIENTES IDOSOS ATENDIDOS COM INSUFICIENCIA CARDIACA CONGESTIVA NA UNIDADE DE EMERGENCIA

PURPOSE: To evaluate the in-hospital (IH) outcome and the short-term follow-up of predominantly elderly patients presenting to an emergency room (ER) with congestive heart failure (CHF). METHODS: In an 11 month period, 57 patients presenting to the ER with CHF were included. Mean age was 69+15 years (27 to 94) and 39 (68,4%) were male. CHF diagnosis was based on the Boston criteria. We evaluated IH outcome and prognosis in a mean follow-up of 5,7+2,7 months (1 to 12). In addition, some mortality predictors and mechanisms of death according on the ACME system were identified. RESULTS: Eight patients (14%) died in the IH period. Modes of death were circulatory failure (CF) in 7, and peri-operative (PO) in one (aortic valve replacement). During follow-up 9 deaths ocurred. Five were due to CF, 2 were sudden and 2 were PO (mitral valve replacement and ventriculectomy). Six-months and 1-year survival rates of the patients who were discharged were 82% and 66%, respectively. Sodium lower than 135mEq/l (p= 0.004) and female gender (p= 0.038) were independent predictors of mortality. CONCLUSION: Elderly patients with CHF admitted to the ER have high in-hospital and short-term follow up mortalities. The majority die from CF due to worsening heart failure.OBJETIVO: Conhecer a evolucao intra-hospitalar (IH) e pos-alta (PA) de uma populacao predominantemente idosa, com insuficiencia cardiaca congestiva (ICC) na unidade de emergencia (UE). METODOS: Durante 11 meses, foram selecionados 57 pacientes consecutivos com ICC, atendidos em EU, com idade media de 69+15 (27 a 94) anos, sendo 39 (68,4%) homens. O diagnostico de ICC baseou-se nos criterios de Boston. Avaliou-se a evolucao IH e PA num periodo medio de 5,7+2,7 (1 a 12) meses, procurando-se identificar variaveis que se correlacionassem com a mortalidade e o mecanismo de morte, avaliado pelo sistema ACME . RESULTADOS: Oito (14%) pacientes faleceram na fase IH, sendo 7 por falencia circulatoria (FC), e 1 em pos-operatorio (PO). Durante o seguimento ocorreram 9 (18,4%) obitos, sendo 5 por FC, 2 mortes subitas e 2 em PO (troca valvar mitral e ventriculectomia). A sobrevida dos pacientes que tiveram alta foi de 82% e 66%, aos 6 meses e 1 ano, respectivamente. Sodio serico <135mEq/l (p= 0,004) e sexo feminino (p= 0,038) foram preditores independentes de mortalidade. CONCLUSAO: Pacientes idosos com ICC atendidos em UE apresentam mortalidade IH e PA elevadas e alta taxa de reinternacao hospitalar. A maioria morre por falencia circulatoria decorrente da progressao da ICC.

Prognostic factors in patients with congestive heart failure.

The natural history of congestive heart failure (CHF) was initially described in the Framingham Heart Study, carried out in the US city of Framingham, Massachusetts, in which 5,209 individuals were randomly selected and followed for four decades (1949 to 1987) . In 1971, the descendents of this initial population and their respective spouses (5,135 individuals) were also included in the study and, in 1993, the evolutional data of this cohort study of 10,344 participants were published . The survival rate in five years was 25% for men and 38% for women; this survival rate is similar to that observed in patients with some types of cancer, such as lung cancer, for example . It is estimated that in the US almost four million people have CHF and that 700,000 new cases occur every year . In addition to the high prevalence, there is another factor of concern. There is evidence that the number of hospital admissions due to CHF has increased in the last two decades. According to North American statistics, the number of hospital admissions of individuals older than 65 years and whose main diagnosis was CHF increased from 7.5 per 1,000 in 1986 to 16.3 per 1,000 in 1989 . These data cause CHF to be regarded as a public health problem throughout the world. The high morbidity and mortality show that the current treatment is still unsatisfactory. On the other hand, economic resources are limited and every strategy should be well assessed to avoid wasting. Therefore it is very important to identify the individuals with poor prognosis who can eventually benefit from aggressive management. This manuscript discusses prosent issues of the main prognostic factors used in the assessment of patients with CHF. Some have recognized value and are used frequently in the clinical practice. Others have a controversial or not well-established value, as we will see below.

Effects of propranolol on the QT dispersion in congestive heart failure.

OBJECTIVE - Studies have shown that therapy with beta-blockers reduces mortality in patients with heart failure. However, there are no studies describing the effects of propranolol on the QT dispersion in this population. The objective of this study was to assess the electrophysiological profile, mainly QT dispersion, of patients with heart failure regularly using propranolol. METHODS - Fifteen patients with heart failure and using propranolol were assessed over a period of 12 months. Twelve-lead electrocardiograms (ECG) were recorded prior to the onset of beta-blocker therapy and after 3 months of drug use. RESULTS - A significant reduction in heart rate, in QT dispersion and in QTc dispersion was observed, as was also an increase in the PR interval and in the QT interval, after the use of propranolol in an average dosage of 100 mg/day. CONCLUSION - Reduction in QT dispersion in patients with heart failure using propranolol may explain the reduction in the risk of sudden cardiac death with beta-blocker therapy, in this specific group of patients.

Soluble ST2 Testing: A Promising Biomarker in the Management of Heart Failure.

ST2 is a member of the interleukin-1 receptor family biomarker and circulating soluble ST2 concentrations are believed to reflect cardiovascular stress and fibrosis. Recent studies have demonstrated soluble ST2 to be a strong predictor of cardiovascular outcomes in both chronic and acute heart failure. It is a new biomarker that meets all required criteria for a useful biomarker. Of note, it adds information to natriuretic peptides (NPs) and some studies have shown it is even superior in terms of risk stratification. Since the introduction of NPs, this has been the most promising biomarker in the field of heart failure and might be particularly useful as therapy guide.

Microalbuminuria is an independent prognostic marker in patients with chronic heart failure

BACKGROUND Microalbuminuria has been described as a risk factor for progressive cardiovascular and renal diseases. Little is known about its prognostic value in patients (pts) with established heart failure (HF). OBJECTIVE To assess the role of microalbuminuria as a prognostic marker in patients with chronic HF receiving standard medication. METHODS From January 2008 through September 2009, 92 pts with chronic HF, were prospectively included. Mean age was 63.7 ± 12.2 and 37 (40.7%) were male. Mean left ventricular ejection fraction (LVEF) was 52.5 ± 17.5%. Pts under dialysis were excluded. Urinary albumin concentration (UAC) was determined in first morning spot sample of urine. Time to first event (HF hospitalization, emergency department visit for HF or cardiovascular death) was defined as endpoint. Mean follow-up was 11 ± 6.1 months. RESULTS At the time of inclusion in the study, 38 (41.3%) pts had microalbuminuria and no patient had overt albuminuria. Pts with microalbuminuria had lower left ventricular ejection fraction than the rest of the individuals (47.9 ± 18.5 vs 54.5 ± 17.7%, p=0.08). UAC was higher in patients with events (median 59.8 vs 18 mg/L, p=0.0005). Event-free survival was lower in pts with microalbuminuria as compared with normoalbuminuria (p<0.0001). Independent variables related to cardiac events were UAC (p<0.0001, hazard ratio=1.02, 95% CI=1.01 to 1.03 per 1-U increase of UAC), and previous myocardial infarction (p=0.025, HR=3.11, 95% CI=1.15 to 8.41). CONCLUSION Microalbuminuria is an independent prognostic marker in pts with chronic HF. Pts with microalbuminuria had a trend for lower LVEF.FUNDAMENTO: A microalbuminuria tem sido descrita como um fator de risco para doencas cardiovasculares e renais progressivas. Pouco se sabe sobre seu valor prognostico em pacientes (pts) com Insuficiencia Cardiaca (IC) estabelecida. OBJETIVO: Avaliar o papel da microalbuminuria como um marcador de prognostico em pacientes com IC cronica recebendo medicacao padrao. METODOS: De janeiro de 2008 ate setembro de 2009, 92 pacientes com IC cronica foram prospectivamente incluidos. A idade media foi de 63,7 ± 12,2 e 37 (40,7%) eram do sexo masculino. A media de fracao de ejecao do ventriculo esquerdo (FEVE) foi de 52,5 ± 17,5%. Pacientes em dialise foram excluidos. A Concentracao de Albumina Urinaria (CAU) foi determinada em primeira amostra de urina da manha. O tempo decorrido ate o primeiro evento (internacao por IC, consulta no departamento de emergencia por IC ou morte cardiovascular) foi definido como endpoint. O seguimento medio foi de 11 ± 6,1 meses. RESULTADOS: No momento da inclusao no estudo, 38 (41,3%) pacientes tinham microalbuminuria e nenhum paciente teve albuminuria evidente. Pacientes com microalbuminuria apresentaram menor fracao de ejecao ventricular esquerda do que o restante dos individuos (47,9 ± 18,5 vs. 54,5 ± 17,7%, p = 0,08). A CAU apresentou-se maior em pacientes com eventos (mediana 59,8 vs. 18 mg/L, p = 0,0005). Sobrevida livre de eventos foi menor nos pacientes com microalbuminuria quando comparados com albuminuria normal (p < 0,0001). As variaveis independentes relacionadas a eventos cardiacos foram CAU (taxa de risco p < 0,0001 = 1,02, 95% CI = 1,01-1,03 por 1-U aumento da CAU), e historico de infarto do miocardio (p = 0,025, IC = 3,11, 95% IC = 1,15-8,41). CONCLUSAO: A microalbuminuria e um marcador prognostico independente em pacientes com IC cronica. Pacientes com microalbuminuria tinham tendencia para FEVE inferior.

Anemia e insuficiência cardíaca na comunidade: comparação com um ambulatório especializado

BACKGROUND Anemia is common in patients with heart failure (HF). Its prevalence in patients with HF from a community-based cohort is unknown in our country. OBJECTIVE evaluate the prevalence and characteristics of patients with anemia in a non-selected population with HF from a community-based cohort, comparing it with that of a HF population treated at a specialized outpatient clinic. METHODS This was a transversal, prospective, observational study, carried out from January 2006 to March 2007. The patients with HF met the Boston criteria, with a score > 8. Anemia was defined through the criteria of the World Health Organization as hemoglobin levels < 13 g/dL for men and <12 g/dl for women. Patients treated at a primary care program in the community were randomly selected, as well as patients treated at a Heart Failure Outpatient Clinic in a university hospital. RESULTS A total of 206 patients were assessed, with a mean age of 61.3+/-13.1 years, of which 53.4% were females. The prevalence of anemia in the community-based cohort (n=114) was 21% and at the outpatient clinic (n=92), of 25% (p=0.50). The patients from the community-based cohort presented a lower rate of kidney dysfunction (GFR<60 ml/min/1,73-5), predominance of HF with normal ejection fraction and female sex. Kidney function parameters (urea or creatinine) independently correlated with anemia in both populations. CONCLUSION The prevalence of anemia was similar in the studied populations. Kidney function was the only factor that independently correlated with anemia in both populations.FUNDAMENTO: La anemia es comun en pacientes con insuficiencia cardiaca (IC). Su prevalencia en pacientes con IC en la comunidad es desconocida en nuestro medio. OBJETIVO: Evaluar la prevalencia y caracteristicas de pacientes con anemia en una poblacion con IC no seleccionada en la comunidad, comparandola a una poblacion con IC atendida en un consultorio especializado. METODOS: Estudio transversal, prospectivo, observacional, realizado de enero de 2006 a marzo de 2007. Los pacientes con IC cumplian los criterios de Boston, con puntuacion >8. La anemia fue definida por los criterios de la Organizacion Mundial de la Salud, como valores de hemoglobina <13 g/dl para hombres y <12 g/dl para mujeres. Se seleccionaron en forma aleatoria pacientes atendidos en un programa de atencion primaria en la comunidad y pacientes atendidos en un consultorio de insuficiencia cardiaca en un hospital universitario. RESULTADOS: Fueron evaluados 206 pacientes con promedio de edad de 61,3±13,1 anos, y un 53,4% de sexo femenino. La prevalencia de la anemia en la comunidad (n=114) fue de 21% y en el consultorio (n=92), de 25% (p=0,50). Los pacientes de la comunidad presentaban menor tasa de disfuncion renal (TFG<60 ml/min/1,73-5), predominio de IC con fraccion de eyeccion normal y sexo femenino. Los parametros de funcion renal (urea o cretinina) se relacionaron de modo independiente con la anemia, en las dos poblaciones. CONCLUSION: La prevalencia de la anemia fue semejante en las poblaciones estudiadas. La funcion renal fue el unico factor relacionado de modo independiente con la anemia en las dos poblaciones.