Humberto Villacorta Junior

B-type natriuretic peptide is predictive of postoperative events in orthopedic surgery

FUNDAMENTO: A avaliacao clinica nem sempre e suficiente para predizer complicacoes cardiacas pos-operatorias (PO). O peptideo natriuretico do tipo B (BNP) tem grande valor prognostico em pacientes (pts) com insuficiencia cardiaca. Seu valor como preditor de eventos em cirurgias ortopedicas ainda nao foi testado. OBJETIVO: Avaliar o valor do BNP em predizer complicacoes cardiacas no PO de cirurgia ortopedica. METODOS: Avaliados de modo prospectivo, 208 pts submetidos a cirurgia para correcao de fratura de femur e artroplastia de quadril ou de joelho. Foram 149 (71,6%) mulheres e a idade media foi de 72,6 ± 8,8 anos. Os pacientes foram submetidos, no pre-operatorio, a avaliacao clinica convencional e estimativa do risco cirurgico pela classificacao da American Society of Anesthesiologists (ASA). O BNP foi dosado no pre-operatorio e avaliou-se a sua capacidade de predizer eventos cardiacos (morte, infarto agudo do miocardio, angina instavel, fibrilacao atrial, taquicardia ventricular ou insuficiencia cardiaca) no PO, atraves de analise multivariada por regressao logistica. RESULTADOS: Dezessete (8,0%) pacientes apresentaram eventos cardiacos. A mediana de BNP foi significativamente maior nesses pacientes quando comparada a dos sem eventos cardiacos (93 [variacao interquartil 73-424] vs 26,6 [13,2-53,1], p = 0,0001). O BNP foi o principal preditor independente de eventos (p = 0,01). A classificacao da ASA nao foi preditor independente. A analise de curva ROC demonstrou que para um corte de 60 pg/ml, o BNP apresentou sensibilidade de 76,0% e especificidade de 79,0% para predizer eventos, com area sob a curva de 83,0%. CONCLUSAO: O BNP e um preditor independente de eventos cardiacos no PO de cirurgias ortopedicas.

Immune-inflammatory activation in heart failure

Despite being relatively recent, a growing and significant accumulation of experimental and clinical evidence has been observed that points to a gradual state of immune-inflammatory activation in patients with heart failure (HF). High levels of several cytokines are found in the circulation and cardiac muscle of individuals with HF, and invariably correlate with the severity of the disease. These cytokines act on endothelial dysfunction, oxidative stress, induction of anemia, myocyte apoptosis, and on the progressive loss of skeletal muscle mass which is conventionally called the inflammatory paradigm of HF. Not only the myocardium, but also several tissues seem to synthesize these cytokines and perpetuate this continuous inflammatory state at a low degree, including leukocytes, monocytes, skeletal muscle cells and endothelial cells in response to hemodynamic and infectious stimuli, to hypoxia, to oxidative stress, to neurohumoral activation, and others. Thus, a network of molecules that interact with each other is formed, and connections with other axes that effectively contribute to the clinical deterioration of the patients are also established which fits into the pathophysiological model of multisystemic involvement that has been increasingly attributed to HF. Although the determination of these biomarkers in peripheral blood provides solid evidence of prognostic power, the results of therapeutic trials that modulated the immune-inflammatory loop in the clinical phase have been, so far, hardly encouraging. Therefore, we believe that a better understanding of the inflammatory activation and its multifaceted relation with the axes of decompensation of the disease is key for new therapeutic perspectives with a relevant impact to be established in the near future.

O peptídeo natriurético do tipo B é preditor de eventos em pós-operatório de cirurgia ortopédica

FUNDAMENTO: A avaliacao clinica nem sempre e suficiente para predizer complicacoes cardiacas pos-operatorias (PO). O peptideo natriuretico do tipo B (BNP) tem grande valor prognostico em pacientes (pts) com insuficiencia cardiaca. Seu valor como preditor de eventos em cirurgias ortopedicas ainda nao foi testado. OBJETIVO: Avaliar o valor do BNP em predizer complicacoes cardiacas no PO de cirurgia ortopedica. METODOS: Avaliados de modo prospectivo, 208 pts submetidos a cirurgia para correcao de fratura de femur e artroplastia de quadril ou de joelho. Foram 149 (71,6%) mulheres e a idade media foi de 72,6 ± 8,8 anos. Os pacientes foram submetidos, no pre-operatorio, a avaliacao clinica convencional e estimativa do risco cirurgico pela classificacao da American Society of Anesthesiologists (ASA). O BNP foi dosado no pre-operatorio e avaliou-se a sua capacidade de predizer eventos cardiacos (morte, infarto agudo do miocardio, angina instavel, fibrilacao atrial, taquicardia ventricular ou insuficiencia cardiaca) no PO, atraves de analise multivariada por regressao logistica. RESULTADOS: Dezessete (8,0%) pacientes apresentaram eventos cardiacos. A mediana de BNP foi significativamente maior nesses pacientes quando comparada a dos sem eventos cardiacos (93 [variacao interquartil 73-424] vs 26,6 [13,2-53,1], p = 0,0001). O BNP foi o principal preditor independente de eventos (p = 0,01). A classificacao da ASA nao foi preditor independente. A analise de curva ROC demonstrou que para um corte de 60 pg/ml, o BNP apresentou sensibilidade de 76,0% e especificidade de 79,0% para predizer eventos, com area sob a curva de 83,0%. CONCLUSAO: O BNP e um preditor independente de eventos cardiacos no PO de cirurgias ortopedicas.

Bioimpedância transtorácica comparada à ressonância magnética na avaliação do débito cardíaco

BACKGROUND Cardiac magnetic resonance imaging is considered the gold-standard method for the calculation of cardiac volumes. Transthoracic impedance cardiography assesses the cardiac output. No studies validating this measurement, in comparison to that obtained by magnetic resonance imaging, are available. OBJECTIVE To evaluate the performance of transthoracic impedance cardiography in the calculation of the cardiac output, cardiac index and stroke volume using magnetic resonance imaging as the gold-standard. METHODS 31 patients with a mean age of 56.7 ± 18 years were assessed; of these, 18 (58%) were males. Patients whose indication for magnetic resonance imaging required pharmacologic stress test were excluded. Correlation between methods was assessed using the Pearsons coefficient, and dispersion of absolute differences in relation to the mean was demonstrated using the Bland-Altmans method. Agreement between methods was analyzed using the intraclass correlation coefficient. RESULTS The mean cardiac output by transthoracic impedance cardiography and by magnetic resonance imaging was 5.16 ± 0.9 and 5.13 ± 0.9 L/min, respectively. Good agreement between methods was observed for cardiac output (r = 0.79; p = 0.0001), cardiac index (r = 0.74; p = 0.0001) and stroke volume (r = 0.88; p = 0.0001). The analysis by the Bland-Altman plot showed low dispersion of differences in relation to the mean, with a low amplitude of agreement intervals. Good agreement between the two methods was observed when analyzed by the intraclass correlation coefficient, with coefficients for cardiac output, cardiac index and stroke volume of 0.78, 0.73 and 0.88, respectively (p < 0.0001 for all comparisons). CONCLUSION Transthoracic impedance cardiography proved accurate in the calculation of the cardiac output in comparison to cardiac magnetic resonance imaging.

Alta Reatividade Plaquetária Durante Tratamento é Preditora de Eventos Cardíacos em Pacientes com Stents Farmacológicos

BACKGROUND The role of platelet reactivity (PR) tests in the prediction of long-term events in Latin-American patients treated with drug-eluting stents (DES) has not been established. OBJECTIVES To assess the role of PR tests in the prediction of events after DES implantation. METHODS From May 2006 through January 2008, 209 Brazilian patients who underwent elective treatment with DES were included. PR was assessed 12 to 18h after the procedure by light transmittance aggregometry with 5µM of ADP. Patients were prospectively followed for up to 4.8 years. Seventeen (8%) individuals were lost to follow-up and the final cohort comprised 192 patients. Receiver operating curve (ROC) was used to determine the best 5µM of ADP cutoff to predict events. The primary endpoint was a combination of cardiovascular death, acute myocardial infarction, definite stent thrombosis, and target-artery revascularization. Cox proportional hazard models were used to determine the variables independently associated with the time to the first event. RESULTS The best ADP 5µM cutoff was 33%. One hundred and seven (55.7%) patients had ADP 5µM >33%. Event-free survival rate at 1,800 days was 55% vs. 70% for individuals with ADP5 above and below such cutoff, respectively (p=0.001). Independent predictors of time to first event were current smoking (HR 3.49; 95% CI 1.76-6.9; p=0.0003), ADP 5µM >33% (HR 1.95; 95% CI 1.09-3.51; p=0.025) and age (HR 1.03; 95% CI 1.0-1.06; p=0.041). CONCLUSIONS In this study, 55.7% of the patients had high on-treatment platelet reactivity. ADP 5µM >33% was an independent predictor of long-term events.

Clinical Applications of B-Type Natriuretic Peptide Assays

YSTEMThe natriuretic peptide system is activated every time the heart is subjected to injury, whether acute or chronic, as a compensatory mechanism for the effects of vasoconstriction changes that take place in these situations. The primary role of the system is to promote urine output and vasodilation. It is known, however, that a series of additional effects are triggered when these peptides are released, such as the inhibition of the renin-angiotensin-aldosterone system, sympathetic nervous system and smooth muscle cells growth, and possibly the reduction of apoptosis

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

Parte 1: Diretriz Brasileira de Insuficiencia Cardiaca Cronica […] Diretriz Brasileira de Insuficiencia Cardiaca Cronica e Aguda

Coronary tortuosity and its role in myocardial ischemia in patients with no coronary obstructions

Este trabalho faz uma revisão sobre o tema de tortuosidade coronariana abordando várias situações na prática clínica aonde a tortuosidade coronariana pode desempenhar um papel relevante e procura avaliar se há correlação entre tortuosidade coronariana e a presença de isquemia miocárdica em pacientes sem obstruções coronarianas fazendo uma busca na literatura das evidências científicas. Livro-texto de Fisiologia em Cardiologia com estudo da circulação coronariana, artigos teóricos com estudos de Hemodinâmica, Dinâmica de Fluidos e de Mecânica e artigos experimentais com simulação em computadores serviram de sustentação para a formulação da hipótese a ser verificada.

Hypotension and Renal Dysfunction: The Ghosts of Heart Failure

Heart failure (HF) is a chronic, high morbidity and high cost disease. The treatment of HF due to left ventricular (LV) systolic dysfunction is well determined and is listed in Medical Guidelines. However, innumerable situations may limit treatment, causing the physician to fail to implement the guidelines. Some serious patients may not tolerate medications or recommended doses; others may have side effects. In some cases, however, there is an excess of caution, failing to prescribe the recommended treatment, fearing complications. The purpose of this article is to demystify, based on the literature, some situations that may prevent the optimized drug treatment from being offered to the HF patient.

Left Ventricular Involvement in Arrhythmogenic Dysplasia of the Right Ventricle

Mailing Address: Karine Betzel Reetz Rua Marquês de Paraná, 349, Centro, Niterói. Postal Code: 24030215. Rio de Janeiro, RJ – Brazil E-mail: kabetzel@gmail.com Left Ventricular Involvement in Arrhythmogenic Dysplasia of the Right Ventricle Karine Betzel Reetz, Marcelo Nacif, Eduardo Nani Silva, Wolney Martins, Humberto Villacorta Junior Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Niterói, Rio de Janeiro, RJ – Brazil