José Paulo Araújo

Prognostic Value of High-Sensitivity C-Reactive Protein in Heart Failure: A Systematic Review

BACKGROUND Several studies have suggested that high-sensitivity C-reactive protein (hsCRP) is a strong independent predictor of acute myocardial infarction and cardiovascular death. In the specific heart failure (HF) context, a low-grade inflammatory state can contribute to HF progression. AIMS To perform a systematic review on the current knowledge about low-grade inflammation, as assessed by hsCRP, in the prediction of HF in general and in high-risk populations as well as its prognostic value in established HF. METHODS We used a computerized literature search in the Medline database using the following key words: C-Reactive Protein, Heart Failure, Cardiomyopathy, Cardiac Failure, Prognosis, and Death. Articles were selected if they had measurements of hsCRP in different patient samples and reference to outcomes in terms of morbidity and mortality. RESULTS hsCRP is associated with incident HF in general and high-risk populations and provides prognostic information in HF patients. In almost all studies, the association of hsCRP with clinical events was independent of other baseline variables known to influence morbidity and mortality. Very different cutoffs have been proposed in each context across studies. CONCLUSIONS The prognostic power of hsCRP, whether we consider incident HF or adverse outcomes in established HF, is consistent in different patient populations.

Adiponectin is increased in cardiac cachexia irrespective of body mass index

Cardiac cachexia (CC) is a complication of chronic heart failure (CHF). Little is known about the mechanisms leading to CC. Adiponectin, leptin, and ghrelin are important regulators of energy metabolism and body weight. Previous studies of CHF and CC had great differences in body mass index (BMI) between cachectic and non‐cachectic patients. To assess serum adiponectin, leptin, and ghrelin concentrations in cachectic and non‐cachectic patients.

Nutritional markers and prognosis in cardiac cachexia

BACKGROUND Cachexia frequently complicates chronic heart failure (CHF) and predicts an ominous prognosis. Hormonal and inflammatory environment differ between cachectic and non-cachectic patients. Nutritional markers of cardiac cachexia and prognostic predictors in this context are not completely understood. OBJECTIVES To study biochemical markers of nutritional status in cardiac cachexia and to investigate variables associated with worse prognosis. METHODS A total of 94 ambulatory patients--38 cachectics and 56 non-cachectics--were recruited. Cardiac cachexia was defined as a weight loss of ≥ 7.5%. An anthropometric evaluation was performed in all patients and blood was collected for several laboratory determinations: haemoglobin, lymphocytes, albumin, transferrin, pre-albumin, cholesterol and triglycerides. Patients were included in a prospective cohort study. RESULTS Cachectics had lower albumin and pre-albumin levels. They also had lower haemoglobin, lymphocytes and triglycerides. Levels of high-sensitivity C-reactive protein, and catabolic hormones were higher in the cachectic group. Low pre-albumin was the only nutritional marker independently associated with cardiac cachexia. (OR = 1.08, CI: 1.01-1.17). During a follow-up of 16.2 ± 5.2 months, 15 (39.4%) cachectic patients and 6 (10.7%) non-cachectics died. In the cachectic group, lower cholesterol was independently associated with worse outcome (HR = 1.32, CI: 1.11-1.57). CONCLUSIONS Pre-albumin seems to be the best laboratory marker of undernutrition in CHF. Low cholesterol independently associates with worse outcome in cardiac cachexia.

Low prealbumin is strongly associated with adverse outcome in heart failure

Objective Prealbumin is one of the best indicators of nutritional status. We previously showed that prealbumin predicted in-hospital mortality in heart failure (HF) patients. We evaluated if a low discharge prealbumin after admission with acute HF would predict morbidity and mortality. Methods We conducted a prospective observational study. Patients admitted with a primary diagnosis of HF were studied. Follow-up was up to 6 months. Endpoints analysed were: all-cause and HF-death; all-cause and worsening HF hospitalisation. Patients with discharge prealbumin ≤15.0 mg/dL and those with prealbumin >15 mg/dL were compared. A Cox-regression analysis was used to evaluate the prognostic impact of low prealbumin. Results We studied 514 patients. Mean age was 78 years and 45.7% were male. During follow-up, 101 patients died (78 for HF) and 209 patients were hospital readmitted (140 for worsening HF). Median prealbumin was 20.1 (15.3–25.3) mg/dL. Patients with lower prealbumin were more often women, older aged and with non-ischaemic HF; they had lower albumin, haemoglobin and total cholesterol; and higher glomerular filtration rate, C-reactive protein, B-type natriuretic peptide and length of hospital stay. Lower prealbumin associated with less β-blocker and statin use. Patients with discharge prealbumin ≤15 mg/dL had a multivariate adjusted HR of 6-month all-cause and HF death of 1.67 (1.00 to 2.80) and 2.12 (1.19 to 3.79) respectively and of all-cause and HF readmission of 1.47 (1.01 to 2.14) and 1.58 (1.01 to 2.47). Conclusions Patients with discharge prealbumin ≤15 mg/dL have an higher risk of 6 months morbidity and mortality. The unbalance between protein–energy demands and its availability predicts ominous HF outcome.

Higher C-Reactive Protein Predicts Worse Prognosis in Acute Heart Failure Only in Noninfected Patients

The prognostic role of C‐reactive protein (CRP) in acute heart failure (HF) is not fully understood, and the impact of an infectious process in its risk‐stratification power was not previously evaluated.

Angiotensin-converting enzyme inhibitors in heart failure: physicians' prescribing behavior.

BACKGROUND Several studies document an underuse of angiotensin-converting enzyme inhibitors (ACEIs) in heart failure (HF) patients, despite their proven efficacy and good tolerability. Also, there is some evidence that the doses used in clinical practice are far lower than those used in clinical trials. METHODS AND RESULTS To identify patterns of ACEI use in HF patients this study examined data collected on admission day regarding demographic, clinical, and medical care characteristics of 355 patients hospitalized because of decompensated HF who were treated with and without ACEIs. Additionally, measures of in-hospital outcome were compared among the two groups. Fifty-eight point six percent of patients were receiving ACEIs at admission and 80.6% were treated with ACEIs during hospitalization. The average ACEI does was low. No differences were observed in age and measures of severity of HF between ACEI-prescribed and nonprescribed patients. Patterns that could explain ACEI underuse included female sex, lower systolic blood pressure, worse renal function, left ventricular diastolic dysfunction, use of alternate drugs (eg, spironolactone), and overall less intense medical management. Patterns associated with the use of lower doses of ACEIs included older age, higher New York Heart Association functional class, and lower systolic blood pressure. In-hospital death rates were significantly higher for patients not treated with ACEIs. CONCLUSIONS This study suggests that many patients eligible for ACEI treatment were deprived of the advantages of these drugs because of erroneous clinical strategies. Nevertheless, the patterns of ACEI use were similar to those reported by other studies. Clinical trials conducted to determine the risk/benefit ratio of ACEI use in patients with renal dysfunction and the utility of ACEIs in diastolic HF, as well as programs to educate care providers on proper use of ACEIs in HF patients, are strongly recommended.

The effects of surface properties on Escherichia coli adhesion are modulated by shear stress.

The adhesion of Escherichia coli to glass and polydimethylsiloxane (PDMS) at different flow rates (between 1 and 10 ml s(-1)) was monitored in a parallel plate flow chamber in order to understand the effect of surface properties and hydrodynamic conditions on adhesion. Computational fluid dynamics was used to assess the applicability of this flow chamber in the simulation of the hydrodynamics of relevant biomedical systems. Wall shear stresses between 0.005 and 0.07 Pa were obtained and these are similar to those found in the circulatory, reproductive and urinary systems. Results demonstrate that E. coli adhesion to hydrophobic PDMS and hydrophilic glass surfaces is modulated by shear stress with surface properties having a stronger effect at the lower and highest flow rates tested and with negligible effects at intermediate flow rates. These findings suggest that when expensive materials or coatings are selected to produce biomedical devices, this choice should take into account the physiological hydrodynamic conditions that will occur during the utilization of those devices.

Developmental trajectories of adiposity from birth until early adulthood and association with cardiometabolic risk factors

Objective:To identify developmental trajectories of adiposity from birth until early adulthood, and to investigate how they relate with cardiometabolic risk factors at 21 years of age.Methods:Participants’ weight and height measurements were obtained using the EPITeen cohort protocol at 13, 17 and 21 years of age, and extracted from child health books as recorded during health routine evaluations since birth. Blood pressure, triglycerides, cholesterol and insulin resistance (HOMA-IR) were assessed at 21 years. Trajectories were defined using 719 participants contributing 11 459 measurements. The individual growth curves were modelled using mixed-effects fractional polynomial, and the trajectories were estimated using normal mixture modelling for model-based clustering. Differences in cardiometabolic risk factors at 21 years according to adiposity trajectories were estimated through analysis of covariance (ANCOVA), and adjusted means are presented.Results:Two trajectories—‘Average body mass index (BMI) growth’ (80.7%) and ‘Higher BMI growth’ (19.3%)—were identified. Compared with those in ‘Average BMI growth’, ‘Higher BMI growth’ participants were more frequently delivered by caesarean section, mothers were younger and had higher BMI, and parental education was lower; and at 21 years showed higher adjusted mean systolic (111.6 vs 108.3 mm Hg, P<0.001) and diastolic blood pressure (71.9 vs 68.4 mm Hg, P<0.001), and lower high-density lipoprotein cholesterol (53.3 vs 57.0 mg dl−1, P=0.001). As there was a significant interaction between trajectories and sex, triglycerides and HOMA-IR were stratified by sex and we found significantly higher triglycerides, in males, and higher HOMA-IR in both sexes in ‘Higher BMI growth’ trajectory. All the differences were attenuated after adjustment for BMI at 21 years.Conclusions:In this long-term follow-up, we were able to identify two adiposity trajectories, statistically related to the BMI and cardiometabolic profile in adulthood. Our results also suggest that the impact of the adiposity trajectory on cardiometabolic profile is mediated by current BMI.

Desmame de ventilação não invasiva: Experiência com períodos de descontinuação

Resumo Introducao: Nos ultimos anos, a ventilacao nao invasiva (VNI) tornou-se numa opcao terapeutica valida nas exacerbacoes agudas de doentes com doenca pulmonar cronica obstrutiva. No entanto, apesar de muito utilizada, existe muito pouca informacao sobre o desmame deste modo ventilatorio. Objectivos: Descrever um protocolo de desmame baseado em periodos progressivos de descontinuacao de VNI. Metodos: Durante um ano foram admitidos 78 doentes na nossa unidade para inicio de VNI devido a exacerbacoes agudas de doentes com doenca pulmonar cronica obstrutiva. O desmame de VNI era considerado em doentes que se apresentavam sem acidose e com frequencia respiratoria inferior a 25 ciclos por minuto. O desmane era realizado da seguinte forma: Durante as primeiras 24 horas, em cada 3 horas de periodo diurno o doente estava sem VNI durante uma hora (excepto a noite); no segundo dia, em cada 3 horas o doente estava sem VNI durante 2 horas (excepto a noite), e no terceiro dia a VNI era utilizada apenas em periodo nocturno. Resultados: Sessenta doentes iniciaram o protocolo de desmame. O tempo medio de VNI foi de 120.9 horas (17 a 192 horas). Nao houve registo de complicacoes nos doentes que iniciaram este protocolo. Todos completaram o protocolo sem necessidade de reinstituir VNI ou ventilacao invasiva durante o internamento. Conclusoes: Descrevemos uma taxa excelente de sucesso de desmame de VNI em doentes com exacerbacoes agudas de doentes com insuficiencia respiratoria cronica. Apesar de este protocolo implicar uma duracao de 72 horas, os resultados sugerem que estrategias baseadas em periodos com e sem VNI sao eficazes. No entanto, estrategias menos demoradas merecem investigacao. Rev Port Pneumol 2008; XIV (1): 49-53

Statin-Induced Low Cholesterol is Not Associated With Poor Outcome in Chronic Heart Failure

Background: Low cholesterol levels are associated with a worse outcome in patients with heart failure (HF). Use of statins in HF remains controversial. We aimed to assess whether the prognosis of patients with intrinsically low cholesterol levels differed from that of those with pharmacologically induced low cholesterol. Materials and Methods: We conducted a retrospective cohort study on 464 ambulatory patients attending a specialized HF clinic. Patients were cross-classified according to statin therapy and admission total cholesterol level (low cholesterol <150 mg/dL and cholesterol ≥150 mg/dL): (1) low total cholesterol level on statin therapy; (2) low total cholesterol level not taking statins; (3) cholesterol ≥150 mg/dL on statin therapy; and (4) cholesterol ≥150 mg/dL not on statin therapy. Patients were followed up to 5 years and the outcome was all-cause death. A Cox regression analysis was used in prognosis assessment. Results: Almost two thirds of the patients were men and the median population age was 69 years; 22.8% of the patients had preserved ejection fraction and 43.5% severe systolic dysfunction. The patients with an intrinsically low cholesterol had a hazard ratio of all-cause death up to 5 years of 2.38 (1.08-7.14) compared to those with low cholesterol induced by statin use. This association was independent of other variables associated with outcome. Conclusions: Patients with HF with instrisically low cholesterol levels have a double risk of death up to 5 years compared to patients with pharmacologically induced low cholesterol. Clinicians should not limit the use of statins by fear of lowering the cholesterol levels.