Juarez Braga

Factors associated with the development of cardiac allograft vasculopathy – a systematic review of observational studies

Braga JR, Santos ISO, McDonald M, Shah PS, Ross HJ. Factors associated with the development of cardiac allograft vasculopathy – a systematic review of observational studies. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01565.x. 
© 2011 John Wiley & Sons A/S.

Predictors of Mortality in Patients With an Implantable Cardiac Defibrillator: A Systematic Review and Meta-analysis

BACKGROUND Many current predictors of mortality in heart failure (HF) were evaluated before the use of implantable cardioverter defibrillators (ICDs). We conducted a meta-analysis to identify factors associated with mortality in ICD-HF patients. METHODS We searched in MedLine, EMBASE, and CINAHL in May 2012. Two reviewers selected citations that included ambulatory ICD patients and addressed the association between any predictor and mortality using multivariable regression. We meta-analyzed mortality using random-effects models. RESULTS Of 10,420 studies reviewed, 72 studies evaluating 63 predictors on 257,692 ICD patients proved eligible. High confidence in estimates was found for age (hazard ratio [HR], 1.45 for 10-year increase; 95% confidence interval [CI], 1.35-1.56), baseline glomerular filtration rate (HR, 1.25 for 15-mL/min decrease; 95% CI, 1.15-1.35), chronic obstructive pulmonary disease (HR, 1.54; 95% CI, 1.38-1.71), diabetes (HR, 1.56; 95% CI, 1.37-1.79), peripheral vascular disease (HR, 1.43; 95% CI, 1.2-1.72), left ventricular ejection fraction (HR, 0.77 for 10% increase; 95% CI, 0.73-0.83), and appropriate or inappropriate ICD shocks (HR, 2.34; 95% CI 1.59-3.44) New York Heart Association class, atrial fibrillation, and congestive HF were strongly associated with mortality but the confidence in estimates was low. Ischemic cardiomyopathy and male sex were not independent predictors of mortality. CONCLUSIONS This meta-analysis identified strong reliable mortality predictors in ICD-HF patients. Age, renal dysfunction, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, decreased left ventricular ejection fraction, and ICD shocks during follow-up were strong predictors of mortality; ischemic cardiomyopathy and male sex were not. Further research is needed to study other potential predictors, particularly biomarkers.

Impacto do diabetes mellitus na mortalidade em síndromes coronarianas agudas

Diabetes mellitus (DM) is a leading cause of mortality in the world, mainly on account of cardiovascular diseases. At present we know that not only DM but also other hyperglycemic states are a risk factor for coronary arterial disease. In the context of acute coronary syndromes, DM determines a worst prognosis, either in short- or long-term outcomes. Since the absolute risk of death is greater among diabetic patients when compared to non-diabetic patients, therapeutical interventions have a greater impact in terms of benefits to these patients as well. Strategies such as strict control of hyperglycemia during hospitalization, acute reperfusion management (either by thrombolysis or by percutaneous coronary intervention), use of platelet glycoprotein IIb/IIIa inhibitors and angiotensin-converting enzyme (ACE)-inhibitors have recently proven to be of greater benefit for diabetics over non-diabetic patients. Meanwhile, in spite of all proven benefits of the use of evidence-based interventions to the treatment of acute coronary syndromes on diabetic patients, there is still an under utilization of these measures. Therefore, taking into account the predictions of an increasing number of diabetics in the world for the future years, and the fact that acute coronary syndromes will be the leading cause of death among them, it becomes increasingly necessary for both cardiologists and endocrinologists to work together in order to reduce the unfavorable outcomes that are expected to arise.

Tricuspid Valve Annular Dilation as a Predictor of Right Ventricular Failure After Implantation of a Left Ventricular Assist Device.

Tricuspid annular (TA) dilation has been suggested as a more reliable marker of concomitant advanced right ventricular failure (RVF) than severity of tricuspid regurgitation (TR). Our objective was to examine the impact of TA dilation on occurrence of RVF and in‐hospital mortality following left ventricular assist device (LVAD) implant.

Management of diabetes mellitus and associated cardiovascular risk factors in Brazil – the Brazilian study on the practice of diabetes care

BackgroundThe Brazilian Study on the Practice of Diabetes Care main objective was to provide an epidemiological profile of individuals with type 1 and 2 diabetes mellitus (DM) in Brazil, concerning therapy and adherence to international guidelines in the medical practice.MethodsThis observational, cross-sectional, multicenter study collected and analyzed data from individuals with type 1 and 2 DM attending public or private clinics in Brazil. Each investigator included the first 10 patients with type 2 DM who visited his/her office, and the first 5 patients with type 1 DM.ResultsA total of 1,358 patients were analyzed; 375 (27.6%) had type 1 and 983 (72.4%) had type 2 DM. Most individuals were women, Caucasian, and private health care users. High prevalence rates of hypertension, dyslipidemia and central obesity were observed, particularly in type 2 DM. Only 7.3% and 5.1% of the individuals with types 1 and 2 DM, respectively, had optimal control of blood pressure, plasma glucose and lipids. The absence of hypertension and female sex were associated with better control of type 1 DM and other cardiovascular risk factors. In type 2 DM, older age was also associated with better control.ConclusionsFemale sex, older age, and absence of hypertension were associated with better metabolic control. An optimal control of plasma glucose and other cardiovascular risk factors are obtained only in a minority of individuals with diabetes. Local numbers, compared to those from other countries are worse.

Recurrent events analysis for examination of hospitalizations in heart failure: insights from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) trial

Aims Hospitalizations often occur multiple times during the disease course of a heart failure (HF) patient. However, repeated hospitalizations have not been explored in a fulsome way in this setting. We investigated the association between patient factors and the risk of hospitalization among patients with HF using an extension of the Cox model for the analysis of recurrent events. Methods and results We examined hospitalizations and predictors of readmission among newly discharged patients with HF in the Enhanced Feedback For Effective Cardiac Treatment phase 1 (April 1999-March 2001) study with the Prentice-Williams-Peterson model with total time. Of 8948 individuals discharged alive from hospital, 7562 (84.5%) were hospitalized at least once during 15-year follow-up. More than 31 000 hospitalizations were observed. There was a progressive shortening of the interval length between hospitalization episodes. An increasing number of comorbidities (average 2.3 per patient) was associated to an increasing hazard of being readmitted to hospital. Most patient factors associated with the risk of hospitalization have been previously described in the literature. However, the estimates were smaller in comparison to a traditional analysis based on the Cox model. Conclusion The importance of patient factors for the risk of being admitted to hospital was variable over the course of the disease. Conditions such as diabetes and chronic pulmonary obstructive disease had a sustained association with the rate of hospitalization across all episodes examined. The analysis of recurrent events can explore the longitudinal aspect of HF and the critical issue of hospitalizations in this population.

Reevaluating Modality of Cardiopulmonary Exercise Testing in Patients with Heart Failure and Resynchronization Therapy: Relevance of Heart Rate-Adaptive Pacing

BACKGROUND Chronotropic incompetence (CI) in heart failure (HF) patients with cardiac resynchronization therapy (CRT) and activity sensors may vary according to exercise modality. We hypothesized that chronotropic response and exercise capacity differ when HF patients with CRT and heart rate (HR) adaptive pacing are exercised on cycloergometer versus treadmill. METHODS AND RESULTS This is a crossover study in which stable HF patients with CRT and HR-adaptive pacing triggered by activity sensors underwent maximal symptom-limited cardiopulmonary exercise testing on both a cycloergometer and treadmill. Adjusted percent of HR reserve (%HRR) was calculated as HRR/age-predicted HRR. CI was defined as ≤62% of age-predicted HRR. Among 16 patients (59 ± 10 years, ejection fraction 27 ± 12%, 87% on beta-blockers), prevalence of CI was high irrespective of exercise modality (87.5% on cycloergometer vs 62.5% on treadmill; P = .12). Chronotropic responses were better on the treadmill; %HRR was higher on a treadmill vs cycloergometer (61 ± 26% vs 22 ± 31%; P = .003). Peak oxygen consumption was increased by 24% on a treadmill vs cycloergometer (15.8 vs 12.7 mL/kg/min; P < .0001). CONCLUSIONS In HF patients with CRT and HR-adaptive pacing, treadmill cardiopulmonary exercise testing enhances chronotropic response, HRR, and peak oxygen consumption compared with a cycloergometer. These findings may have implications in exercise prescription and thresholds for advanced therapies such as heart transplantation and ventricular assist devices.