Juliano Novaes Cardoso

Re-hospitalizações e morte por insuficiência cardíaca: índices ainda alarmantes

BACKGROUND Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS We followed the progress of 263 patients with a mean EF of 27.1%, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9+/-15.2 years, most were men, and 63.1% required inotropic drugs for cardiac compensation in the acute phase. RESULTS Average hospital stay was 25.1+/-16.7 days. During hospitalization, 23 (8.8%) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2%) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5+/-18.0 days. Over the first year of follow-up, 62 (25.8%) patients died. CONCLUSIONS HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5% of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

Reverse Cardiac Remodeling: A Marker of Better Prognosis in Heart Failure

In heart failure syndrome, myocardial dysfunction causes an increase in neurohormonal activity, which is an adaptive and compensatory mechanism in response to the reduction in cardiac output. Neurohormonal activity is initially stimulated in an attempt to maintain compensation; however, when it remains increased, it contributes to the intensification of clinical manifestations and myocardial damage. Cardiac remodeling comprises changes in ventricular volume as well as the thickness and shape of the myocardial wall. With optimized treatment, such remodeling can be reversed, causing gradual improvement in cardiac function and consequently improved prognosis.

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.

Papel dos níveis de BNP no prognóstico da insuficiência cardíaca avançada descompensada

BACKGROUND Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

Anemia nos pacientes com insuficiência cardíaca avançada

FUNDAMENTO: Anemia esta associada a pior evolucao nos pacientes com insuficiencia cardiaca (IC). Entretanto, ha poucos estudos sobre a anemia nos pacientes com IC avancada. OBJETIVO: Avaliar as caracteristicas da anemia na IC em fase avancada. METODOS: Foram incluidos 99 pacientes hospitalizados para compensacao de IC (CF IV/NYHA), com idade > 18 anos e FEVE 12 g/dl. A anemia foi marcador independente de mau prognostico na analise multivariada (mortalidade 47% vs 24,6%, p = 0,016, risco relativo 2,54). CONCLUSAO: Anemia acomete, aproximadamente, 1/3 dos pacientes com IC avancada, e a deficiencia de ferro e uma importante etiologia. Pacientes anemicos sao mais idosos e apresentaram funcao renal mais deteriorada. A melhora da congestao nao foi suficiente para melhorar a anemia na maioria dos casos. Nos pacientes com IC avancada, a anemia e marcador independente de mau prognostico.

Microneurography and venous occlusion plethysmography in heart failure: correlation with prognosis

BACKGROUND Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.FUNDAMENTO: Microneurografia e pletismografia de oclusao venosa podem ser considerados metodos de avaliacao da atividade simpatica. OBJETIVO: Avaliar a intensidade da atividade simpatica atraves da microneurografia e da pletismografia de oclusao venosa em pacientes com insuficiencia cardiaca, e correlacionar essa intensidade com prognostico. METODOS: 52 pacientes com insuficiencia cardiaca (FE 53,5 impulsos/min para ANSM (S=90,55. E=73,68%) e 1,81 ml/min/100gr (P<0,001). Analise de regressao logistica: quanto maior a ANSM e menor o FSM, maior e a probabilidade de morte. CONCLUSAO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognosticos na insuficiencia cardiaca avancada.

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.

Temporal variation in the prognosis and treatment of advanced heart failure - before and after 2000.

Background The treatment of heart failure has evolved in recent decades suggesting that survival is increasing. Objective To verify whether there has been improvement in the survival of patients with advanced heart failure. Methods We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis. Results The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7). Conclusions Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.

Haemodynamic effects of aliskiren in decompensated severe heart failure

Aim: The renin–angiotensin–aldosterone system (RAAS) has dual pathways to angiotensin II production; therefore, multiple blockages may be useful in heart failure. In this study, we evaluated the short-term haemodynamic effects of aliskiren, a direct renin inhibitor, in patients with decompensated severe heart failure who were also taking angiotensin-converting enzyme (ACE) inhibitors. Materials and methods: A total of 16 patients (14 men, two women, mean age: 60.3 years) were enrolled in the study. The inclusion criteria included hospitalisation due to decompensated heart failure, ACE inhibitor use, and an ejection fraction < 40% (mean: 21.9 ± 6.7%). The exclusion criteria were: creatinine > 2.0 mg/dl, cardiac pacemaker, serum K+ > 5.5 mEq/l, and systolic blood pressure < 70 mmHg. Patients either received 150 mg/d aliskiren for 7 days (aliskiren group, n = 10) or did not receive aliskiren (control group, n = 6). Primary end points were systemic vascular resistance and cardiac index values. Repeated-measures analysis of variance (ANOVA) was used to assess variables before and after intervention. A two-sided p-value < 0.05 was considered statistically significant. Results: Compared to pre-intervention levels, systemic vascular resistance was reduced by 20.4% in aliskiren patients, but it increased by 2.9% in control patients (p = 0.038). The cardiac index was not significantly increased by 19.0% in aliskiren patients, but decreased by 8.4% in control patients (p = 0.127). No differences in the pulmonary capillary or systolic blood pressure values were observed between the groups. Conclusion: Aliskiren use reduced systemic vascular resistance in patients with decompensated heart failure taking ACE inhibitors.