Lídia Zytynski Moura

I Latin American Guidelines for the assessment and management of decompensated heart failure

Edimar Alcides Bocchi, Fabio Vilas-Boas, Sergio Perrone, Angel G Caamano, Nadine Clausell, Maria da Consolacao VMoreira, Jorge Thierer, Hugo Omar Grancelli, Carlos Vicente Serrano Junior, Denilson Albuquerque, Dirceu Almeida,Fernando Bacal, Luis Felipe Moreira, Adonay Mendonza, Antonio Magana, Arturo Tejeda, Daniel Chafes, Efraim Gomez,Erick Bogantes, Estela Azeka, Evandro Tinoco Mesquita, Francisco Jose Farias B Reis, Hector Mora, Humberto Vilacorta,Jesus Sanches, Joao David de Souza Neto, Jose Luis Vuksovic, Juan Paes Moreno, Julio Aspe y Rosas, Lidia ZytynskiMoura, Luis Antonio de Almeida Campos, Luis Eduardo Rohde, Marcos Parioma Javier, Martin Garrido Garduno, MucioTavares, Pablo Castro Galvez, Raul Spinoza, Reynaldo Castro de Miranda, Ricardo Mourilhe Rocha, Roberto Paganini,Rodolfo Castano Guerra, Salvador Rassi, Sofia Lagudis, Solange Bordignon, Solon Navarette, Waldo Fernandes, AntonioCarlos Pereira Barretto, Victor Issa, Jorge Ilha Guimaraes.

Sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda 2009/2011

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Reduced Progression of Cardiac Allograft Vasculopathy with Routine Use of Induction Therapy with Basiliximab

Background Cardiac allograft vasculopathy (CAV) is a major limitation for long-term survival of patients undergoing heart transplantation (HT). Some immunosuppressants can reduce the risk of CAV. Objectives The primary objective was to evaluate the variation in the volumetric growth of the intimal layer measured by intracoronary ultrasound (IVUS) after 1 year in patients who received basiliximab compared with that in a control group. Methods Thirteen patients treated at a single center between 2007 and 2009 were analyzed retrospectively. Evaluations were performed with IVUS, measuring the volume of a coronary segment within the first 30 days and 1 year after HT. Vasculopathy was characterized by the volume of the intima of the vessel. Results Thirteen patients included (7 in the basiliximab group and 6 in the control group). On IVUS assessment, the control group was found to have greater vessel volume (120–185.43 mm3 vs. 127.77–131.32 mm3; p = 0.051). Intimal layer growth (i.e., CAV) was also higher in the control group (27.30–49.15 mm3 [∆80%] vs. 20.23–26.69 mm3 [∆33%]; p = 0.015). Univariate regression analysis revealed that plaque volume and prior atherosclerosis of the donor were not related to intima growth (r = 0.15, p = 0.96), whereas positive remodeling was directly proportional to the volumetric growth of the intima (r = 0.85, p < 0.001). Conclusion Routine induction therapy with basiliximab was associated with reduced growth of the intima of the vessel during the first year after HT.

Effects of the recombinant form of the natural human B-type natriuretic peptide and levosimendan on pulmonary hyperventilation and chemosensivity in heart failure.

BACKGROUND The origin of dyspnea in chronic heart failure (HF) is multifactorial, and excessive ventilation is thought to play a role in inducing this symptom. Chemosensivity is augmented in HF, correlates with increased pulmonary ventilation (VE), and is an adverse prognostic marker. Despite increased blood levels of natriuretic peptides in clinical conditions associated with dyspnea, their effect on pulmonary VE and chemoreceptor activity remains unexplored. METHODS We tested in a prospective, placebo-controlled, three-way cross-over, double-blind randomized study the effects of the recombinant form of the natural human B-type natriuretic peptide (R-BNP) in comparison with placebo and levosimendan on chemoreflex sensitivity at rest, as well as their effects on pulmonary VE, systemic blood pressure, heart rate and sympathetic serum activity both at rest and during exercise. RESULTS Eleven stable chronic HF patients were randomized to sessions of 6-min treadmill-walking tests during placebo, or levosimendan or R-BNP intravenous infusion in the following conditions: room air, hypoxia, and hypercapnia. R-BNP administration determined higher pulmonary ventilatory response at rest and during exercise (P < 0.001) consequent to a boost of respiratory rate (P < 0.001) under room air and hypoxia conditions. Norepinephrine blood levels increased from rest to exercise in all conditions without differences among placebo, levosimendan, and R-BNP effects. BNP blood levels remained unchanged. CONCLUSIONS The novelty of the present findings is that R-BNP infusion in HF patients can boost pulmonary ventilatory response at rest and during exercise.

Interaction of anemia and decrease in renal function on survival of patients with heart failure

heart failure Marcia Olandoski , Raphael Rodrigues de Lima , Miguel Morita Fernandes da Silva , Roberto Pecoits-Filho , Angela Olandoski Barboza , Bruna Olandoski Erbano , Lidia Zytynski Moura , Paulo Roberto Slud Brofman , Jose Rocha Faria-Neto a,b,⁎ a Center for Health and Biological Sciences, Pontificia Universidade Catolica do Parana, Brazil b Hospital Cardiologico Costantini, Brazil c Universidade Tecnologica Federal do Parana, Brazil d Faculdade Evangelica do Parana, Brazil

Quimiossensibilidade durante exercício na insuficiência cardíaca: respostas ventilatórias, cronotrópicas e neurohormonais

BACKGROUND: Heart failure (HF) is associated with resting increased peripheral and central chemosensitivity which may correlate with an increased ventilatory response to exercise. However, its sensitivity in HF during exercise was never really reported. OBJECTIVE: We tested if stimulation of central and peripheral chemoreceptors in HF patients could modulate ventilatory, chronotropic, and neurohormonal response during submaximal exercise. METHODS: We investigated central and peripheral chemosensitivity in 15 HF and 7 control (C) comparing response through three 6 minute walking tests conducted in a treadmill with : room air, hypoxia, and hypercapnia (in a randomic order). RESULTS: RR at room air C and HF was 17±2 and 22±2 (p<.0001); at hypoxia 17±1 and 23±2 (p<.02); at CO25% was 20±2 and 22±5 (p<.02). Tidal volume (TV) at room air was 1.25±0.17 and 1.08±0.19 (p<.01); at hypoxia 1.65±0.34 and 1.2±0.2 (p<.0001); at CO25% 1.55±0.46 and 1.29±0.39 (p<.0001). At rest the increment in HF was higher for VE (C 33±40%, HF 62±94%, p<.01), HR(C 7±10%, HF 10±10%, p<0.05) at rest. During hypoxia exercise increment in HF was higher for RR (C 1±4, HF 11±6,p<.05), HR (C 12±2, HF 14±3, p<.05), VE/VO2 (C -4±18%, HF 24±21%, p<.01), HR/VO2 (C -26±11%, HF 11±5%, p<.01), VE/WD (C 36±10%, 46±14, p<.05%) and HR/WD (C 18±8%, HF 29±11, p<.01). During HF hypoxia exercise NO reduced, and IL-6, aldosterone levels increased. Neurohormonal levels unchanged in C. CONCLUSION: Exercise peripheral and central chemosensitivity are increased in HF and may modulate respiratory pattern, cardiac chronotropic, and neurohormonal activity during exercise.BACKGROUND Heart failure (HF) is associated with resting increased peripheral and central chemosensitivity which may correlate with an increased ventilatory response to exercise. However, its sensitivity in HF during exercise was never really reported. OBJECTIVE We tested if stimulation of central and peripheral chemoreceptors in HF patients could modulate ventilatory, chronotropic, and neurohormonal response during submaximal exercise. METHODS We investigated central and peripheral chemosensitivity in 15 HF and 7 control (C) comparing response through three 6 minute walking tests conducted in a treadmill with : room air, hypoxia, and hypercapnia (in a randomic order). RESULTS RR at room air C and HF was 17±2 and 22±2 (p<.0001); at hypoxia 17±1 and 23±2 (p<.02); at CO25% was 20±2 and 22±5 (p<.02). Tidal volume (TV) at room air was 1.25±0.17 and 1.08±0.19 (p<.01); at hypoxia 1.65±0.34 and 1.2±0.2 (p<.0001); at CO25% 1.55±0.46 and 1.29±0.39 (p<.0001). At rest the increment in HF was higher for VE (C 33±40%, HF 62±94%, p<.01), HR(C 7±10%, HF 10±10%, p<0.05) at rest. During hypoxia exercise increment in HF was higher for RR (C 1±4, HF 11±6,p<.05), HR (C 12±2, HF 14±3, p<.05), VE/VO₂ (C -4±18%, HF 24±21%, p<.01), HR/VO₂ (C -26±11%, HF 11±5%, p<.01), VE/WD (C 36±10%, 46±14, p<.05%) and HR/WD (C 18±8%, HF 29±11, p<.01). During HF hypoxia exercise NO reduced, and IL-6, aldosterone levels increased. Neurohormonal levels unchanged in C. CONCLUSION Exercise peripheral and central chemosensitivity are increased in HF and may modulate respiratory pattern, cardiac chronotropic, and neurohormonal activity during exercise.

Exercise chemosensitivity in heart failure: ventilatory, chronotropic and neurohormonal responses

BACKGROUND: Heart failure (HF) is associated with resting increased peripheral and central chemosensitivity which may correlate with an increased ventilatory response to exercise. However, its sensitivity in HF during exercise was never really reported. OBJECTIVE: We tested if stimulation of central and peripheral chemoreceptors in HF patients could modulate ventilatory, chronotropic, and neurohormonal response during submaximal exercise. METHODS: We investigated central and peripheral chemosensitivity in 15 HF and 7 control (C) comparing response through three 6 minute walking tests conducted in a treadmill with : room air, hypoxia, and hypercapnia (in a randomic order). RESULTS: RR at room air C and HF was 17±2 and 22±2 (p<.0001); at hypoxia 17±1 and 23±2 (p<.02); at CO25% was 20±2 and 22±5 (p<.02). Tidal volume (TV) at room air was 1.25±0.17 and 1.08±0.19 (p<.01); at hypoxia 1.65±0.34 and 1.2±0.2 (p<.0001); at CO25% 1.55±0.46 and 1.29±0.39 (p<.0001). At rest the increment in HF was higher for VE (C 33±40%, HF 62±94%, p<.01), HR(C 7±10%, HF 10±10%, p<0.05) at rest. During hypoxia exercise increment in HF was higher for RR (C 1±4, HF 11±6,p<.05), HR (C 12±2, HF 14±3, p<.05), VE/VO2 (C -4±18%, HF 24±21%, p<.01), HR/VO2 (C -26±11%, HF 11±5%, p<.01), VE/WD (C 36±10%, 46±14, p<.05%) and HR/WD (C 18±8%, HF 29±11, p<.01). During HF hypoxia exercise NO reduced, and IL-6, aldosterone levels increased. Neurohormonal levels unchanged in C. CONCLUSION: Exercise peripheral and central chemosensitivity are increased in HF and may modulate respiratory pattern, cardiac chronotropic, and neurohormonal activity during exercise.BACKGROUND Heart failure (HF) is associated with resting increased peripheral and central chemosensitivity which may correlate with an increased ventilatory response to exercise. However, its sensitivity in HF during exercise was never really reported. OBJECTIVE We tested if stimulation of central and peripheral chemoreceptors in HF patients could modulate ventilatory, chronotropic, and neurohormonal response during submaximal exercise. METHODS We investigated central and peripheral chemosensitivity in 15 HF and 7 control (C) comparing response through three 6 minute walking tests conducted in a treadmill with : room air, hypoxia, and hypercapnia (in a randomic order). RESULTS RR at room air C and HF was 17±2 and 22±2 (p<.0001); at hypoxia 17±1 and 23±2 (p<.02); at CO25% was 20±2 and 22±5 (p<.02). Tidal volume (TV) at room air was 1.25±0.17 and 1.08±0.19 (p<.01); at hypoxia 1.65±0.34 and 1.2±0.2 (p<.0001); at CO25% 1.55±0.46 and 1.29±0.39 (p<.0001). At rest the increment in HF was higher for VE (C 33±40%, HF 62±94%, p<.01), HR(C 7±10%, HF 10±10%, p<0.05) at rest. During hypoxia exercise increment in HF was higher for RR (C 1±4, HF 11±6,p<.05), HR (C 12±2, HF 14±3, p<.05), VE/VO₂ (C -4±18%, HF 24±21%, p<.01), HR/VO₂ (C -26±11%, HF 11±5%, p<.01), VE/WD (C 36±10%, 46±14, p<.05%) and HR/WD (C 18±8%, HF 29±11, p<.01). During HF hypoxia exercise NO reduced, and IL-6, aldosterone levels increased. Neurohormonal levels unchanged in C. CONCLUSION Exercise peripheral and central chemosensitivity are increased in HF and may modulate respiratory pattern, cardiac chronotropic, and neurohormonal activity during exercise.

Tronco de coronária esquerda ocluso secundário a Lues terciária

A 27-year-old patient with tertiary syphilis, manifested as myocardial ischemia, presenting unstable angina, secondary to left coronary trunk occlusion. The diagnosis was confirmed by the serological findings and the pathological assessment of the aorta fragment.

Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial

Aims Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC‐1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals. Methods The ReBIC‐1 trial is currently enrolling HF patients in NYHA functional class I‐II, left ventricular ejection fraction ≤ 45%, without a HF‐related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double‐blinded protocol. The trial has two co‐primary outcomes: (1) dyspnea assessment using a visual‐analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow‐up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre‐defined sub‐group analysis based on NT‐proBNP levels at baseline is planned. Perspective Evidence‐based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC‐1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.

Assessment of cardiac allograft vasculopathy in cardiac transplantation: experience of a Brazilian center

BACKGROUND Cardiac transplantation continues to be the treatment of choice for heart failure refractory to optimized treatment. Two methods have high sensitivity for diagnosing allograft rejection episodes and cardiac allograft vasculopathy (CAV), important causes of mortality after transplantation. OBJECTIVE To assess the relationship between intravascular ultrasound (IVUS) results and endomyocardial biopsy (BX) reports in the follow-up of patients undergoing cardiac transplantation in a Brazilian reference service. METHODS A retrospective epidemiological observational study was carried out with patients undergoing orthotopic cardiac transplantation from 2000 to 2009. The study assessed the medical records of those patients and the results of the IVUS and BX routinely performed in the clinical post-transplant follow-up, as well as the therapy used. RESULTS Of the 77 patients assessed, 63.63% were males, their ages ranging from 22 to 69 years. Regarding the IVUS results, 33.96% of the patients were classified as Stanford class I, and 32.08%, as Stanford class IV. Of the 143 BX reports, 51.08% were 1R, and 0.69%, 3R. The Quilty effect was described in 14.48% of the BX reports. All patients used antiproliferative agents, 80.51% used calcineurin inhibitors, and 19.48% used proliferation signal inhibitors. CONCLUSION The assessment of cardiac transplant patients by use of IVUS provides detailed information for the early and sensitive diagnosis of CAV, which is complemented by histological data derived from BX, establishing a possible causal relationship between CAV and humoral rejection episodes.