Luís Beck-da-Silva

IRON-HF study: A randomized trial to assess the effects of iron in heart failure patients with anemia

BACKGROUNDnAnemia in heart failure patients and has been associated with increased morbi-mortality. Previous studies have treated anemia in heart failure patients with either erythropoietin alone or combination of erythropoietin and intravenous (i.v.) iron. However, the effect of i.v. or oral (p.o.) iron supplementation alone in heart failure patients with anemia was virtually unknown.nnnAIMnTo compare, in a double-blind design, the effects of i.v. iron versus p.o. iron in anemic heart failure patients.nnnMETHODSnIRON-HF study was a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that enrolled anemic heart failure patients with preserved renal function, low transferrin saturation (TSat) and low-to-moderately elevated ferritin levels. Interventions were Iron Sucrose i.v. 200 mg, once a week, for 5 weeks, ferrous sulfate 200 mg p.o. TID, for 8 weeks, or placebo. Primary endpoint was variation of peak oxygen consumption (peak VO2) assessed by ergospirometry over 3 month follow-up.nnnRESULTSnEighteen patients had full follow-up data. There was an increment of 3.5 ml/kg/min in peak VO2 in the i.v. iron group. There was no increment in peak VO2 in the p.o. iron group. Patients ferritin and TSat increased significantly in both treated groups. Hemoglobin increased similarly in all groups.nnnCONCLUSIONnI.v. iron seems to be superior in improving functional capacity of heart failure patients. However, correction of anemia seems to be at least similar between p.o. iron and i.v. iron supplementation.

Nurses’ performance in classifying heart failure patients based on physical exam: comparison with cardiologist’s physical exam and levels of N-terminal pro-B-type natriuretic peptide

AIMnThe purpose of this study is to compare clinical assessment of congestion performed by a nurse to that performed by cardiologist and correlate them with NT-ProBNP levels.nnnBACKGROUNDnThe nurses role in heart failure has been strongly focused in therapeutic, educational and self-care interventions. The diagnostic performance of nurses in heart failure outpatients is not well explored. N-terminal pro-B-type natriuretic peptide is a cardiac marker that reflects elevated filling pressures.nnnDESIGNnCross-sectional contemporaneous study.nnnMETHODSnHeart failure outpatients underwent a systematic clinical assessment of clinical congestion score performed by cardiologist and nurse during the same visit. Assessments were performed independently and N-terminal pro-B-type natriuretic peptide levels obtained. The nurses ability to classify patients in hemodynamic profile was compared to the cardiologists.nnnRESULTSnEighty-nine assessments were performed in 63 patients with heart failure. The correlation of clinical congestion scores obtained by nurse with those obtained by cardiologist was rs=0.86; p<0.001. The correlation of clinical congestion scores from nurse and cardiologist with levels of N-terminal pro-B-type natriuretic peptide were as follows: rs=0.45; p<0.0001 and rs=0.51, respectively, p<0.0001. Patients with clinical congestion score≥3 had levels of NT-ProBNP significantly higher than those with clinical congestion score<3, in the assessment performed by the cardiologist (1866 SD 1151 vs. 757 SD 988u2003pg/ml; p<0.0001) and by the nurse (1720 SD 1228 vs. 821 SD 914u2003pg/ml; p<0.0001). The nurse and cardiologist had similar capacity in classifying patients in congested quadrants (p=0.027) or in dry quadrants (p=0.03), according to the levels of N-terminal pro-B-type natriuretic peptide. Area under the receiver-operating characteristic curve of the nurse and cardiologist to detect congestion was, respectively, 0.77 and 0.72.nnnCONCLUSIONSnOur data suggests that nurses trained in heart failure may have a similar performance to that of the cardiologist for the clinical detection of congestion and assessment of the hemodynamic profile in patients with chronic heart failure.nnnRELEVANCE TO CLINICAL PRACTICEnConsidering that consistent clinical assessment can identify congested or hypovolemic patients with reasonable reliability, as well as patients with low or normal cardiac output, our results may help confirm nurses capability in performing reliable clinical assessment in heart failure patients. While nurses led heart failure programmes are usually focused on the management of patients, nurses ability to perform accurate assessment would expand nurses role in these programmes. As many institutions now focus on home visits by heart failure nurses, accurate assessment would benefit patients and improve their clinical outcomes.

Are scores useful in advanced heart failure

Advanced heart failure (HF) is becoming an increasingly challenging problem as more patients with this disease are living longer, yet experiencing its inexorable progression. Adding to this complex matter, there are different views on how to define advanced HF, whereby an acute decompensation episode does not necessarily indicate advanced disease. Several scores have been described aiming at a better prognostic performance across the HF spectrum. These include the Heart Failure Survival Score, the Seattle Heart Failure Model, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure predictive schemes, the Acute Decompensated Heart Failure National Registry regression tree discrimination, among others. Most scoring systems have been built based on outpatient populations or recently hospitalized HF subjects. The setting of advanced HF has not gained much attention as far as prognostication is concerned, and yet there lies potentially challenging decision-making situations where issues, such as heart transplantation, use of costly devices and end-of-life questions, are raised.

A nurse-based strategy reduces heart failure morbidity in patients admitted for acute decompensated heart failure in Brazil: the HELEN-II clinical trial

Home‐based interventions for heart failure (HF) patients might be particularly effective in middle‐income countries, where social, cultural, and economic constraints limit the effectiveness of HF treatment outside the hospital environment.

Trepopnea may explain right-sided pleural effusion in patients with decompensated heart failure

BACKGROUNDnPhysicians often overlook trepopnea as a symptom, and its prevalence and clinical repercussions are not usually described. We propose that trepopnea is a common symptom in heart failure (HF) and, because of patient avoidance of left lateral decubitus position, contributes to the greater prevalence of right-sided pleural effusion in patients with HF. Accordingly, this study aimed to determine trepopnea prevalence and to evaluate the association of trepopnea and the laterality of pleural effusion in decompensated HF.nnnMETHODSnConsecutive patients (n = 37) with decompensated HF and evidence of pleural effusion by chest x-ray were included. Data were collected at the emergency department by a standard clinical examination in which patients were specifically asked about the presence of trepopnea and preferred decubitus position while recumbent. Chest x-ray and echocardiographic parameters were recorded.nnnRESULTSnOf the 37 patients, 19 (51%) reported trepopnea. Most patients presented with right-sided pleural effusion; only 2 patients (5.4%) presented with left-sided pleural effusion. Patients who reported trepopnea had predominant right-sided pleural effusion more frequently than patients without this symptom (73.7% vs 26.3%; P = .049). The participants that reported trepopnea or avoidance of left lateral decubitus position while recumbent or both had a greater probability of having predominant right-sided pleural effusion (likelihood ratio, 1.85; 95% confidence interval, 1.02-3.35).nnnCONCLUSIONSnTrepopnea is a common symptom in patients with decompensated HF and is associated with predominant right-sided pleural effusion in this population. Our results indicate that trepopnea may be a contributory factor for pleural effusion laterality in patients with decompensated HF.

Pulse Pressure and QRS Width Evaluation as an Inexpensive Tool for Heart Failure Assessment

Decreased pulse pressure (PP) is associated with low cardiac output and increased mortality in heart failure (HF) inpatients. QRS width is a well-known prognostic factor in HF. The study purpose was to explore the mortality effect of combining PP and QRS width in HF outpatients. Initial sphygmomanometrically determined PP and QRS width on the first electrocardiograph in 327 consecutive patients at an HF clinic were recorded. According to PP > or = or <40 mm Hg and QRS width > or = or <120 ms, patients were classified into 4 groups. Study groups were analyzed for their effect on mortality using Cox proportional hazards regression analysis. Patients with PP <40 mm Hg had higher mortality (59% vs 45%; P=.015). QRS width > or =120 ms indicated a trend toward higher mortality (57% vs 48%; P=.067). Actuarial survival curves showed that group 4 (QRS width > or =120 ms and PP <40 mm Hg) had significant increased mortality risk in 3.5 years mean follow-up. Group 4 had a mean survival time of 1124 days (SD=124) vs 2233 days (SD=285) in group 1 (QRS width <120 ms and PP > or =40 mm Hg) (P=.022). There was a linear association between left ventricular ejection fraction (LVEF) and study groups. PP and QRS width are readily available, inexpensive, and relevant clinical measures to help identify HF outpatients with significantly worse prognosis and decreased LVEF.

Effect of fluid and dietary sodium restriction in the management of patients with heart failure and preserved ejection fraction: study protocol for a randomized controlled trial

BackgroundAlthough half of all patients with heart failure (HF) have a normal or near-normal ejection fraction and their prognosis differs little from that of patients with a reduced ejection fraction, the pathophysiology of HF with preserved ejection fraction (HF-PEF) is still poorly understood, and its management poorly supported by clinical trials. Sodium and fluid restriction is the most common self-care measure prescribed to HF patients for management of congestive episodes. However, its role in the treatment of HF-PEF remains unclear. This trial seeks to compare the effects of a sodium- and fluid-restricted diet versus an unrestricted diet on weight loss, neurohormonal activation, and clinical stability in patients admitted for decompensated HF-PEF.Methods/DesignThis is a randomized, parallel trial with blinded outcome assessment. The sample will include adult patients (aged ≥18xa0years) with a diagnosis of HF-PEF admitted for HF decompensation. The patients will be randomized to receive a diet with sodium and fluid intake restricted to 0.8xa0g/day and 800xa0mL/day respectively (intervention group) or an unrestricted diet, with 4xa0g/day sodium and unlimited fluid intake (control group), and followed for 7xa0days or until hospital discharge. The primary outcome shall consist of weight loss at 7xa0days or discharge. The secondary outcome includes assessment of clinical stability, neurohormonal activation, daily perception of thirst and readmission rate at 30xa0days.DiscussionAssessment of the effects of sodium and fluid restriction on neurohormonal activation and clinical course of HF-PEF can promote a deeper understanding of the pathophysiology and progression of this complex syndrome.Trial registration numberClinicalTrials.gov identifier: NCT01896908 (date of registration: 8 August 2013).

QRS Widening Rates and Genetic Polymorphisms of Matrix Metalloproteinases in a Cohort of Patients With Chronic Heart Failure

BACKGROUNDnQRS duration is considered to be an indicator of adverse outcome in patients with heart failure (HF), and genetic polymorphisms may be involved in this conductivity impairment. We studied the prognostic impact of the QRS widening rate (QRS-WR) on patients with HF and the influence of the matrix metalloproteinases gene polymorphisms on the QRS-WR.nnnMETHODSnThis prospective cohort study included 184 patients with left ventricular (LV) systolic dysfunction (LV ejection fraction [LVEF] < 45%). The QRS-WR was calculated as the difference between 2 electrocardiogram assessments (in ms) divided by the time elapsed between each evaluation (months). The MMP-1 -1607 1G/2G, MMP-2 -790G/T and -1575G/A, MMP-3 -1171 5A/6A, MMP-9 -1562 C/T and R279Q, and MMP-12 -82A/G polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism.nnnRESULTSnPatients were predominantly white (68%) men (67%) in New York Heart Association functional classes I and II (77%). Patients with HF with a QRS-WR ≥ 0.5 ms/month had more HF-related deaths and more combined clinical events than those with a QRS-WR < 0.5 ms/month (P = 0.03 and P = 0.01, respectively). After adjusting for other covariates, the QRS-WR remained an independent predictor of combined clinical events (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5; P = 0.02). The MMP-1 2G2G genotype was associated with nearly a 2-fold increase in QRS-WR (P = 0.03). Conversely, patients with the MMP-3 5A5A genotype and a nonischemic cause of HF were protected against QRS enlargement (P = 0.03).nnnCONCLUSIONSnQRS-WR retains prognostic value in patients with chronic HF receiving guideline-based pharmacologic treatment. MMP gene polymorphisms can influence the rate of QRS enlargement over time.

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.

Preditores clínicos de fração de ejeção preservada em insuficiência cardíaca descompensada

BACKGROUND: Identification and clinical impact of preserved left ventricular ejection fraction (LVEF) on in-hospital outcomes in patients with acute decompensated heart failure (HF) remain poorly defined. OBJECTIVE: To describe clinical predictors and in-hospital outcomes of acute decompensated HF patients and preserved LVEF, and to develop a clinically-based predictive rule based on data acquired on admission. METHODS: Consecutive admissions for HF (n=721) at a tertiary care hospital were followed up to discharge or death. More than 80 clinical variables were evaluated to identify predictors of preserved LVEF upon admission. RESULTS: Preserved LVEF (>50%) was identified in 224 (31%) hospitalizations. Clinical predictors of preserved LVEF were age > 70 years old (p=0.04), female gender (p 45 mmHg (p<0.01) and absence of EKG conduction abnormalities (p<0.001). A clinical score based on these variables was accurate to predict preserved LVEF upon hospital admission (area under ROC curve of 0.76). No significant differences were observed on in-hospital mortality or clinical complications according to quintiles of LVEF. CONCLUSION: Preserved LVEF is a prevalent and morbid condition among hospitalized HF patients. Simple clinical data obtained on admission might be useful for predicting preserved LVEF.