Luis Beck-da-Silva

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure: A Randomized Clinical Trial

IMPORTANCEnThe benefits of fluid and sodium restriction in patients hospitalized with acute decompensated heart failure (ADHF) are unclear.nnnOBJECTIVEnTo compare the effects of a fluid-restricted (maximum fluid intake, 800 mL/d) and sodium-restricted (maximum dietary intake, 800 mg/d) diet (intervention group [IG]) vs a diet with no such restrictions (control group [CG]) on weight loss and clinical stability during a 3-day period in patients hospitalized with ADHF.nnnDESIGNnRandomized, parallel-group clinical trial with blinded outcome assessments.nnnSETTINGnEmergency room, wards, and intensive care unit.nnnPARTICIPANTSnAdult inpatients with ADHF, systolic dysfunction, and a length of stay of 36 hours or less.nnnINTERVENTIONnFluid restriction (maximum fluid intake, 800 mL/d) and additional sodium restriction (maximum dietary intake, 800 mg/d) were carried out until the seventh hospital day or, in patients whose length of stay was less than 7 days, until discharge. The CG received a standard hospital diet, with liberal fluid and sodium intake.nnnMAIN OUTCOMES AND MEASURESnWeight loss and clinical stability at 3-day assessment, daily perception of thirst, and readmissions within 30 days.nnnRESULTSnSeventy-five patients were enrolled (IG, 38; CG, 37). Most were male; ischemic heart disease was the predominant cause of heart failure (17 patients [23%]), and the mean (SD) left ventricular ejection fraction was 26% (8.7%). The groups were homogeneous in terms of baseline characteristics. Weight loss was similar in both groups (between-group difference in variation of 0.25 kg [95% CI, -1.95 to 2.45]; P = .82) as well as change in clinical congestion score (between-group difference in variation of 0.59 points [95% CI, -2.21 to 1.03]; P = .47) at 3 days. Thirst was significantly worse in the IG (5.1 [2.9]) than the CG (3.44 [2.0]) at the end of the study period (between-group difference, 1.66 points; time × group interaction; P = .01). There were no significant between-group differences in the readmission rate at 30 days (IG, 11 patients [29%]; CG, 7 patients [19%]; P = .41).nnnCONCLUSIONS AND RELEVANCEnAggressive fluid and sodium restriction has no effect on weight loss or clinical stability at 3 days and is associated with a significant increase in perceived thirst. We conclude that sodium and water restriction in patients admitted for ADHF are unnecessary.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT01133236.

Mortality Reduction of Cardiac Resynchronization and Implantable Cardioverter-Defibrillator Therapy in Heart Failure: An Updated Meta-Analysis. Does Recent Evidence Change the Standard of Care?

BACKGROUNDnThe recent publication of the MADIT-CRT and RAFT trials has more than doubled the number of patients in which a direct comparison of the combination of cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillator (ICD) versus ICD alone was carried out. The present meta-analysis aims to assess the impact of combined CRT and ICD therapy on survival of heart failure (HF) patients.nnnMETHODS AND RESULTSnMedline, Embase, and the Cochrane Library databases were searched, and all randomized controlled trials of CRT alone or combined with ICDs in HF resulting from left ventricular systolic dysfunction were included. Main outcome was all-cause mortality. Summary relative risk (RR) and 95% confidence interval (CI) were calculated employing random-effects models. Twelve studies were included, with a total of 8,284 randomized patients. For the comparison of CRT alone versus medical therapy, pooled analysis of 5 available trials demonstrated a significant reduction in all-cause mortality with CRT (RR 0.76, 95% CI: 0.64-0.9). Pooled analysis of 6 trials that compared the combination of CRT and ICD therapy to ICD alone also showed a statistically significant reduction in all-cause mortality (RR 0.83, 95% CI: 0.72-0.96). Stratified analysis showed significant mortality reductions in all New York Heart Association class subgroups, with greater effect in classes III-IV (RR 0.70; 95% CI: 0.57-0.88). Pooled estimates of implant-related risks were 0.6% for death and 8% for implant failure.nnnCONCLUSIONnCombined CRT and ICD therapy reduces overall mortality in HF patients when compared with ICD alone.

Anemia in Heart Failure: Association of Hepcidin Levels to Iron Deficiency in Stable Outpatients

Background: Anemia is a prevalent condition in heart failure with multiple potential causes. The complex interaction between iron stores, hepcidin, inflammation and anemia is poorly comprehended. We tested the hypothesis that, in stable heart failure patients with anemia, hepcidin is associated with iron deficiency status irrespective of inflammation. Methods and Results: Stable systolic heart failure outpatients with and without anemia underwent a complete iron panel, erythropoietin, hepcidin and tumor necrosis factor (TNF)-α assessment. Sixty outpatients were studied. Anemic patients (n = 38, mean hemoglobin 11.4 ± 1 g/dl) were older (69.6 ± 9.6 vs. 58 ± 10.8 years old, p < 0.01) compared with nonanemic patients (n = 22, mean hemoglobin 13.8 ± 1.1 g/dl). Iron deficiency was present in 42% of patients with anemia. TNF-α and hepcidin were 29 and 21% higher in patients with anemia, respectively, compared to nonanemic patients; however, no correlations were found between hepcidin and TNF-α levels. Hepcidin levels in the lower tertile (<31.7 ng/ml) were strongly associated with iron deficiency (OR 16.5, 95% CI 2.2–121.2; p < 0.01). Conclusion: In stable heart failure patients with anemia, hepcidin levels may be more importantly regulated by patients’ iron stores than by inflammation.

Alcohol and the heart: the good, the bad and the worse in heart failure

There is a general acceptance among researchers, physicians and even the general population that the consumption of moderate amounts of alcoholic beverages may have beneficial effect in the heart. A large number of experimental, clinical and epidemiological studies presumably give scientific support to this perception. There have been reports on favourable effects of different alcoholic beverages on several surrogate end-points of atherosclerosis, such as blood lipoproteins, clotting and fibrinolytic factors, endothelin and oxidative stress. Wine is the prototype beverage associated to cardioprotection, with additional positive consequences in the cardiovascular system allegedly attributed to the presence of natural polyphenols, particularly resveratrol. The mechanisms involved in the potential cardioprotective effects of polyphenols are numerous and include antioxidant, vasodilator, anti-inflammatory, antifibrotic, antiapoptotic and anti-ischaemic properties. Recent experimental data also demonstrate that polyphenols can exert its cardioprotective effect via the activation of several powerful prosurvival cellular pathways.1 Unfortunately, all these persuasive data must be interpreted with great caution in the clinical arena for several reasons. Data from observational studies have intrinsic methodological pitfalls …

Critical appraisal of costly therapy modalities for heart failure in a developing country.

Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas’ disease is epidemiologically important in Brazil; outcomes of patients with Chagas’ on electric devices are unclear while these patients fare better post-transplant than non-Chagas’ patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.