Luiz Cláudio Danzmann

Iliopsoas muscle hematoma during treatment with warfarin

La warfarina es un farmaco ampliamente utilizado en la prevencion de fenomenos tromboembolicos, y el conocimiento de sus efectos adversos se hace necesario para el seguimiento de los pacientes. Aunque el desarrollo de discrasias sanguineas es la complicacion potencial en estos pacientes, la ocurrencia de sangrado retroperitoneal es rara. Este articulo discute el caso de un paciente que evoluciono con hematoma del musculo ileopsoas durante tratamiento con el referido farmaco en el postimplante de protesis mitral metalica, con cuadro clinico implicando importantes diagnosticos diferenciales.Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.

Left Ventricular Diastolic Function in Hemodialysis Patients: Role of Preload Increase Maneuver on Tissue Doppler Imaging Evaluation

Objective: Tissue Doppler imaging (TDI) has recently been proposed as a relatively preload-independent method to evaluate left ventricular diastolic function. We sought to investigate the higher-accuracy of TDI to assess diastolic function in end-stage renal disease (ESRD) patients on hemodialysis (HD) associated with a preload increase maneuver. Methods: Thirty-two consecutiveESRD patients (16 female, ages 48.8 ± 17.5 years, 14 ≤45 and 18 >45 years old) were evaluated. Measurements of E, A velocities and the E/A ratio from transmitral inflow pulsed wave Doppler, and E’, A’ velocities and the E’/A’ ratio from TDI were obtained 1 h before and 1 h after HD at baseline and with a preload increase maneuver. Results: The E/A ratio changed significantly in all patients aged >45 before and after HD with the preload increase maneuver. The E’/A’ ratio increased in all subjects with the preload increase maneuver before HD but did not change with the maneuver after HD in the euvolemic state in all patients. Conclusion: In ESRD patients on routine HD, TDI evaluation associated with a preload increase maneuver proved to be a more accurate method to identify diastolic dysfunction when the evaluation is performed in euvolemic patients after HD.

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.

Prevalence of oral anticoagulation in atrial fibrillation

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores.

Hematoma de músculo iliopsoas na vigência de tratamento com varfarina

La warfarina es un farmaco ampliamente utilizado en la prevencion de fenomenos tromboembolicos, y el conocimiento de sus efectos adversos se hace necesario para el seguimiento de los pacientes. Aunque el desarrollo de discrasias sanguineas es la complicacion potencial en estos pacientes, la ocurrencia de sangrado retroperitoneal es rara. Este articulo discute el caso de un paciente que evoluciono con hematoma del musculo ileopsoas durante tratamiento con el referido farmaco en el postimplante de protesis mitral metalica, con cuadro clinico implicando importantes diagnosticos diferenciales.Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.

Yoga and breathing technique training in patients with heart failure and preserved ejection fraction: study protocol for a randomized clinical trial

BackgroundCurrent therapies for heart failure (HF) are followed by strategies to improve quality of life and exercise tolerance, besides reducing morbidity and mortality. Some HF patients present changes in the musculoskeletal system and inspiratory muscle weakness, which may be restored by inspiratory muscle training, thus increasing respiratory muscle strength and endurance, maximal oxygen uptake (VO2), functional capacity, respiratory responses to exercise, and quality of life. Yoga therapies have been shown to improve quality of life, inflammatory markers, and peak VO2 mostly in HF patients with a reduced ejection fraction. However, the effect of different yoga breathing techniques in patients showing HF with a preserved ejection fraction (HFpEF) remain to be assessed.Methods/designA PROBE (prospective randomized open blinded end-point) parallel-group trial will be conducted at two specialized HF clinics. Adult patients previously diagnosed with HFpEF will be included. After signing informed consent and performing a pre-test intervention, patients will be randomized into three groups and provided with either (1) active yoga breathing techniques; (2) passive yoga breathing techniques (pranayama); or and (3) control (standard pharmacological treatment). Follow-up will last 8 weeks (16 sessions). The post-intervention tests will be performed at the end of the intervention period for analysis of outcomes. Interventions will occur continuously according to patients’ enrollment. The main outcome is respiratory muscular resistance. A total of 33 enrolled patients are expected. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist.DiscussionThis trial is probably the first to assess the effects of a non-pharmacological intervention, namely yoga and specific breathing techniques, to improve cardiorespiratory function, autonomic system, and quality of life in patients with HFpEF.Trial registrationREBEC Identifier: RBR-64mbnx (August 19, 2012).Clinical Trials Register: NCT03028168. Registered on 16 January 2017).

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

Parte 1: Diretriz Brasileira de Insuficiencia Cardiaca Cronica […] Diretriz Brasileira de Insuficiencia Cardiaca Cronica e Aguda

Avaliação da Relação do Índice Tornozelo-Braquial com a Gravidade da Doença Arterial Coronária

Introducao: A Doenca Arterial Periferica (DAP) esta associada a eventos cardiovasculares podendo ser diagnosticada e estimada atraves do Indice Tornozelo-Braquial (ITB). Esta bem estabelecido que o ITB e fator agravante na estratificacao de risco cardiovascular, mas sua contribuicao para definir a gravidade do acometimento arterial coronariano nao esta bem estabelecida. Objetivo: O estudo comparou o valor do ITB com a gravidade da doenca aterosclerotica coronariana pelo Escore de Syntax (ES) em pacientes com Sindrome Coronariana Aguda (SCA). Metodos: Estudo prospectivo com a medida do ITB de todos pacientes internados com SCA no Hospital Sao Lucas da PUCRS, consecutivamente, de maio a setembro de 2016, e a comparacao de seu valor com o ES destes pacientes e as respectivas formas de apresentacao da SCA. Resultados: Estudamos 101 pacientes, com media de idade de 62,6±12,0 anos, 58 (57,4% ) masculinos, 74 (82,2% ) hipertensos, 33 (45,8%) diabeticos e 46 (45,5% ) apresentaram infarto agudo do miocardio com infradesnivel do segmento ST (IAMCSST). A gravidade da DAP nao teve relacao com a gravidade anatomica da doenca coronariana. Encontramos uma associacao significativa dos pacientes com ES intermediario com o infarto agudo do miocardio sem supradesnivel do segmento ST (IAMSSST) e de ES baixo com angina instavel (AI) OR (IC95%): 1,11 (1,03-1,20) (P=0,004), que se manteve apos analise multivariada, ajustada para idade, tabagismo, historia familiar de doenca arterial coronaria (DAC) e DAC previa OR (IC95%): 1,13 (1,02-1,25) (P=0,019). Conclusoes: A analise dos nossos resultados, demonstram que pacientes com ITB menor que 0,9 nao apresentaram associacao com maior complexidade de doenca aterosclerotica coronariana determinados pelo ES em pacientes com SCA. Os pacientes com IAMSSST estiveram mais associados com ES intermediario.

Ergospirometry and Echocardiography in Early Stage of Heart Failure with Preserved Ejection Fraction and in Healthy Individuals

Background Heart failure with preserved ejection fraction is a syndrome characterized by changes in diastolic function; it is more prevalent among the elderly, women, and individuals with systemic hypertension (SH) and diabetes mellitus. However, in its early stages, there are no signs of congestion and it is identified in tests by adverse remodeling, decreased exercise capacity and diastolic dysfunction. Objective To compare doppler, echocardiographic (Echo), and cardiopulmonary exercise test (CPET) variables - ergospirometry variables - between two population samples: one of individuals in the early stage of this syndrome, and the other of healthy individuals. Methods Twenty eight outpatients diagnosed with heart failure according to Framingham’s criteria, ejection fraction > 50% and diastolic dysfunction according to the european society of cardiology (ESC), and 24 healthy individuals underwent Echo and CPET. Results The group of patients showed indexed atrial volume and left ventricular mass as well as E/E’ and ILAV/A´ ratios significantly higher, in addition to a significant reduction in peak oxygen consumption and increased VE/VCO2 slope, even having similar left ventricular sizes in comparison to those of the sample of healthy individuals. Conclusion There are significant differences between the structural and functional variables analyzed by Echo and CPET when comparing two population samples: one of patients in the early stage of heart failure with ejection fraction greater than or equal to 50% and another of healthy individuals.

Hematoma de músculo iliopsoas en la vigencia de tratamiento con warfarina

La warfarina es un farmaco ampliamente utilizado en la prevencion de fenomenos tromboembolicos, y el conocimiento de sus efectos adversos se hace necesario para el seguimiento de los pacientes. Aunque el desarrollo de discrasias sanguineas es la complicacion potencial en estos pacientes, la ocurrencia de sangrado retroperitoneal es rara. Este articulo discute el caso de un paciente que evoluciono con hematoma del musculo ileopsoas durante tratamiento con el referido farmaco en el postimplante de protesis mitral metalica, con cuadro clinico implicando importantes diagnosticos diferenciales.Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.