Luiz Eduardo Fonteles Ritt

Use of beta-blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: A systematic review

INTRODUCTION Advanced Life Support guidelines recommend the use of epinephrine during Cardiopulmonary Resuscitation (CPR), as to increase coronary blood flow and perfusion pressure through its alpha-adrenergic peripheral vasoconstriction, allowing minimal rises in coronary perfusion pressure to make defibrillation possible. Contrasting to these alpha-adrenergic effects, epinephrines beta-stimulation may have deleterious effects through an increase in myocardial oxygen consumption and a reduction of subendocardial perfusion, leading to postresuscitation cardiac dysfunction. OBJECTIVE The present paper consists of a systematic review of the literature regarding the use of beta-blockade in cardiac arrest due to ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). METHODS Studies were identified through MEDLINE electronic databases research and were included those regarding the use of beta-blockade during CPR. RESULTS Beta-blockade has been extensively studied in animal models of CPR. These studies not only suggest that beta-blockade could reduce myocardial oxygen requirements and the number of shocks necessary for defibrillation, but also improve postresuscitation myocardial function, diminish arrhythmia recurrences and prolong survival. A few case reports described successful beta-blockade use in patients, along with two prospective human studies, suggesting that it could be safe and effectively used during cardiac arrest in humans. CONCLUSION Even though the existing literature points toward a beneficial effect of beta-blockade in patients presenting with cardiac arrest due to VF/pulseless VT, high quality human trials are still lacking to answer this question definitely.

Cardiopulmonary exercise and 6-min walk tests as predictors of quality of life and long-term mortality among patients with heart failure due to Chagas disease

long-term mortality among patients with heart failure due to Chagas disease☆ Luiz Eduardo Ritt , Antonio Carlos Carvalho , Gilson Soares Feitosa , Joel A. Pinho-Filho , Marcus Vinicius Santos Andrade , Gilson Soares Feitosa-Filho , L. Kristin Newby , Renato D. Lopes a,c,d,⁎ a Cardiology Division, Sao Paulo Federal University, Sao Paulo, Brazil b Cardiology Division, Santa Izabel Hospital, Bahia, Brazil c Brazilian Clinical Research Institute, Sao Paulo, Brazil d Duke Clinical Research Institute, Durham, NC, USA

Patients With Heart Failure in the "Intermediate Range" of Peak Oxygen Uptake: ADDITIVE VALUE OF HEART RATE RECOVERY AND THE MINUTE VENTILATION/CARBON DIOXIDE OUTPUT SLOPE IN PREDICTING MORTALITY.

PURPOSE: While patients with heart failure who achieve a peak oxygen uptake (peak O2) of 10 mL·kg−1·min−1 or less are often considered for intensive surveillance or intervention, those achieving 14 mL·kg−1·min−1 or more are generally considered to be at lower risk. Among patients in the “intermediate” range of 10.1 to 13.9 mL·kg−1·min−1, optimally stratifying risk remains a challenge. METHODS: Patients with heart failure (N = 1167) referred for cardiopulmonary exercise testing were observed for 21 ± 13 months. Patients were classified into 3 groups of peak o2 (⩽10, 10.1–13.9, and ≥14 mL·kg−1·min−1). The ability of heart rate recovery at 1 minute (HRR1) and the minute ventilation/carbon dioxide output ( E/ co2) slope to complement peak o2 in predicting cardiovascular mortality were determined. RESULTS: Peak o2, HRR1 (<16 beats per minute), and the E/ co2 slope (>34) were independent predictors of mortality (hazard ratio 1.6, 95% CI: 1.2–2.29, P = .006; hazard ratio 1.7, 95% CI: 1.1–2.5, P = .008; and hazard ratio 2.4, 95% CI: 1.6–3.4, P < .001, respectively). Compared with those achieving a peak o2 ≥ 14 mL·kg−1·min−1, patients within the intermediate range with either an abnormal E/ co2 slope or HRR1 had a nearly 2-fold higher risk of cardiac mortality. Those with both an abnormal HRR1 and E/ co2 slope had a higher mortality risk than those with a peak o2 ⩽ 10 mL·kg−1·min−1. Survival was not different between those with a peak o2 ⩽ 10 mL·kg−1·min−1 and those in the intermediate range with either an abnormal HRR1 or E/ co2 slope. CONCLUSIONS: HRR1 and the E/ co2 slope effectively stratify patients with peak o2 within the intermediate range into distinct groups at high and low risk.

Additive prognostic value of a cardiopulmonary exercise test score in patients with heart failure and intermediate risk

), which has beenshown to be more objective and reproducible [3]. Patients in Weberclass B are similar to NYHA class II patients in that they are a large,generally stable, and heterogeneous group in whom risk stratificationcan be relatively complex.Werecentlydevelopedacardiopulmonaryexercise test(CPX)scoreusing a summation of readily available responses that improved theprognostic utility of the test [4,5]. We sought to determine whetherthis score could enhance risk stratification among patients withinWeber class B, and compared it to other clinical and CPX responses.Westudied2635HFpatientswhowerereferredforCPXat5centersbetween1993and2010,followedforupto3 years.HFdiagnosisinclud-ed ejection fraction (EF) b40% or a history of decompensated HF withnormalEF(35%ofthesample).AvalidatedCPXscore[5]wascalculatedfor each patient based on the summation of abnormal responses asfollows: VE/VCO

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

Puntuación Heart Failure Survival Score en pacientes con enfermedad de Chagas, correlación con variables funcionales

INTRODUCTION AND OBJECTIVES Chagas disease is a prevalent cause of heart failure in Latin America, and its prognosis is worse than other etiologies. The Heart Failure Survival Score has been used to assess prognosis in patients with heart failure; however, this score has not yet been studied in patients with Chagas cardiopathy. METHODS The Heart Failure Survival Score was calculated in 55 patients with severe left ventricular systolic dysfunction due to Chagas disease. Correlations were assessed between the Heart Failure Survival Score and variables obtained from, cardiopulmonary exercise tests, quality-of-life measures, and 6-minute walking tests. RESULTS Patients were distributed among New York Heart Association classes II-IV; 89% were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, 62% were taking beta-blockers, 86% were taking diuretics, and 74% were taking aldosterone receptor blockers. The mean Heart Failure Survival Score was 8.75 (0.80). The score correlated well with cardiopulmonary test variables such as peak oxygen uptake (0.662; P<.01), oxygen uptake at the anaerobic threshold (0.644; P<.01), ventilation carbon dioxide efficiency slope (-0.417; P<.01), oxygen pulse (0.375; P<.01), oxygen uptake efficiency slope (0.626; P<.01), 6-minute walking test (0.370; P<.01), left ventricle ejection fraction (0.650; P=.01), and left atrium diameter (-0.377; P<.01). There was also a borderline significant correlation between the Heart Failure Survival Score and quality of life (-0.283; P<.05). CONCLUSIONS In heart failure patients with Chagas disease, the Heart Failure Survival Score correlated well with the main prognostic functional test variables.

CLINICAL PREDICTORS OF MAJOR CLINICAL EVENTS 30-DAYS AFTER AN ACUTE CORONARY SYNDROME: INSIGHTS FROM BRAZILIAN CARDIOVASCULAR REGISTRY ACCEPT

Acute coronary syndromes (ACS) gathered a major role in the triggering of clinical events (MACE) worldwide. Reinforcing the identification of the targets that require intervention is recommended. ACCEPT (Acute Coronary Care Evaluation of Clinical Practice) is a nationwide registry sponsored by the

Highlights from the Tenth International Symposium of Thrombosis and Anticoagulation (ISTA X), September 22 and 23, 2017, Salvador, Bahia, Brazil

To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Tenth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, on September 22 and 23, 2017. This scientific program was developed by clinicians for clinicians and was promoted by two major clinical research institutes—the Brazilian Clinical Research Institute and the Duke Clinical Research Institute of the Duke University School of Medicine. Comprising academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.

FUNCTIONAL, PULMONARY, METABOLIC AND QUALITY OF LIFE RESPONSES AFTER CARDIOVASCULAR REHABILITATION PROGRAM

BACKGROUND: clinical trials showed improvement in functional capacity, quality of life, morbidity and mortality with cardiovascular rehabilitation (CVR). OBJECTIVE: to verify clinical responses of a CVR program in a tertiary center. METHODS: 85 patients evaluated in a CVR program. Results for functional capacity obtained by cardiopulmonary exercise test (CPET), sitting rising chair test (SRCT), six minute step test (6MST), inspiratory pressure (Pins), expiratory pressure (Pexp), peak-flow and quality of life score (Minnesota Living With Heart Failure Quality of Life Score - MLWHFS) were compared before and after the program. RESULTS: 69% were men, mean age was 61 ± 15 years and the mean ejection fraction was 61 ± 24%. There was an absolute mean increase of 2.4 ± 3.5 ml -1 .kg -1 .min -1 in peak VO 2 (p <0.001), 14 ± 17 repetitions on the SRCT (p <0.001), 44 ± 41 steps on the 6MST (p <0.001). In pulmonary function, there was an increase of -20 ± 40 cmH 2 O in Pins (p <0.01) and of 9 ± 29 cmH 2 O (p <0.001) in Pexp and 52 ± 77 L.min -1 in peak-flow (p <0.01) and there was a significant gain in quality of life with a mean reduction of 21 ± 15 points in the MLWHFS (P <0.001). CONCLUSION: CVR program resulted in a increase in functional, pulmonary capacity and improvement of quality of life. These data reproduce and reinforce the findings of randomized clinical trials, but in a real and uncontrolled clinical setting.

Highlights from the Ninth International Symposium of Thrombosis and Anticoagulation (ISTA IX), October 15, 2016, Salvador, Bahia, Brazil

To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Ninth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, on October 15, 2016. This scientific program was developed by clinicians for clinicians and was promoted by two major clinical research institutes—the Brazilian Clinical Research Institute and the Duke Clinical Research Institute of the Duke University School of Medicine. Comprising academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.