Manuel Campelo

Iron deficiency status irrespective of anemia: a predictor of unfavorable outcome in chronic heart failure patients.

Objective: To assess the prognostic significance of iron deficiency (ID) in a chronic heart failure (CHF) outpatient population. Methods and Results: We prospectively evaluated 127 patients with stable CHF and left ventricular ejection fraction ≤45%. Clinical and analytical data as well as information regarding the occurrence of the composite endpoint of overall mortality and nonfatal cardiovascular events were assessed. Among the 127 patients enrolled [81% men, median age: 62 years (25th-75th percentile: 53-68)], 46 (36%) patients had ID. Women, patients with higher plasma brain natriuretic peptide levels (>400 pg/ml) and with right ventricular systolic dysfunction presented ID more frequently (p < 0.05 for all). At 225 ± 139 days of follow-up, the composite endpoint occurred in 15 (12%) patients. It was more frequent in ID (24 vs. 5%, p = 0.001) and anemic patients (25 vs. 8%, p = 0.014). In a Cox regression analysis, ID was associated with a higher likelihood of composite endpoint occurrence (HR 5.00, 95% CI 1.59-15.78, p = 0.006). In a multivariable analysis adjusted for clinical variables, including the presence of anemia, ID remained a significant predictor of the composite endpoint (HR 5.38, 95% CI 1.54-18.87, p = 0.009). Conclusion: In a CHF outpatient population, ID carried a higher risk of unfavorable outcome, irrespectively of the presence of anemia.

Evaluation of the Sympathetic Nervous System Using Heart Rate Variability and Plasma Hormones in Hypertensive Patients Treated with Cilazapril and Atenolol

In a double-blind placebo-controlled parallel study, we assessed basal and post-therapeutic sympathetic activity both in supine and standing positions in mildly to moderately hypertensive patients by two different methods: frequency domain indices of heart rate variability (HRV) and plasma levels of both noradrenaline (NA) and its metabolite, 3,4-dihydroxyphenylglycol (DOPEG). Patients were evaluated on placebo and after 8 weeks of treatment with either cilazapril, 2.5-5 mg/day (13 patients) or atenolol, 50-100 mg/day (14 patients). Twenty-four-hour blood pressure was similarly reduced (p < 0.01) by both cilazapril and atenolol. Heart rate decreased with atenolol by 14 beats per min (p < 0.001) but did not change with cilazapril. When compared to the placebo, cilazapril did not modify sympathetic activity indices of HRV but did significantly reduce NA and DOPEG levels in both the supine and standing (p < 0.05) positions. As expected, atenolol reduced (p < 0.05) sympathetic activity indices of HRV but did not modify NA levels in either position. Moreover, while on placebo, patients showed no significant correlations between values of NA or DOPEG, nor in any of the HRV indices. We conclude that: (1) the antihypertensive effects of cilazapril and atenolol are similar, but in these patients, sympathetic activity indices showed divergent results both before and after therapy; (2) this may be due to different aspects of sympathetic activators, assessed independently by different methods, and (3) these discrepancies must be taken into account when evaluating autonomous nervous system parameters.

Prevalence, predictors and prognosis of ventricular reverse remodeling in idiopathic dilated cardiomyopathy

INTRODUCTION Cardiac remodeling is manifested as changes in size, shape and function of the heart. We studied the prevalence, prognosis and predictors of left ventricular reverse remodeling (LVRR) in idiopathic dilated cardiomyopathy (IDCM) after optimized medical therapy. METHODS A total of 113 IDCM patients were followed for 7.1±5.6 years. LVRR was defined as an increase of 10 units in ejection fraction (EF) and decrease in left ventricular diastolic diameter (LVDD), in the absence of resynchronization therapy. RESULTS Baseline EF was 27±8% and LVDD index was 37.1±6.3 mm/m(2). LVRR occurred in 34.5% within 22.6 months. Final EF was 47.5±10.1%, LVDD index was 30.2±3.9 mm/m(2). LVRR was associated with better NYHA class (I-II) and lower BNP (p<0.01) and all patients were alive. Univariate predictive factors of LVRR (p<0.05) were mild hypertension, atrial fibrillation, ventricular hypertrophy on ECG, absence of left bundle branch block, shorter QRS duration, higher hematocrit, lower LVDD index, higher peak oxygen uptake efficiency (VO2/log 10[VE]) and lower dVE/VCO2/VO2, treatment with angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) and use of maximal doses of ACEI/ARB and beta-blockers. Multivariate regression analysis showed that higher doses of ACEI/ARB (OR: 0.32, 95% CI 0.11-0.92) were independently associated with LVRR. Non-transmural late enhancement on cardiac MRI was not a predictor of LVRR. CONCLUSIONS LVRR occurred in one third of IDCM patients, especially in those with mild hypertension and with less advanced disease, who may have benefited from maximal drug titration.

Accuracy of general practitioners’ readings of ECG in primary care

BackgroundThe electrocardiogram (ECG) is a diagnostic test commonly used in daily Primary Care practice. General Practitioners (GP) often feel unsure about their interpretation of ECGs, so they engage external services to provide it.AimTo evaluate accuracy of ECG readings done by GPs by comparison with those done by a cardiologist as the gold standard.MethodsWe studied 195 ECGs collected consecutively during first semester of 2010 in an urban Health Centre of Portugal. Each ECG was read by each physician and inter-observer agreement was evaluated. After coding by Novacode, sensitivity and specificity of GP’s readings were calculated.ResultsInter-observer agreement between GP readings was “good” with an intraclass correlation coefficient of 0.727 (CI 95%: 0.670–0.779). When compared with gold standard, GP achieved a “good” agreement with an intraclass correlation coefficient of 0.712 (CI 95%: 0.659–0.762). The overall accuracy of GP for detecting abnormalities was 81.0% (95%CI: 75.7–85.6%), with a sensitivity of 84.8% (95%CI: 77.3–90.6%) and a specificity of 77.5% (95%CI: 69.7–84.2%). For normal tests, accuracy was 79.9% (95%CI: 74.7–84.3). In the most prevalent classes of abnormalities, accuracy was higher than 90%.ConclusionGP showed good skills in reading ECGs in their practice of Primary Care. Better attention should be given to ischemic abnormalities present on ECGs. Key message: General Practitioners demonstrate good skills for reading the ECGs of patients on a primary care centre when compared to the gold standard defined by a cardiologist reading.

Cardiotoxicidade na terapêutica com antraciclinas: estratégias de prevenção

The increasing use of anthracyclines, together with the longer survival of cancer patients, means the toxic effects of these drugs need to be monitored. In order to detect, prevent or mitigate anthracycline-induced cardiomyopathy, it is essential that all patients undergo a rigorous initial cardiovascular assessment, followed by close monitoring. Several clinical trials have shown the cardioprotective effect of non-pharmacological measures such as exercise, healthy lifestyles, control of risk factors and treatment of comorbidities; a cardioprotective effect has also been observed with pharmacological measures such as beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, statins, dexrazoxane and liposomal formulations. However, there are currently no guidelines for managing prevention in these patients. In this review the authors discuss the state of the art of the assessment, monitoring, and, above all, the prevention of anthracycline-induced cardiotoxicity.

Post-cardiac injury syndrome following transvenous pacing: Case report

Post-cardiac injury syndrome (PCIS) is an inflammatory process involving the pericardium secondary to cardiac injury. It can develop after cardiac trauma, cardiac surgery, myocardial infarction, and, rarely, after certain intravascular procedures. We report a rare case of an iatrogenic cardiac rupture followed by PCIS with delayed inflammatory pericardial effusion after pacemaker implantation. A comprehensive literature review on this topic is provided.

Hipocalcemia como uma causa reversível de insuficiência cardíaca

Calcium plays a key role in heart muscle contraction and relaxation. Hypocalcemic heart failure is a rare and potentially reversible disturbance, which reflects this intrinsic relationship. The authors present the case of a 35-year-old woman who developed acute heart failure during the early postoperative period following total thyroidectomy. The echocardiogram showed severe global left ventricular dysfunction. Laboratory tests showed severe hypocalcemia and new-onset hypoparathyroidism. Cardiac catheterization showed angiographically normal coronary arteries. After clinical, hemodynamic and metabolic stabilization, a repeat echocardiogram revealed recovery of left ventricular function. Subsequently, cardiac magnetic resonance imaging was performed, which also showed no alterations. The patient was discharged asymptomatic, medicated with calcium carbonate, calcitriol and levothyroxine. This case highlights the importance of considering hypocalcemia as a cause of reversible myocardial dysfunction.

Meta-iodobenzylguanidine iodine-123 and cardiac adrenergic activity in familial dilated cardiomyopathy.

Familial dilated cardiomyopathy (FDCM) is characterized by genetic heterogeneity, incomplete age-dependent penetrance, and a multifactorial pathogenesis ([1][1]). Diagnosis is still dependent on clinical criteria and familial investigation ([2][2]). On the other hand, several abnormalities have been

O fenómeno migratório e fatores de risco cardiovascular

Migration of human populations is universal and continues to the present day. Migrations are frequently associated with problems of adaptation, which in turn can lead to increased cardiovascular risk. Most developing countries do not have reliable recording systems that enable them to assess mortality rates or to quantify cardiovascular risk factors in the real world. Attempts to estimate the true burden of cardiovascular disease (CVD) in these countries, as well as to make projections of future trends, must therefore be based on local registries or on inferences using suitable data from other countries in the region. However, somewhat paradoxically, the burden of CVD in individuals of African descent living in the US and, to a lesser extent, in the Caribbean and the UK, has been the subject of considerable research over the last fifty years. This has shown, for example, that rates of hypertension are approximately 50% higher in African-Americans than in other races and, as a result, they suffer significantly increased mortality from stroke. There have been studies comparing hypertension in African and European populations, while others have demonstrated increased cardiovascular risk in immigrants to

Massive hemoptysis as an unusual complication of right heart catheterization: Successful treatment with percutaneous stent

The authors present a case report of successful treatment of pulmonary artery perforation by endovascular stent graft implantation.