Marcelo Eidi Ochiai

Uric acid renal excretion and renal insufficiency in decompensated severe heart failure

To evaluate uric acid renal excretion, hyperuricemia, renal dysfunction, and prognosis in patients with decompensated severe heart failure, as there are few data available.

Predictors of low cardiac output in decompensated severe heart failure.

OBJECTIVE: To identify predictors of low cardiac output and mortality in decompensated heart failure. INTRODUCTION: Introduction: Patients with decompensated heart failure have a high mortality rate, especially those patients with low cardiac output. However, this clinical presentation is uncommon, and its management is controversial. METHODS: We studied a cohort of 452 patients hospitalized with decompensated heart failure with an ejection fraction of <0.45. Patients underwent clinical‐hemodynamic assessment and Chagas disease immunoenzymatic assay. Low cardiac output was defined according to L and C clinical‐hemodynamic profiles. Multivariate analyses assessed clinical outcomes. P<0.05 was considered significant. RESULTS: The mean age was 60.1 years; 245 (54.2%) patients were >60 years, and 64.6% were men. Low cardiac output was present in 281 (63%) patients on admission. Chagas disease was the cause of heart failure in 92 (20.4%) patients who had higher B type natriuretic peptide levels (1,978.38 vs. 1,697.64 pg/mL; P = 0.015). Predictors of low cardiac output were Chagas disease (RR: 3.655, P<0.001), lower ejection fraction (RR: 2.414, P<0.001), hyponatremia (RR: 1.618, P = 0.036), and renal dysfunction (RR: 1.916, P = 0.007). Elderly patients were inversely associated with low cardiac output (RR: 0.436, P = 0.001). Predictors of mortality were Chagas disease (RR: 2.286, P<0.001), ischemic etiology (RR: 1.449, P = 0.035), and low cardiac output (RR: 1.419, P = 0.047). CONCLUSIONS: In severe decompensated heart failure, predictors of low cardiac output are Chagas disease, lower ejection fraction, hyponatremia, and renal dysfunction. Additionally, Chagas disease patients have higher B type natriuretic peptide levels and a worse prognosis independent of lower ejection fraction.

Delirium in hospitalized elderly patients and post-discharge mortality

OBJECTIVE: To determine the impact of delirium on post-discharge mortality in hospitalized older patients. INTRODUCTION: Delirium is frequent in hospitalized older patients and correlates with high hospital mortality. There are only a few studies about its impact on post-discharge mortality. METHODS: This is a prospective study of patients over 60 years old who were hospitalized in the Geriatric Unit at Hospital das Clínicas of São Paulo between May 2006 and March 2007. Upon admission, demographics, comorbidities, number of drugs taken, and serum albumin concentration were evaluated for each patient. Delirium was diagnosed according to the DSM-IV criteria. Patients were divided into group A (with delirium) and group B (without delirium). One year after discharge, the patients or their caregivers were contacted to assess days of survival. RESULTS: The sample included 199 patients, 66 (33%) of whom developed delirium (Group A). After one year, 33 (50%) group A patients had died, and 45 (33.8%) group B patients had died (p = 0.03). There was a significant statistical difference in average age (p = 0.001) and immobility (p <0.001) between groups A and B. There were no statistically significant differences between groups A and B in number of drugs taken greater than four (p = 0.62), sex (p = 0.54) and number of diagnoses greater than four (p = 0.21). According to a multivariate analysis, delirium was not an independent predictor of post-discharge mortality. The predictors of post-discharge mortality were age ≥ 80 years (p = 0.029), albumin concentration < 3.5 g/dl (p = 0.001) and immobility (p = 0.007). CONCLUSION: Delirium is associated with higher post-discharge mortality as a dependent predictor.

Anemia nos pacientes com insuficiência cardíaca avançada

FUNDAMENTO: Anemia esta associada a pior evolucao nos pacientes com insuficiencia cardiaca (IC). Entretanto, ha poucos estudos sobre a anemia nos pacientes com IC avancada. OBJETIVO: Avaliar as caracteristicas da anemia na IC em fase avancada. METODOS: Foram incluidos 99 pacientes hospitalizados para compensacao de IC (CF IV/NYHA), com idade > 18 anos e FEVE 12 g/dl. A anemia foi marcador independente de mau prognostico na analise multivariada (mortalidade 47% vs 24,6%, p = 0,016, risco relativo 2,54). CONCLUSAO: Anemia acomete, aproximadamente, 1/3 dos pacientes com IC avancada, e a deficiencia de ferro e uma importante etiologia. Pacientes anemicos sao mais idosos e apresentaram funcao renal mais deteriorada. A melhora da congestao nao foi suficiente para melhorar a anemia na maioria dos casos. Nos pacientes com IC avancada, a anemia e marcador independente de mau prognostico.

Microneurography and venous occlusion plethysmography in heart failure: correlation with prognosis

BACKGROUND Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.FUNDAMENTO: Microneurografia e pletismografia de oclusao venosa podem ser considerados metodos de avaliacao da atividade simpatica. OBJETIVO: Avaliar a intensidade da atividade simpatica atraves da microneurografia e da pletismografia de oclusao venosa em pacientes com insuficiencia cardiaca, e correlacionar essa intensidade com prognostico. METODOS: 52 pacientes com insuficiencia cardiaca (FE 53,5 impulsos/min para ANSM (S=90,55. E=73,68%) e 1,81 ml/min/100gr (P<0,001). Analise de regressao logistica: quanto maior a ANSM e menor o FSM, maior e a probabilidade de morte. CONCLUSAO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognosticos na insuficiencia cardiaca avancada.

Chagas cardiomyopathy: prognosis in clinical and hemodynamic profile C

BACKGROUND patients with heart failure (HF) who are admitted showing poor perfusion and congestion (clinical-hemodynamic profile C) are the group that evolves with the worst prognosis in decompensated heart failure. However, there is little information in literature on the etiology of cardiopathy influences the outcome of patients in advanced stage. OBJECTIVE to assess the outcome of patients admitted with clinical and hemodynamic profile C and verify the role of the etiology in this phase. METHODS a cohort study was performed including patients with left ventricle ejection fraction (LVEF) < 45.0%, functional class IV and hospitalization presenting clinical-hemodynamic profile C. The group was divided into patients with chagasic (Ch) and non chagasic (NCh) cardiomyopathy. Statistical analysis used Student t test, Fisher exact test, chi-square and SPSS tests. The significance of p < 0.05 was considered. RESULTS one hundred patients, with mean age 57.6 ± 15.1 years and mean LVEF of 23.8 ± 8.5%, were included. Among the patients studied, 33.0% were chagasic and, in comparison with NCh, had lower systolic blood pressure (Ch 89.3 ± 17.1 mmHg versus NCh 98.8 ± 21.7 mmHg, p = 0.03 ) and lowest average age - Ch 52.9 ± 14.5 years versus NCh 59.8 ± 14.9 years, p = 0.03). During follow-up of 25 months, mortality was 66.7% for Ch and 37.3% in NCh (p = 0.019). The Chagas disease etiology was an independent marker of poor prognosis in multivariate analysis with risk ratio of 2.75 (HF 95.0%, from 1.35 to 5.63). CONCLUSION in patients with advanced HF, Chagas disease is an important predictor of the worst prognosis.FUNDAMENTO: Os pacientes com insuficiencia cardiaca (IC) que sao internados apresentando ma perfusao e congestao (perfil clinico-hemodinâmico C) constituem o grupo que evolui com pior prognostico na IC descompensada. Entretanto, ha pouca informacao na literatura se a etiologia da cardiopatia influencia na evolucao dos pacientes na fase avancada. OBJETIVO: Avaliar a evolucao dos pacientes que se internaram com perfil clinico-hemodinâmico C e verificar o papel da etiologia nesta fase. METODOS: Um estudo de coorte foi realizado incluindo pacientes com fracao de ejecao do ventriculo esquerdo (FEVE) < 45,0%, classe funcional IV e internacao hospitalar apresentando perfil clinico-hemodinâmico C. O grupo foi dividido em pacientes portadores de cardiomiopatia chagasica (Ch) e nao chagasica (NCh). Para analise estatistica foram utilizados os testes t de Student, exato de Fisher, qui-quadrado e o programa SPSS. O significante de p < 0,05 foi considerado. RESULTADOS: Cem pacientes, com idade media de 57,6 ± 15,1 anos e FEVE media de 23,8 ± 8,5%, foram incluidos. Dentre os pacientes estudados, 33,0% eram chagasicos e, na comparacao com os NCh, apresentaram menor pressao arterial sistolica (Ch 89,3 ± 17,1 mmHg versus NCh 98,8 ± 21,7 mmHg; p = 0,03) e menor idade media - Ch 52,9 ± 14,5 anos versus NCh 59,8 ± 14,9 anos; p = 0,03). Durante o acompanhamento de 25 meses, a mortalidade foi de 66,7% nos Ch e de 37,3% nos NCh (p = 0,019). A etiologia chagasica foi um marcador independente de mau prognostico na analise multivariada com razao de risco de 2,75 (IC 95,0%; 1,35 - 5,63). CONCLUSAO: Nos pacientes com IC avancada, a etiologia chagasica e um importante preditor de pior prognostico.

Cardiomiopatia chagásica: prognóstico no perfil clínico-hemodinâmico C

BACKGROUND patients with heart failure (HF) who are admitted showing poor perfusion and congestion (clinical-hemodynamic profile C) are the group that evolves with the worst prognosis in decompensated heart failure. However, there is little information in literature on the etiology of cardiopathy influences the outcome of patients in advanced stage. OBJECTIVE to assess the outcome of patients admitted with clinical and hemodynamic profile C and verify the role of the etiology in this phase. METHODS a cohort study was performed including patients with left ventricle ejection fraction (LVEF) < 45.0%, functional class IV and hospitalization presenting clinical-hemodynamic profile C. The group was divided into patients with chagasic (Ch) and non chagasic (NCh) cardiomyopathy. Statistical analysis used Student t test, Fisher exact test, chi-square and SPSS tests. The significance of p < 0.05 was considered. RESULTS one hundred patients, with mean age 57.6 ± 15.1 years and mean LVEF of 23.8 ± 8.5%, were included. Among the patients studied, 33.0% were chagasic and, in comparison with NCh, had lower systolic blood pressure (Ch 89.3 ± 17.1 mmHg versus NCh 98.8 ± 21.7 mmHg, p = 0.03 ) and lowest average age - Ch 52.9 ± 14.5 years versus NCh 59.8 ± 14.9 years, p = 0.03). During follow-up of 25 months, mortality was 66.7% for Ch and 37.3% in NCh (p = 0.019). The Chagas disease etiology was an independent marker of poor prognosis in multivariate analysis with risk ratio of 2.75 (HF 95.0%, from 1.35 to 5.63). CONCLUSION in patients with advanced HF, Chagas disease is an important predictor of the worst prognosis.FUNDAMENTO: Os pacientes com insuficiencia cardiaca (IC) que sao internados apresentando ma perfusao e congestao (perfil clinico-hemodinâmico C) constituem o grupo que evolui com pior prognostico na IC descompensada. Entretanto, ha pouca informacao na literatura se a etiologia da cardiopatia influencia na evolucao dos pacientes na fase avancada. OBJETIVO: Avaliar a evolucao dos pacientes que se internaram com perfil clinico-hemodinâmico C e verificar o papel da etiologia nesta fase. METODOS: Um estudo de coorte foi realizado incluindo pacientes com fracao de ejecao do ventriculo esquerdo (FEVE) < 45,0%, classe funcional IV e internacao hospitalar apresentando perfil clinico-hemodinâmico C. O grupo foi dividido em pacientes portadores de cardiomiopatia chagasica (Ch) e nao chagasica (NCh). Para analise estatistica foram utilizados os testes t de Student, exato de Fisher, qui-quadrado e o programa SPSS. O significante de p < 0,05 foi considerado. RESULTADOS: Cem pacientes, com idade media de 57,6 ± 15,1 anos e FEVE media de 23,8 ± 8,5%, foram incluidos. Dentre os pacientes estudados, 33,0% eram chagasicos e, na comparacao com os NCh, apresentaram menor pressao arterial sistolica (Ch 89,3 ± 17,1 mmHg versus NCh 98,8 ± 21,7 mmHg; p = 0,03) e menor idade media - Ch 52,9 ± 14,5 anos versus NCh 59,8 ± 14,9 anos; p = 0,03). Durante o acompanhamento de 25 meses, a mortalidade foi de 66,7% nos Ch e de 37,3% nos NCh (p = 0,019). A etiologia chagasica foi um marcador independente de mau prognostico na analise multivariada com razao de risco de 2,75 (IC 95,0%; 1,35 - 5,63). CONCLUSAO: Nos pacientes com IC avancada, a etiologia chagasica e um importante preditor de pior prognostico.

Haemodynamic effects of aliskiren in decompensated severe heart failure

Aim: The renin–angiotensin–aldosterone system (RAAS) has dual pathways to angiotensin II production; therefore, multiple blockages may be useful in heart failure. In this study, we evaluated the short-term haemodynamic effects of aliskiren, a direct renin inhibitor, in patients with decompensated severe heart failure who were also taking angiotensin-converting enzyme (ACE) inhibitors. Materials and methods: A total of 16 patients (14 men, two women, mean age: 60.3 years) were enrolled in the study. The inclusion criteria included hospitalisation due to decompensated heart failure, ACE inhibitor use, and an ejection fraction < 40% (mean: 21.9 ± 6.7%). The exclusion criteria were: creatinine > 2.0 mg/dl, cardiac pacemaker, serum K+ > 5.5 mEq/l, and systolic blood pressure < 70 mmHg. Patients either received 150 mg/d aliskiren for 7 days (aliskiren group, n = 10) or did not receive aliskiren (control group, n = 6). Primary end points were systemic vascular resistance and cardiac index values. Repeated-measures analysis of variance (ANOVA) was used to assess variables before and after intervention. A two-sided p-value < 0.05 was considered statistically significant. Results: Compared to pre-intervention levels, systemic vascular resistance was reduced by 20.4% in aliskiren patients, but it increased by 2.9% in control patients (p = 0.038). The cardiac index was not significantly increased by 19.0% in aliskiren patients, but decreased by 8.4% in control patients (p = 0.127). No differences in the pulmonary capillary or systolic blood pressure values were observed between the groups. Conclusion: Aliskiren use reduced systemic vascular resistance in patients with decompensated heart failure taking ACE inhibitors.

Microneurografia e pletismografia de oclusão venosa na insuficiência cardíaca: correlação com prognóstico

BACKGROUND Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.FUNDAMENTO: Microneurografia e pletismografia de oclusao venosa podem ser considerados metodos de avaliacao da atividade simpatica. OBJETIVO: Avaliar a intensidade da atividade simpatica atraves da microneurografia e da pletismografia de oclusao venosa em pacientes com insuficiencia cardiaca, e correlacionar essa intensidade com prognostico. METODOS: 52 pacientes com insuficiencia cardiaca (FE 53,5 impulsos/min para ANSM (S=90,55. E=73,68%) e 1,81 ml/min/100gr (P<0,001). Analise de regressao logistica: quanto maior a ANSM e menor o FSM, maior e a probabilidade de morte. CONCLUSAO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognosticos na insuficiencia cardiaca avancada.

Associação entre evolução da função cognitiva e mortalidade após a alta hospitalar em pacientes idosos com insuficiência cardíaca avançada

OBJECTIVE: To assess the relation between the evolution of cognitive performance and the prognosis of elderly patients after compensation of advanced heart failure. METHODS: Thirty-one patients older than 64 (68 ± 7) years and admitted with New York Heart Association class IV heart failure and ejection fraction = 0.45 (0.38 ± 0.06) were consecutively selected. They underwent cognitive tests (digit span, digit symbol, letter cancellation, trail making A and B) and the 6-minute walking test 4 days before (T1) and 6 weeks after (T2) hospital discharge, and their performances were compared using the t test. The prognostic value of the scores of the cognitive tests was analyzed with logistic regression, and the value of greatest accuracy of the tests was associated with the prognosis determined by the ROC curve. RESULTS: After 24.7 months, 17 (55%) patients had died. The performances in the 6-minute walking test and most cognitive tests improved between T1 and T2. The digit span score of the survivors ranged from 3.9 to 5.2 (P=0.003) and remained unaltered among those who died (4.1 to 3.9; P=0.496). An improvement < 0.75 points in the score was associated with mortality (relative risk of 8.1; P=0.011). CONCLUSION: In the elderly, after compensation of advanced heart failure, the lack of evolutionary improvement in cognitive performance was associated with a worse prognosis.