Milena Curiati

Papel dos níveis de BNP no prognóstico da insuficiência cardíaca avançada descompensada

BACKGROUND Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

Diuretic titration based on weight change in decompensated congestive heart failure: A randomized trial

doses of diuretics are related to worsening renal function (WRF), which is associated with an increase of morbidity and mortality and is a frequent complication in decompensated HF [1–9]. Clinically important increase in body weight begins at least 1 week before hospitalization for heart failure. Moreover, during this period, the risk of heart failure hospitalization increases with increasing amounts of weight gain [10]. The objective of the present study was to assess the effects of flexible diuretic titration, based on weight change, on the treatment of decompensated congestive HF. This study was carried out in the intensive Cardiology Unit in a tertiary reference university hospital. This was a prospective, randomized, single-blinded study to compare two treatment regimens of diuretics used for hospitalized patients with decompensated congestive HF: tailored (Group T) or conventional group (Group C) diuretic therapy. The primary endpoint of this study was the time to being free from congestion. The secondary endpoint was: WRF (as defined by the increase in serum creatinine N0.3 mg/dL). Patients who were eligible for screening: were ≥18 years of age, in NYHA functional class IV, ejection fraction b45% (transthoracic echocardiography), decompensated heart failure, and had the presence of two or more signs of water retention (e.g., moderate or marked edema in the lower limbs and/or sacrum, pulmonary crepitations, jugular venous pressure N10 cm, or hepatomegaly N4 cm). The exclusion criteria were: a serum urea level N150 mg/dL, serum creatinine level N3 mg/dL, peritoneal dialysis or hemodialysis, severe aortic stenosis and insulindependent diabetes mellitus. The patients were informed about the study, and if they agreed to participate, they signed the informed consent. The present study was approved by the Ethics Committee for the Analysis of the Research Project at the University of Sao Paulo. We evaluated blood tests (urea, creatinine, sodium, and potassium) every day until 24 h following congestion improvement. All the patients were followed until they were free from congestion (defined as jugular venous pressure b8 cm, a trace to no edema in the lower limbs and sacrum, no pulmonary crepitations, and hepatomegaly b 2c m). The intervention of the researcher after inclusion in the study was only correct daily dose of the diuretic in the intervention group. All the rest of the prescription, including the diuretic in the conventional group was decided by the team who attended the patient. Tailored therapy was initial dose (furosemide 120 mg/d) corrected daily by observed/expected (O/E) weight change ratio. Expected weight change was defined − 1.4%/day. If the daily weight loss was twice or more than expected, the furosemide dose was decreased by one third. If the daily weight loss was lower than expected (half or less), the furosemide dose was increased by one third. In all the other cases, the furosemide dose was maintained. The furosemide was administered until congestive signs improved. To project our needed sample size, we estimated that diuretic titration would result in a 40% reduction in the length of time to being congestion free, an alpha error of 0.05, and a power of 95%. Therefore, we required a sample size of 30 patients in both groups. For detecting associations between the diuretic treatment and the occurrence of renal failure, we used a multivariate model and a logistic regression. A p-value b 0.05 was considered significant. 34 patients were randomized to the diuretic administered according to weight evolution (titrated group), and 38 patients were randomized to the conventional group (control group). The two groups had similar baseline characteristics (Tabl e 1). The patients in the titrated group received an average dose of furosemide higher than that of the control group. The mean dose of dobutamine was similar: titrated group (6 ± 2.6 μg/kg/min vs. 7.1 ± 3.5 μg/kg/min; p =0 .2). The mean dose of furosemide in the Group T was 78.3 (29.5) mg/day vs. Group C 44.8 (23.6) mg/day p b 0.001. The mean doses of vasodilators and beta-blockers were similar in both groups.

Altered Expression in Patients with Heart Failure of Circulating MicroRNAs Related to Lipoprotein Metabolism

Objective: This study aimed to investigate, for the first time, the expression of circulating miRNAs (microRNAs) related to lipoprotein metabolism in patients with HF (heart failure). Methods: Twenty patients with HF and 10 controls without HF were included. BNP (brain natriuretic peptide), a marker of HF severity, plasma lipid parameters and the expression of circulating miRNAs were determined. Key findings: Total, LDL-, non-HDLand HDL-cholesterol, triglycerides, and apo A-I did not differ between both groups, but apo B was lower in the HF group compared to controls (p = 0.007). In respect to miRNAs, miR-33a, miR-144, miR-125, miR-30c, miR-122, miR-26a, miR-185, miR-758 and miR-106b were higher, from tento 25-fold, and miR-10b was lower about 4-fold, in HF group compared to controls. In HF patients a negative correlation between miR-26a and BNP, the marker of disease severity, was found (r = -0.552; p = 0.041). Conclusions: Plasma levels of miRNAs involved in HDL and LDL metabolism regulation were strikingly changed in HF patients. The negative correlation between miR-26a and BNP values may suggest the possibility of the rise of a novel biomarker or therapeutic target in HF.

Mortality rates are going down in clinical use of inotropics. Temporal trends for prognosis in acute decompensated heart failure (1992/1999–2005/ 2006)

use in primary care: the Framingham heart study. Circulation 2008;117:743–53. [6] Verdecchia P, Angeli F. Does brachial pulse pressure predict coronary events? Adv Cardiol 2007;44:150–9. [7] Corretti MC, Anderson TJ, Benjamin EJ, et al. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the international brachial artery reactivity task force. J Am Coll Cardiol 2002;39:257–65. [8] Ghiadoni L, Faita F, Salvetti M, et al. Assessment of flow-mediated dilation reproducibility: a nationwide multicenter study. J Hypertens 2012;30:1399–405. [9] Ghiadoni L, Versari D, Giannarelli C, Faita F, Taddei S. Non-invasive diagnostic tools for investigating endothelial dysfunction. Curr Pharm Des 2008;14:3715–22. [10] Witte DR, van der Graaf Y, Grobbee DE, Bots ML. Measurement of flow-mediated dilatation of the brachial artery is affected by local elastic vessel wall properties in high-risk patients. Atherosclerosis 2005;182:323–30.