Nuno Lousada

The Importance of Assessing Nutritional Status in Elderly Patients with Heart Failure

Heart failure (HF) is a syndrome characterized by high morbidity and mortality, despite advances in medical and device therapy that have significantly improved survival. The outcome of HF in elderly patients results from a combination of biological, functional, psychological, and environmental factors, one of which is nutritional status. Malnutrition, as well as HF, is frequently present with aging. Early detection might lead to earlier intervention. It is our goal to review the importance of nutritional status in elderly patients with HF, as well as tools for assessing it. We also propose a simple decision algorithm for the nutritional assessment of elderly patients with HF.

Atomic force microscopy as a tool to evaluate the risk of cardiovascular diseases in patients

The availability of biomarkers to evaluate the risk of cardiovascular diseases is limited. High fibrinogen levels have been identified as a relevant cardiovascular risk factor, but the biological mechanisms remain unclear. Increased aggregation of erythrocytes (red blood cells) has been linked to high plasma fibrinogen concentration. Here, we show, using atomic force microscopy, that the interaction between fibrinogen and erythrocytes is modified in chronic heart failure patients. Ischaemic patients showed increased fibrinogen-erythrocyte binding forces compared with non-ischaemic patients. Cell stiffness in both patient groups was also altered. A 12-month follow-up shows that patients with higher fibrinogen-erythrocyte binding forces initially were subsequently hospitalized more frequently. Our results show that atomic force microscopy can be a promising tool to identify patients with increased risk for cardiovascular diseases.

Nutritional status of geriatric outpatients with systolic heart failure and its prognostic value regarding death or hospitalization, biomarkers and quality of life

IntroductionThe prevalence of malnutrition in ambulatory patients with heart failure is difficult to determine, depending on the timing and methodology.ObjectiveTo determine the nutritional status of outpatients with systolic heart failure with the Mini Nutritional Assessment (MNA) full and short-form versions, and evaluate its relationship with the short-term prognosis, biomarkers and quality of life.MethodsFifty consecutive (70% male), geriatric (74.3+ 6.2years old) stable outpatient with heart failure (NYHA class II 68%, III 32%) and left ventricular ejection fraction of 26.7 +11.5% were included and followed during 12 months. At a routine visit to the heart failure clinic, the MNA, the Minnesota Living with Heart Failure questionnaire (MLHFQ) were applied. According to the MNA screening score the nutritional status was classified using the MNA full (MNA-F) and the short-form (MNA-F) versions of the questionnaire. The recorded events were death and hospitalization. Statistics: The-survival and hospitalizations curves were evaluated with the Log-Rank test and Cox Regression analysis. The association between parameters was analyzed with the Pearson and Spearmann correlation coefficient.Results(1) The mortality and hospitalization rates were 12% and 42%, respectively. (2) With the MNA-SF 7.6% of the patients had malnutrition and 20% were at risk of malnutrition. There was a good agreement (90%) between the MNA-SF and the MNA-F classifications. (3) There was a significant relationship between the MNA screening score and the MLHFQ (rs= −0.592 p<0.00l), Nt-ProBNP (rs= −0.49 p<0.001) and total plasma protein (r= 0.672 p=0.006); (3) The-MNA-SF nutritional classification was associated with the 12 months survival (Log-Rank p=0.044) and hospitalization (Log-Rank p=0.005) curves. (4) Those patients with malnutrition by the MNA-SF were at greater risk of death (HR= 8.0 p=0.059) and hospitalization (HR 8.1 p=0.008).ConclusionThe MNA is useful for the evaluation of the nutritional status of elderly outpatients with systolic heart failure. It is a good predictor of the short-term outcome and is also associated with the quality of life and Nt-ProBNP.

Early NT-proBNP Decrease With Ivabradine in Ambulatory Patients With Systolic Heart Failure

Heart rate (HR) reduction in patients with systolic heart failure (HF) is a cornerstone of current therapy. The aim of this study was to evaluate the short‐term effect of the HR reduction with ivabradine on N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) in outpatients with systolic HF.

Left atrial function index predicts long-term survival in stable outpatients with systolic heart failure

Aims Left atrial (LA) function index (LAFI) is a rhythm-independent index that combines LA emptying fraction (LAEF), adjusted LA volume (LAVi), and stroke volume. We evaluated LAFI as a predictor of long-term survival in outpatients with heart failure with reduced ejection fraction (HFrEF). Methods and results For 3 years, we followed up 203 outpatients with a left ventricular ejection fraction <40%, who were clinically stable and on optimal therapy. The endpoint was all-cause death. LAFI was calculated as LAFI = ([LAEF × left ventricular outflow tract-velocity time integral]/[LAVi]), and was categorized into quartiles (9.26/16.56/31.92) and median (16.57). Incremental Cox regression models adjusted for significant confounders were used for survival analyses. The 3-year death rate was 30%. Higher quartiles had lower death rates (43.1%/45.1%/25.5%/6%, P < 0.001). The receiver operating characteristic curve for death was associated with LAFI (area under curve = 0.695, 95% CI 0.62–0.77, P < 0.001). In the direct comparison with LAVi and LAEF, LAFI (HRcox 0.93, 95% CI 0.89–0.97, P < 0.001) was the only predictor of survival. LAFI (HRcox 0.95, 95% CI 0.88–1.01, P = 0.099), LAFI quartiles (HR 0.29, 95% CI 0.125–0.672, P=0.004), and LAFI ≥16.57 (HRcox 0.62, 95% CI 0.38–1.02, P=0.058) were adjusted predictors of survival. Subgroup analysis by heart rhythm (sinus vs. atrial fibrillation) showed that LAFI per unit increase and LAFI quartiles were independent predictors of death in both subgroups. Conclusion LAFI determination in HFrEF stable outpatients is a predictor of long-term survival and provides increased prognostic value over a wide range of confounder risk factors.

Serial measurements of the Nt-ProBNP during the dry state in patients with systolic heart failure are predictors of the long-term prognosis.

Abstract Objective: To evaluate the long-term predictive value of serial Nt-ProBNP during dry-state in patients with systolic heart failure (SHF). Methods: Nt-ProBNP was measured quarterly during a 6-month dry-state period in 40 SHF outpatients. Events: all-cause mortality or hospitalization. Follow-up: 5 years. Results: The Nt-ProBNP >1000 pg/ml (baseline and 6 months) and the variation rate (VR) >30% were independently associated with the survival and composite endpoint curve. VR >30% added significant prognostic information to the single Nt-ProBNP 1000 pg/ml cut-off. Patients with at least one Nt-ProBNP determination >1000 pg/ml were at greater risk of death. Conclusion: Serial Nt-ProBNP measurements in patients with SHF during the dry-state are strong predictors of the long-term prognosis.

Furosemide Prescription During the Dry State Is a Predictor of Long-Term Survival of Stable, Optimally Medicated Patients With Systolic Heart Failure

Background: Furosemide is associated with poor prognosis in patients with heart failure and reduced ejection fraction (HFrEF). Aim: To evaluate the association between daily furosemide dose prescribed during the dry state and long-term survival in stable, optimally medicated outpatients with HFrEF. Population and Methods: Two hundred sixty-six consecutive outpatients with left ventricular ejection fraction <40%, clinically stable in the dry state and on optimal heart failure therapy, were followed up for 3 years in a heart failure unit. The end point was all-cause death. There were no changes in New York Heart Association class and therapeutics, including diuretics, and no decompensation or hospitalization during 6 months. Furosemide doses were categorized as low or none (0-40 mg/d), intermediate (41-80 mg/d), and high (>80 mg). Cox regression was adjusted for significant confounders. Results: The 3-year mortality rate was 33.8%. Mean dose of furosemide was 57.3 ± 21.4 mg/d. A total of 47.6% of patients received the low dose, 42.1% the intermediate dose, and 2.3% the high dose. Receiver operating characteristics for death associated with furosemide dose showed an area under the curve of 0.74 (95% confidence interval [CI]: 0.68-0.79; P < .001), and the best cutoff was >40 mg/d. An increasing daily dose of furosemide was associated with worse prognosis. Those receiving the intermediate dose (hazard ratio [HR] = 4.1; 95% CI: 2.57-6.64; P < .001) or high dose (HR = 19.8; 95% CI: 7.9-49.6; P < .001) had a higher risk of mortality compared to those receiving a low dose. Patients receiving >40 mg/d, in a propensity score–matched cohort, had a greater risk of mortality than those receiving a low dose (HR = 4.02; 95% CI: 1.8-8.8; P = .001) and those not receiving furosemide (HR = 3.9; 95% CI: 0.07-14.2; P = .039). Conclusion: Furosemide administration during the dry state in stable, optimally medicated outpatients with HFrEF is unfavorably associated with long-term survival. The threshold dose was 40 mg/d.

Nt-ProBNP, Anaemia and Renal function are independent predictors of hospitalization in outpatients with pulmonary artery hypertension

The clinical course of pulmonary arterial hypertension (PAH) is highly variable; therefore, reliable parameters are needed to characterize the severity of the disease and to detect the disease progression sensitively. In recent years, several parameters have been tested. Anaemia and renal function are unspecific markers, while Nt-ProBNP has been extensively studied and is recommended in current guidelines. However, renal function may interfere with its levels. We sought to evaluate in patients with PAH, already on specific therapy, which would be the best parameter to predict the long-term hospitalization within the routine laboratory workup. Thirty consecutive adult patients (73.3% women) with PAH, age of 63.7 ± 12.6 years, Group I PAH, on specific pulmonary vasodilator target therapy >12 months (sildenafil 83.3%, bosentan 60%; both 43.3%), stable outpatients (last hospitalization and diuretic therapy changes >3 months) were included in this 2-year clinical follow-up. Also, at inclusion sPAP and mPAP should be >35 mmHg and >25 mmHg, respectively. Our Unit routine laboratorial workup includes the determination of the Nt-ProBNP, complete blood count including haemoglobin, haematocrit, erythrocyte count, red

Control of breathing, respiratory patterns and dyspnoea in patients with congestive heart failure

Abstract The aim of this paper was the evaluation of the control of breathing and respiratory patterns in patients with congestive heart failure (CHF) and its relation with the genesis of dyspnoea. Forty seven patients were studied with CHF, with a mean age of 60.9±12.5 years and compared them with 35 age-matched controls, free of cardiopulmonary diseases. The evaluation included: (a) measurements of lung function using the helium dilution method; (b) determination of occlusion pressure (P0.1) at rest; (c) noninvasive breathing pattern at rest assessed by means of respiratory inductive plethysmography (RIP); (d) CO 2 re-breathing test with the simultaneous recording of ventilation, P0.1 and dyspnoea perception using a visual analogue scale. A mild restrictive ventilatory defect was found in CHF patients, together with an abnormal breathing pattern at rest defined by a significant increase in respiratory frequency and a decrease in tidal volume, when compared with the control group. However, the mean pulmonary ventilation at rest did not differ between the two groups whereas the baseline P0.1 was higher in CHF, (median 1.6; range 2.00 cmH 2 O), than in controls (median 1.20; range 1.00 cmH 2 O), ( P 2 ), than in controls (median 1.30; range 1.29), ( P

Fisiopatologia da Dispneia em doentes cardíacos com Congestão Pulmonar

The purpose of this study was to evaluate whether pulmonary congestion (PC) in cardiac patients may induce changes in the control of breathing or in the respiratory muscles strength, that could be implicated in the genesis of dyspnea in this group of patients. We have compared 48 patients (GI), with a mean age of 61 years and a mean pulmonary capillary (wedge) pressure of 19.9 mmHg, with a group of 35 controls (GII) with a mean age of 62 years. We have performed the following measurements: pulmonary volumes and capacities using the helium dilution method, airway flows by pneumotachography. We also determined the occlusion pressure and the ventilatory response to C02, with simultaneous quantification of dyspnea using a visual analogue scale. Measurements of maximal inspiratory and expiratory pressures were also performed. PC patients underwent right heart catheterization and assessment of cardiac output by thermodilution technic. Cardiac patients had an increase in the central output to breathing (P0.1 GI-1.7 cmH20/GII - l.35 cmH20; < 0.001), probably due to the respiratory restrictive pattern. Because we found no changes in the P0.1, during C02 stimulation, we admit that the central command is not altered. During the C02 stimulation, and for a similar increase in ventilation, the cardiac patients showed a higher degree of dyspnea. The reduction of maximal respiratory pressures and the increased basal respiratory drive can be important factors in the generation of dyspnea presented by these patients.