Paulo Cesar Morgado

Re-hospitalizações e morte por insuficiência cardíaca: índices ainda alarmantes

BACKGROUND Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS We followed the progress of 263 patients with a mean EF of 27.1%, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9+/-15.2 years, most were men, and 63.1% required inotropic drugs for cardiac compensation in the acute phase. RESULTS Average hospital stay was 25.1+/-16.7 days. During hospitalization, 23 (8.8%) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2%) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5+/-18.0 days. Over the first year of follow-up, 62 (25.8%) patients died. CONCLUSIONS HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5% of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

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.

Repercussão Nutricional na Insuficiência Cardíaca Avançada e seu Valor na Avaliação Prognóstica Nutritional Repercussion in Advanced Heart Failure and its Value in Prognostic Assessment

OBJECTIVE To analyze the nutritional repercussion in heart failure and its relations with left ventricular dysfunction and mortality. METHODS A series of nutritional parameters in a group of 95 patients with advanced chronic heart failure, arising out of dilated cardiomyopathy and age < 65 years old, without concomitant diseases was studied. The duration of symptons, final diastolic diameter and left ventricular ejection fraction were verified. The nutritional assessment, included the ideal percentage of weight the triceps skin fold thickness, percentiles of circumference of muscular mass of the arm, the albumin serum levels and the lymphocytes global count. RESULTS The nutritional situation was alterated in 45.3% to 94.7% of the patients in accordance to the assessment parameter used. There was neither correlation between the nutritional parameters and the length of symptoms, nor with the ventricular dysfunction level. That group of patients had a homogenous evolution, and 75.8% of them died in an average time of 21.86 weeks. The left ventricular diastolic diameter and ejection fraction did not allow for the prediction of survival. A diminished body mass identified a group with higher risk of death. The ideal percentage of the body mass was predictive of survival (p=0.0352), the patients with less than 80% of ideal weight had a higher relative risk of death of 1.99 (1.12-3.02) (p=0.0132). CONCLUSION Malnutrition is frequent in patients with advanced heart failure and dilated cardiomyopathy. The reduced body mass was a better predictor of survival than the left ventricular ejection fraction in patients under advanced stage of myocardial compromising.OBJETIVO: Analisar a repercussao nutricional na insuficiencia cardiaca e suas relacoes com a disfuncao ventricular esquerda e a mortalidade. METODOS: Estudou-se uma serie de parâmetros nutricionais num grupo de 95 pacientes com insuficiencia cardiaca cronica avancada decorrente de cardiomiopatia dilatada e idade < 65 anos, sem evidencias de doencas concomitantes. Foram verificados a duracao dos sintomas, o diâmetro diastolico final e a fracao de ejecao do ventriculo esquerdo. A avaliacao nutricional incluiu a percentagem ideal do peso, a espessura da prega tricipital, os percentis da circunferencia da massa muscular do braco, os niveis sericos de albumina e a contagem global dos linfocitos. RESULTADOS: A situacao nutricional esteve alterada em 45,3% a 94,7% dos pacientes conforme o parâmetro da avaliacao empregado. Nao houve correlacao entre os parâmetros nutricionais e a duracao dos sintomas, nem com o grau de disfuncao ventricular. Este grupo de pacientes teve uma evolucao homogenea e 75,8% dos pacientes faleceram num tempo medio de 21,86 semanas. O diâmetro diastolico e a fracao de ejecao do ventriculo esquerdo nao permitiram predizer a sobrevida. Uma massa corporea diminuida identificou um grupo com maior risco de morte. A percentagem ideal do peso corporeo foi preditiva da sobrevida (p=0,0352), os pacientes com menos de 80% do peso ideal tiveram um risco relativo maior de morte de 1,99 (1,12-3,02) (p=0,0132). CONCLUSAO: A desnutricao e frequente nos pacientes com insuficiencia cardiaca avancada e cardiomiopatia dilatada. A massa corporea reduzida foi melhor preditor de sobrevida do que a fracao de ejecao do ventriculo esquerdo, nos pacientes em fase avancada de comprometimento miocardico.

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.

Escore para avaliação do estado nutricional: seu valor na estratificação prognóstica de portadores de cardiomiopatia dilatada e insuficiência cardíaca avançada

OBJECTIVE Develop a method for the evaluation of patients nutritional status through a score that expresses universal nutritional status, as well as investigate if that score would be efficient for the prognostic stratification of advanced heart failure (HF) pts. METHODS The score was reached by the selection of evaluation methods that would quantify nutritional status: ideal body weight percentage, thickness of tricipital skinfold, percentiles for arm muscular mass circumference, albumin serum level, lymphocyte total count. In order to be validated, the score was applied to a group of 95 pts. Pts were under 65 years old no evidence of consumptive diseases. The score was analyzed to confirm whether it would keep correlation with HF clinical data and whether it would stratify its prognostic. RESULTS Nutritional status suggesting moderate or severe malnutrition could be observed in 31/95 (32.6%). No correlation was found between nutritional score values and the duration of symptoms, or the level of ventricular dysfunction. Pts with high nutritional score showed a trend towards higher mortality rate (p=0.0606). CONCLUSION Those data suggest malnutrition is reported by 1/3 of pts with advanced HF. A score comprising 5 parameters for nutritional status showed good correlation with the clinical, global evaluation of pts with HF. A score over 8 identified pts with higher probability of death as outcome, confirming that pts under higher malnutrition exhibit worse evolution.OBJETIVO: Desenvolver metodo de avaliacao do estado nutricional do paciente atraves de escore que expresse o estado nutricional de maneira universal e verificar se esse escore seria eficaz na estratificacao prognostica de pacientes com insuficiencia cardiaca (IC) avancada. METODOS: Para compor o escore foram selecionados metodos de avaliacao que procurassem quantificar forma de medida do estado nutricional: a porcentagem ideal do peso, a espessura da prega tricipital, os percentis da circunferencia da massa muscular do braco, os niveis sericos de albumina, a contagem global de linfocitos. Para valida-lo, aplicou-se o escore num grupo de 95 pacientes com idade inferior a 65 anos, sem evidencias de doencas consumptivas e analisou-se se esse escore manteria correlacao com os dados clinicos da IC e permitiria estratificar o prognostico. RESULTADOS: A situacao nutricional esteve alterada nos pacientes e escore elevado sugerindo desnutricao moderada ou intensa foi observado em 31/95 (32,6%) dos casos. Nao houve correlacao entre os valores do escore nutricional, duracao dos sintomas e grau de disfuncao ventricular. Os pacientes com escore nutricional elevado apresentaram tendencia de maior mortalidade (p=0,0606). CONCLUSOES: Os dados sugerem que a desnutricao atinge cerca de 1/3 dos pacientes com IC avancada. Um escore que englobou cinco parâmetros de avaliacao nutricional teve boa correlacao com a avaliacao clinica e permitiu avaliar globalmente a desnutricao de portadores de IC. Escore superior a 8 identificou pacientes com maior probabilidade de morrer, confirmando que pacientes mais desnutridos tem pior evolucao.

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.

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.

Relationship between depression, BNP levels and ventricular impairment in heart failure

FUNDAMENTO: A depressao e uma comorbidade frequente na insuficiencia cardiaca (IC), mas os mecanismos relacionados a pior evolucao de pacientes deprimidos com IC ainda nao estao esclarecidos. OBJETIVO: Avaliar o papel da depressao grave na evolucao dos pacientes com IC descompensada. METODOS: Estudamos consecutivamente 43 pacientes com IC avancada e FE < 40,0%, hospitalizados para compensacao cardiaca. Os pacientes, apos historia e exame fisico, foram submetidos a exames laboratoriais, incluindo a dosagem de BNP. Apos o diagnostico de depressao, aplicou-se a escala de Hamilton-D. Depressao grave foi definida por escore igual ou maior que 18. As variaveis clinico-laboratoriais, segundo a presenca ou nao de depressao grave, foram analisadas pela regressao logistica. A curva ROC definiu o ponto de corte para o BNP. RESULTADOS: Depressao grave ou muito grave foi identificada em 24 (55,8%) pacientes. Os pacientes deprimidos graves nao diferiram dos nao deprimidos quanto a idade, sexo e funcao renal, mas apresentaram menor comprometimento cardiaco (FE 23,4 ± 7,2% vs 19,5 ± 5,2%; p = 0,046) e valores mais elevados do BNP (2.582,8 ± 1.596,6 pg/ml vs 1.206,6 ± 587,0 pg/ml; p < 0,001). Entretanto, os pacientes com BNP maior que 1.100 pg/ml tiveram 12,0 (odds ratio [IC 95%] = 2,61 - 55,26) vezes mais chance de desenvolverem quadros de depressao grave. CONCLUSAO: Os pacientes com depressao grave apresentaram maior grau de estimulacao neuro-hormonal, apesar do grau de disfuncao ventricular ser menor. As alteracoes fisiopatologicas relacionadas a depressao, aumentando a estimulacao neuro-hormonal e as citocinas, provavelmente contribuiram para essa maior manifestacao clinica, mesmo em presenca de menor dano cardiaco.BACKGROUND Depression is a common comorbidity in heart failure (HF); however, the mechanisms related to a poorer outcome of depressed patients with HF remain unclear. OBJECTIVE To evaluate the role of severe depression in the outcome of patients with decompensated HF. METHODS A total of 43 patients with advanced HF, EF < 40.0%, and hospitalized for cardiac compensation were consecutively studied. After history taking and physical examination, the patients underwent laboratory tests including BNP determination. After the diagnosis of depression was made, the Hamilton-D scale was applied. Severe depression was defined by a score equal to or greater than 18. The clinical and laboratory variables according to the presence or absence of severe depression were analyzed using logistic regression. The ROC curve defined the cut-off point for BNP. RESULTS Severe or very severe depression was identified in 24 (55.8%) patients. Severely depressed patients did not differ from non-depressed patients as regards age, gender and renal function, but showed less cardiac impairment (EF 23.4 ± 7.2% vs 19.5 ± 5.2%; p = 0.046) and higher BNP levels (2,582.8 ± 1,596.6 pg/ml vs 1,206.6 ± 587.0 pg/ml; p < 0.001). However, patients with BNP levels higher than 1,100 pg/ml had a 12.0-fold higher chance (odds ratio [95% CI] = 2.61 - 55.26) of developing severe depression. CONCLUSION Patients with severe depression showed a higher degree of neurohormonal stimulation despite their lower degree of ventricular dysfunction. The pathophysiological changes related to depression, leading to increased neurohormonal stimulation and cytokines, probably contributed to this more intense clinical manifestation even in the presence of less cardiac damage.

Endocardite infecciosa causada por Eikenella corrodens

The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) account for 3% of the cases of endocarditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of upper respiratory tract and oropharynx. The following characteristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings; difficult diagnosis due to the fastidious nature of the microorganisms; and negative cultures. The Eikenella corrodens endocarditis was first described in 1972. That microorganism continues to be a rare etiological agent. We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.