Reis Rp

Usefulness of Doppler myocardial imaging for identification of mutation carriers of familial hypertrophic cardiomyopathy

Because myocyte dysfunction and disarray are early abnormalities in hypertrophic cardiomyopathy (HC), we tested if Doppler myocardial imaging (DMI) could identify systolic and diastolic dysfunction in mutation carriers (MC) (genotype positive patients without hypertrophy, defined as phenotype negative after conventional screening tests). In a single family with a missense mutation in the myosin binding protein C gene (Arg 502 Gln) we identified 5 MCs; these subjects were asymptomatic and had normal physical examination, normal electrocardiogram, treadmill stress test, ambulatory Holter electrocardiogram, and normal conventional M-mode, 2-dimensional, and Doppler echocardiography. In each patient we performed a DMI study and measured the peak velocities of the systolic (S), rapid filling (E), and atrial contraction (A) waves in the 4 sides of the mitral annulus, in 8 left ventricular segments (apical views), in the tricuspid annulus, and in 2 right ventricular segments. These data were compared with those from 10 normal volunteers matched for sex, age, and body surface. Compared with the normal volunteers, the MCs had lower left ventricular systolic velocities and higher right ventricular systolic velocities; lower diastolic rapid filling velocities; higher or similar atrial contraction velocities; reduced E/A; lower percentage of annular sides and segments with E/A >1 and lower average number of sides and/or segments with E/A >1 per patient; similar right ventricular rapid filling velocities; and similar or higher atrial contraction wave velocities. Thus, DMI detects important left and right ventricular annular and regional myocardial contraction and relaxation abnormalities independently of the presence of hypertrophy, in HC. These results show that DMI is more sensitive than conventional echocardiography and establishes a new and highly accurate method for the noninvasive screening of MCs of the disease.

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.

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.

Editorial commentPhysical activity after coronary revascularizationAtividade física após revascularização coronária

Sedentary lifestyle is a reversible risk factor for cardiovascular disease (CVD) and CVD mortality. Conversely, regular physical activity (PA) reduces vascular mortality by 20-30% in healthy individuals and in patients with coronary artery disease (CAD). In this context, PA leads to significant improvements in prognosis, particularly in CAD patients with or without intervention. PA increases fitness and improves mental health, as well as exerting a positive effect on various risk factors, including hypertension, LDL cholesterol and triglyceride levels, diabetes and overweight. The improvements resulting from PA are independent of and additional to those of drugs. In their study published in this issue of the Journal, Acar et al. analyze the factors influencing PA in patients who have undergone coronary revascularization. In a population in which most patients (77%) were inactive, the parameters influencing sedentary habits on multivariate analysis were low education level and lack of regular follow-up. The first point to be noted in this study is the low level of regular PA in these patients (only 23%). Bearing in mind the known benefits of PA, this means that intervention in this area could significantly improve prognosis of CAD patients.

Bilateral aneurysmatic coronary artery-pulmonary artery trunk fistulae

A 54-year-old asymptomatic woman presented to our echocardiography department for assessment of a continuous heart murmur. The transthoracic echocardiogram in parasternal short-axis view (Figure 1A) revealed a tunnellike communication between the pulmonary artery trunk and the pericardial space (maximum width 8 mm). Color Doppler showed turbulent flow and pulsed wave Doppler showed typical continuous flow (Figure 1B). No valvular abnormalities were noted. There was a normal balance between the right and left ventricle, with preserved global systolic function. The estimated shunt by Qp/Qs was 1.3:1.0. The cardiac computed tomography scan revealed a large coronary artery fistula (CAF) between the left descending coronary artery and pulmonary artery trunk and also an aneurysmatic, tortuous CAF between the right coronary artery and pulmonary artery trunk (Figure 1C--F). A maximal exercise test was performed that excluded myocardial ischemia. She is currently asymptomatic and no cardiac events were noted in two-year follow-up. We present this case because bilateral coronary to pulmonary artery fistulae are a very rare entity. CAFs found