Robinson Tadeu Munhoz

Increased muscle sympathetic nerve activity predicts mortality in heart failure patients

BACKGROUND Previous studies have associated neurohumoral excitation, as estimated by plasma norepinephrine levels, with increased mortality in heart failure. However, the prognostic value of neurovascular interplay in heart failure (HF) is unknown. We tested the hypothesis that the muscle sympathetic nerve activity (MSNA) and forearm blood flow would predict mortality in chronic heart failure patients. METHODS One hundred and twenty two heart failure patients, NYHA II-IV, age 50+/-1 ys, LVEF 33+/-1%, and LVDD 7.1+/-0.2 mm, were followed up for one year. MSNA was directly measured from the peroneal nerve by microneurography. Forearm blood flow was obtained by venous occlusion plethysmography. The variables were analyzed by using univariate, stepwise multivariate Cox proportional hazards analysis, and Kaplan-Meier analysis. RESULTS After one year, 34 pts died from cardiac death. The univariate analysis showed that MSNA, forearm blood flow, LVDD, LVEF, and heart rate were significant predictors of mortality. The multivariate analysis showed that only MSNA (P=0.001) and forearm blood flow (P=0.003) were significant independent predictors of mortality. On the basis of median levels of MSNA, survival rate was significantly lower in pts with >49 bursts/min. Similarly, survival rate was significantly lower in pts with forearm blood flow <1.87 ml/min/100 ml (P=0.002). CONCLUSION MSNA and forearm blood flow predict mortality rate in patients with heart failure. It remains unknown whether therapies that specifically target these abnormalities will improve survival in heart failure.

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.

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.

Chylothorax after myocardial revascularization with the left internal thoracic artery.

A 38-year-old male underwent coronary artery bypass grafting (CABG). A saphenous vein graft was attached to the left marginal branch. The left internal thoracic artery was anastomosed to the left anterior descending artery (LAD). The early recovery was uneventful and the patient was discharged on the 5th postoperative day. After three months, he came back to the hospital complaining of weight loss, weakness, and dyspnea on mild exertion. Chest X-rays showed left pleural effusion. On physical examination, a decreased vesicular murmur was detected. After six days, the diagnosis of chylothorax was made after a milky fluid was detected in the plural cavity and total pulmonary expansion did not occur. On the next day, both anterior and posterior pleural drainage were performed by videothoracoscopy, and prolonged parenteral nutrition (PPN) was instituted for ten days. After seven days the patient was put on a low-fat diet for 8 days. The fluid accumulation ceased, the drains were removed and the patient was discharged with normal pulmonary expansion.

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.

Angiotensin II receptor blocker add-on therapy for low cardiac output in decompensated heart failure

BACKGROUND During heart failure (HF) decompensation, an intense activation of the renin-angiotensin-aldosterone system occurs; however, the use of angiotensin-converting enzyme inhibitor (ACEI) cannot block it completely. Otherwise, the addition of angiotensin II receptor blocker (ARB) can be useful when the inotropic dependence occurs. We evaluated the efficacy of the ARB-ACEI association on dobutamine withdrawal in advanced decompensated HF. OBJECTIVE To assess the efficacy of association angiotensin receptor blocker--angiotensin converting enzyme inhibitor to withdraw the intravenous inotropic support in decompensated severe heart failure. METHODS In a case-control study (N = 24), we selected patients admitted at the hospital due to HF that had been using dobutamine for more than 15 days, with one or more unsuccessful drug withdrawal attempts; optimized dose of ACEI and ejection fraction (EF) < 0.45. Then, the patients additionally received ARB (n=12) or not (control, n=12). The outcome was the successful dobutamine withdrawal, evaluated by logistic regression, with a p < 0.05. RESULTS The EF was 0.25 and the age was 53 years, with a dobutamine dose of 10.7 microg/kg x min. The successful drug withdrawal was observed in 8 patients from the ARB group (67.7%) and in 2 patients from the control group (16.7%). The odds ratio (OR) was 10.0 (95%CI: 1.4 to 69.3; p = 0.02). The worsening in renal function was similar (ARB group: 42% vs. control group: 67%; p=0.129). CONCLUSION In this pilot study, the ARB-ACEI association was associated with successful dobutamine withdrawal in advanced decompensated heart failure. The worsening in renal function was similar in both groups. Further studies are necessary to clarify the issue.