Salvador Rassi

I Latin American Guidelines for the assessment and management of decompensated heart failure

Edimar Alcides Bocchi, Fabio Vilas-Boas, Sergio Perrone, Angel G Caamano, Nadine Clausell, Maria da Consolacao VMoreira, Jorge Thierer, Hugo Omar Grancelli, Carlos Vicente Serrano Junior, Denilson Albuquerque, Dirceu Almeida,Fernando Bacal, Luis Felipe Moreira, Adonay Mendonza, Antonio Magana, Arturo Tejeda, Daniel Chafes, Efraim Gomez,Erick Bogantes, Estela Azeka, Evandro Tinoco Mesquita, Francisco Jose Farias B Reis, Hector Mora, Humberto Vilacorta,Jesus Sanches, Joao David de Souza Neto, Jose Luis Vuksovic, Juan Paes Moreno, Julio Aspe y Rosas, Lidia ZytynskiMoura, Luis Antonio de Almeida Campos, Luis Eduardo Rohde, Marcos Parioma Javier, Martin Garrido Garduno, MucioTavares, Pablo Castro Galvez, Raul Spinoza, Reynaldo Castro de Miranda, Ricardo Mourilhe Rocha, Roberto Paganini,Rodolfo Castano Guerra, Salvador Rassi, Sofia Lagudis, Solange Bordignon, Solon Navarette, Waldo Fernandes, AntonioCarlos Pereira Barretto, Victor Issa, Jorge Ilha Guimaraes.

Estudo dos principais fatores de risco maternos nas síndromes hipertensivas da gestação

FUNDAMENTO: Os fatores de risco para as sindromes hipertensivas gestacionais (SHG) sao varios e podem relacionar-se a regiao e etnia da populacao. No Estado de Goias, sao escassos os estudos sobre esse tema. OBJETIVO: Investigar os fatores de risco maternos para SHG. METODOS: Utilizou-se um estudo caso-controle por meio da analise dos prontuarios das parturientes da Maternidade do Hospital das Clinicas da Universidade Federal de Goias (HC-UFG), em 2005. Os fatores de risco foram analisados pela analise de regressao logistica e pelo teste exato de Fisher. RESULTADOS: Em 2005, houve 890 partos na Maternidade do HC-UFG, e 129 gestantes apresentaram diagnostico de SHG (14,5%). A analise multivariada identificou a obesidade como fator de risco tanto para hipertensao gestacional (HG) (OR: 17,636; IC 95%: de 2,859 a 108,774) como para hipertensao arterial cronica superajuntada a pre-eclâmpsia (HCSPE) (OR: 27,307; IC 95%: de 4,453 a 167,440). Primiparidade constituiu fator de risco para HG (OR: 5,435; IC 95%: de 1,923 a 15,385). Idade acima de 30 anos foi fator de risco para HCSPE (OR: 5,218; IC 95%: de 1,873 a 14,536) e fator de protecao para pre-eclâmpsia (PE) (OR: 0,035; IC 95%: de 0,003 a 0,364). Raca nao-branca representou risco independente para PE (OR: 13,158; IC 95%: de 1,672 a 100,000) e PE previa para HCSPE (OR: 4,757; IC 95%: de 1,261 a 17,938). Das gestantes com hipertensao arterial cronica (HAC), 73,5% desenvolveram HCSPE (p < 0,001). CONCLUSAO: Os fatores obesidade, raca nao-branca, PE previa, idade acima de 30 anos e HAC identificados foram semelhantes a maioria dos achados da literatura.

Cell Therapy in Chagas Cardiomyopathy (Chagas Arm of the Multicenter Randomized Trial of Cell Therapy in Cardiopathies Study) A Multicenter Randomized Trial

Background —Previous studies suggested that transplantation of autologous bone marrow derived mononuclear cells (BMNC) improves heart function in chronic chagasic cardiomyopathy (CCC). We report the results of the first randomized trial of BMNC therapy in CCC. Methods and Results —Patients aged 18-75 years with CCC, NYHA class III or IV, LVEF less than 35%, and optimized therapy were randomized to intracoronary injection of autologous BMNC or placebo. Primary endpoint was the difference in LVEF from baseline to 6 and 12 months after treatment between groups. Analysis was by intention to treat and powered to detect an absolute between-group difference of 5%. Between July 2005 and October 2009 234 patients were enrolled. Two abandoned the study and 49 were excluded due to protocol violation. The remaining 183 patients, 93 in the placebo group and 90 in the BMNC group, had trimmed mean age of 52.4 years (50.8 to 54.0) and LVEF of 26.1% (25.1 to 27.1) at baseline. Median number of injected BMNCs was 2.20 x 108 (1.40-3.50 x 108). Change in LVEF did not differ significantly between treatment groups: trimmed mean ΔEF= 3.0 (1.3 to 4.8) for BMNC and 2.5 (0.6 to 4.5) for placebo (p=0.519) at 6 months; ΔEF= 3.5 (1.5 to 5.5) for BMNC and ΔEF= 3.7 (1.5 to 6.0) for placebo (p=0.850) at 12 months. Left ventricular systolic and diastolic volumes, NYHA class, Minnesota life quality questionnaire, BNP concentrations, and 6-min walking test did also not differ between groups. Conclusions —Intracoronary injection of autologous BMNCs does not improve left ventricular function or quality of life in patients with CCC. Clinical Trial Registration Information —ClinicalTrials.gov; Identifier: [NCT00349271][1] [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00349271&atom=%2Fcirculationaha%2Fearly%2F2012%2F04%2F19%2FCIRCULATIONAHA.111.067785.atomBackground— Previous studies suggested that transplantation of autologous bone marrow–derived mononuclear cells (BMNCs) improves heart function in chronic chagasic cardiomyopathy. We report the results of the first randomized trial of BMNC therapy in chronic chagasic cardiomyopathy. Methods and Results— Patients 18 to 75 years of age with chronic chagasic cardiomyopathy, New York Heart Association class II to IV heart failure, left ventricular ejection fraction (LVEF) <35, and optimized therapy were randomized to intracoronary injection of autologous BMNCs or placebo. The primary end point was the difference in LVEF from baseline to 6 and 12 months after treatment between groups. Analysis was by intention to treat and powered to detect an absolute between-group difference of 5. Between July 2005 and October 2009, 234 patients were enrolled. Two patients abandoned the study and 49 were excluded because of protocol violation. The remaining 183 patients, 93 in the placebo group and 90 in the BMNC group, had a trimmed mean age of 52.4 years (range, 50.8–54.0 years) and LVEF of 26.1 (range, 25.1–27.1) at baseline. Median number of injected BMNCs was 2.20×108 (range, 1.40–3.50×108). Change in LVEF did not differ significantly between treatment groups: trimmed mean change in LVEF at 6 months, 3.0 (1.3–4.8) for BMNCs and 2.5 (0.6–4.5) for placebo (P=0.519); change in LVEF at 12 months, 3.5 (1.5–5.5) for BMNCs and 3.7 (1.5–6.0) for placebo (P=0.850). Left ventricular systolic and diastolic volumes, New York Heart Association functional class, Minnesota quality-of-life questionnaire, brain natriuretic peptide concentrations, and 6-minute walking test did also not differ between groups. Conclusion— Intracoronary injection of autologous BMNCs does not improve left ventricular function or quality of life in patients with chronic chagasic cardiomyopathy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00349271.

Survival and prognostic factors in systolic heart failure with recent symptom onset

OBJECTIVE To study survival and prognostic factors associated with mortality in patients with systolic heart failure followed up since symptom onset. METHODS We carried out a study with a cohort of 204 consecutive patients with systolic heart failure, whose symptom onset occurred within the 6 weeks preceding the first medical visit. They were followed up for 46 months. The prognostic variables analyzed were collected when the patients were included in the study and were correlated with cardiovascular mortality. An EF < or =40% on echocardiography characterized systolic ventricular dysfunction. RESULTS The overall survival rates according to the Kaplan-Meier technique were 98.0%, 90.6%, and 70.2% at 3, 12, and 48 months of follow-up, respectively. The multivariate analysis identified the independent effect of 6 variables on the risk of cardiovascular death. Functional classes III and IV increased risk 2.7 times as compared with class II; 10-mmHg increments in systolic blood pressure reduced the risk of death by 25%; each 10-bpm increase in heart rate increased the risk of death 1.6 times; and each 0.25-mg/dL increment in serum creatinine caused a 60% increase in risk. The presence of the third cardiac sound caused a 3-fold increase in the risk of death, and chagasic etiology was also associated with cardiovascular mortality (P<0.0001). CONCLUSION Evidence shows that mortality in the initial phase is not elevated, and that etiology, advanced functional class, arterial hypotension, tachycardia, presence of the third cardiac sound, and elevated serum creatinine lead to a worse prognosis.

Levosimendana em pacientes com insuficiência cardíaca descompensada: eficácia em uma coorte brasileira. Resultados do estudo BELIEF

BACKGROUND Levosimendan is a new inodilatory agent that enhances cardiac contractility via Ca(2+) sensitization and induces vasodilation through the activation of KATP/BKCa. OBJECTIVE To study the efficacy and safety of levosimendan in a decompensated heart failure (DHF) Brazilian cohort, and in b-adrenergic agonist resistant patients. METHODS The Brazilian Evaluation of Levosimendan Infusion Efficacy (BELIEF) study was prospective, multicenter, observational and included 182 high-risk DHF patients, all of which received open-label levosimendan. Primary end point was hospital discharge without additional inotropic therapy (responder). Secondary end points were changes in hemodynamics, clinical parameters, and brain natriuretic peptide (BNP). RESULTS Mortality rate was 14.8%, and 139 of 182 patients were responders. In non responders it was 62.8%. Systolic blood pressure was a predictor of response. In b-adrenergic agonist resistant group, 55.8% were responders. Overall, 54 patients experienced at least one adverse event; most of them resolved either spontaneously or after levosimendan dose reduction. A significant improvement in quality of life was verified at 2-6 months of follow-up (p<0.0001). CONCLUSION Our results suggest levosimendan infusion as an alternative therapy in the short term management of DHF patients. HF severity can influence the response to levosimendan treatment. Prospective studies are warranted in a Brazilian cohort including Chagas heart disease.

Insuficiência Cardíaca com Função Sistólica Preservada

numa populacao de idosos foi feita por Topol e cols., em 1985.As evidencias cientificas sobre o impacto do tratamento medica-mentoso da insuficiencia cardiaca com funcao sistolica preserva-da sobre a qualidade de vida, alivio sintomatico ou mortalidadesao escassas e, no momento atual, seis ensaios clinicos multi-centricos estao em curso, avaliando os efeitos sobre a morbi-mortalidade, dos inibidores da ECA e ou ARA-II nesta sindrome

Perfil epidemiológico, clínico e terapêutico da insuficiência cardíaca em hospital terciário

FUNDAMENTO: A insuficiencia cardiaca e uma sindrome complexa com multiplos fatores de risco envolvidos em sua genese, tornando dificil a prevencao e o manejo. OBJETIVO: Identificar as principais etiologias e os fatores de risco na insuficiencia cardiaca; comparar caracteristicas clinicas e demograficas dos pacientes conforme a etiologia; analisar se o tratamento utilizado esta de acordo com o preconizado pelas diretrizes brasileiras. METODOS: Estudo retrospectivo, descritivo e observacional realizado no Hospital das Clinicas da Universidade Federal de Goias. Os pacientes foram reunidos em quatro grupos, conforme etiologia, para comparacao: cardiomiopatia chagasica, cardiomiopatia hipertensiva, cardiomiopatia dilatada e outras e cardiomiopatia isquemica. Os testes de Qui-quadrado e Exato de Fisher, a ANOVA e o teste de Kruskal-Wallis foram utilizados na analise dos grupos e das formas de tratamento. RESULTADOS: Foram analisados 144 prontuarios de pacientes, com media de idade 61 ± 15 anos, sendo 54,2% do sexo masculino. A cardiomiopatia chagasica destacou-se como principal etiologia (41%). Hipertensao arterial (48,6%), anemia (22,9%), doenca coronariana (19,4%), dislipidemia (17,3%) e diabete (16,6%) foram os principais fatores de risco. Os hipertensos apresentaram prevalencia maior do sexo feminino (p=0,044) e maior frequencia de estertores pulmonares (p<0,01). A frequencia cardiaca foi menor nos chagasicos (p<0,001). Os medicamentos prescritos foram diureticos (81,2%), inibidores da enzima conversora da angiotensina ou bloqueadores dos receptores da angiotensina (77,7%), betabloqueadores (45,8%), espironolactona (35,4%), digitalicos (30,5%) e vasodilatadores (8,3%). CONCLUSAO: A cardiomiopatia chagasica foi a principal causa de insuficiencia cardiaca. Nao se observou diferencas clinicas entre pacientes dos quatro grupos etiologicos.

Right Ventricular Doppler Echocardiographic Study of Indeterminate Form of Chagas Disease

Background Patients with indeterminate form of Chagas disease/cardiac normality (ICD/CN) exhibited normal electrocardiograms and chest X-rays; however, more sophisticated tests detected some degree of morphological and functional changes in the heart. Objective To assess the prevalence of systolic and diastolic dysfunction of the right ventricle (RV) in patients with ICD/CN. Methods This was a case–control and prevalence study. Using Doppler two-dimensional echocardiography (2D), 92 patients were assessed and divided into two groups: group I (normal, n = 31) and group II (ICD/CN, n = 61). Results The prevalence of RV systolic dysfunction in patients in groups I and II was as follows: fractional area change (0.0% versus 0.6%), mobility of the tricuspid annulus (0.0% versus 0.0%), and S-wave tissue Doppler (6.4% versus 26.0%, p = 0.016). The prevalence of global disorders such as the right myocardial performance index using tissue Doppler (16.1% versus 27.8%, p = 0.099) and pulsed Doppler (61.3% versus 68%, p = 0.141) and diastolic disorders such as abnormal relaxation (0.0% versus 6.0%), pseudonormal pattern (0.0% versus 0.0%), and restrictive pattern (0.0% versus 0.0%) was not statistically different between groups. Conclusion The prevalence of RV systolic dysfunction was estimated to be 26% (S wave velocity compared with other variables), suggesting incipient changes in RV systolic function in the ICD/CN group.

Asymptomatic Coronary Artery Disease in Chagasic Patients with Heart Failure: Prevalence and Risk Factors

FUNDAMENTO: A concomitância de doenca arterial coronaria assintomatica em pacientes com cardiomiopatia chagasica em IC e controversa na literatura medica, pois ambas as doencas se mostram prevalentes em algumas regioes do Brasil. Objetivo: Determinar a prevalencia da coronariopatia (lesoes > 50%) em uma populacao especifica de pacientes com cardiomiopatia chagasica em IC classes funcionais III e IV, que nao apresentavam eventos coronarianos previos. OBJETIVO: Determinar a prevalencia da coronariopatia (lesoes > 50%) em uma populacao especifica de pacientes com cardiomiopatia chagasica em IC classes funcionais III e IV, que nao apresentavam eventos coronarianos previos. METODOS: Realizou-se cineangiocoronariografia em 61 pacientes consecutivos, portadores de cardiomiopatia chagasica, em IC classes funcionais III e IV, para se excluir coronariopatia. Esses pacientes faziam parte do protocolo do Estudo de Terapia Celular em Cardiopatias, o qual exigia a realizacao de cineangiocoronariografia antes de se injetarem celulas-tronco. Os fatores de risco para aterosclerose tambem analisados nessa populacao foram: idade, hipertensao arterial, diabetes, dislipidemia, tabagismo e sobrepeso. RESULTADOS: Idade media 51,6 + 9,6 anos, 65,5% (n = 40) homens. A prevalencia de coronariopatia encontrada nessa populacao foi de 1,6% (1). As prevalencias dos fatores de risco foram: hipertensao arterial 18% (11), tabagismo 59% (36), diabetes 1,6% (1) e dislipidemia 6,5% (4). CONCLUSAO: A prevalencia da coronariopatia assintomatica em pacientes com IC grave de etiologia chagasica e baixa e, entre os fatores de risco para doenca coronaria, o tabagismo foi o mais prevalente.BACKGROUND Concomitant asymptomatic coronary artery disease in patients with Chagas cardiomyopathy in heart failure is controversial in the medical literature, as both diseases are prevalent in some regions of Brazil. OBJECTIVE To determine the prevalence of coronary artery disease (lesions > 50%) in a specific population of patients with Chagas cardiomyopathy in HF functional class III and IV, who had no previous coronary events. METHODS Coronary angiography was performed in 61 consecutive patients with Chagasic cardiomyopathy, in heart failure functional class III and IV, to exclude coronary artery disease. These patients were part of the Cell Therapy Study in Heart Diseases protocol, which required the coronary angiography to be carried out before stem cells were injected. Risk factors for atherosclerosis also analyzed in this population were: age, arterial hypertension, diabetes, dyslipidemia, smoking and overweight. RESULTS mean age was 51.6 + 9.6 years and 65.5% (n = 40) of them were males. The prevalence of coronary disease in this population was 1.6% (1). The prevalence of risk factors were: arterial hypertension 18% (11), smoking 59% (36), diabetes 1.6% (1) and dyslipidemia, 6.5% (4). CONCLUSION The prevalence of asymptomatic coronary artery disease in patients with severe heart failure due to Chagas disease is low and among the risk factors for coronary heart disease, smoking was the most prevalent.

Epidemiological, clinical e therapeutic profile of heart failure in a tertiary hospital

FUNDAMENTO: A insuficiencia cardiaca e uma sindrome complexa com multiplos fatores de risco envolvidos em sua genese, tornando dificil a prevencao e o manejo. OBJETIVO: Identificar as principais etiologias e os fatores de risco na insuficiencia cardiaca; comparar caracteristicas clinicas e demograficas dos pacientes conforme a etiologia; analisar se o tratamento utilizado esta de acordo com o preconizado pelas diretrizes brasileiras. METODOS: Estudo retrospectivo, descritivo e observacional realizado no Hospital das Clinicas da Universidade Federal de Goias. Os pacientes foram reunidos em quatro grupos, conforme etiologia, para comparacao: cardiomiopatia chagasica, cardiomiopatia hipertensiva, cardiomiopatia dilatada e outras e cardiomiopatia isquemica. Os testes de Qui-quadrado e Exato de Fisher, a ANOVA e o teste de Kruskal-Wallis foram utilizados na analise dos grupos e das formas de tratamento. RESULTADOS: Foram analisados 144 prontuarios de pacientes, com media de idade 61 ± 15 anos, sendo 54,2% do sexo masculino. A cardiomiopatia chagasica destacou-se como principal etiologia (41%). Hipertensao arterial (48,6%), anemia (22,9%), doenca coronariana (19,4%), dislipidemia (17,3%) e diabete (16,6%) foram os principais fatores de risco. Os hipertensos apresentaram prevalencia maior do sexo feminino (p=0,044) e maior frequencia de estertores pulmonares (p<0,01). A frequencia cardiaca foi menor nos chagasicos (p<0,001). Os medicamentos prescritos foram diureticos (81,2%), inibidores da enzima conversora da angiotensina ou bloqueadores dos receptores da angiotensina (77,7%), betabloqueadores (45,8%), espironolactona (35,4%), digitalicos (30,5%) e vasodilatadores (8,3%). CONCLUSAO: A cardiomiopatia chagasica foi a principal causa de insuficiencia cardiaca. Nao se observou diferencas clinicas entre pacientes dos quatro grupos etiologicos.