The Medical Burden of Heart Failure: A Comparative Delineation with Cancer in Brazil

Abstract Background: Due to its poor prognosis and mortality rates, heart failure (HF) has been recognized as a malignant condition, comparable to some cancers in developed countries. Objectives: To compare mortality from HF and prevalent cancers using data from a nationwide database in Brazil. Methods: This was a descriptive, cross-sectional study using secondary data obtained from Brazilian administrative databases of death records and hospitalization claims maintained by the Ministry of Health. Data were analyzed according to main diagnosis, year of occurrence (2005-2015), sex and age group. Descriptive analyses of absolute number of events, hospitalization rate, mortality rate, and in-hospital mortality rate were performed. Results: The selected cancers accounted for higher mortality, lower hospitalization and higher in-hospital mortality rates than HF. In a group analysis, HF showed mortality rates of 100-150 per 100,000 inhabitants over the period, lower than the selected cancers. However, HF had a higher mortality rate than each type of cancer, even when compared to the most prevalent and deadly ones. Regarding hospitalization rates, HF was associated with a higher risk of hospitalization when compared to cancer-related conditions as a group. Conclusions: Our findings indicate that HF has an important impact on mortality, hospitalization and in-hospital mortality, comparable to or even worse than some types of cancer, representing a potential burden to the healthcare system.

Inspiratory Muscle Weakness is Related to Poor Short-Term Outcomes for Heart Transplantation

Abstract Introduction: In heart transplantation (HT) recipients, several factors are critical to promptly adopting appropriate rehabilitation strategies and may be important to predict outcomes way after surgery. This study aimed to determine preoperative patient-related risk factors that could adversely affect the postoperative clinical course of patients undergoing HT. Methods: Twenty-one hospitalized patients with heart failure undergoing HT were evaluated according to respiratory muscle strength and functional capacity before HT. Mechanical ventilation (MV) time, reintubation rate, and intensive care unit (ICU) length of stay were recorded, and assessed postoperatively. Results: Inspiratory muscle strength as absolute and percentpredicted values were strongly correlated with MV time (r=-0.61 and r=-0.70, respectively, at P<0.001). Concerning ICU length of stay, only maximal inspiratory pressure (MIP) absolute and percent-predicted values were significantly associated. The absolute -MIP- was significantly negatively correlated with ICU length of stay (r=-0.58 at P=0.006) and the percent-predicted MIP was also significantly negatively correlated with ICU length of stay (r=-0.68 at P=0.0007). No associations were observed between preoperative functional capacity, age, sex, and clinical characteristics and MV time and ICU length of stay in the cohort included in this study. Patients with respiratory muscle weakness had a higher prevalence of prolonged MV, reintubation, and delayed ICU length of stay. Conclusion: An impairment of preoperative MIP was associated with poorer short-term outcomes following HT. As such, inspiratory muscle strength is an important clinical preoperative marker in patients undergoing HT.

Inspiratory Muscle Weakness is Related to Poor Short-Term Outcomes for Heart Transplantation.

INTRODUCTION: In heart transplantation (HT) recipients, several factors are critical to promptly adopting appropriate rehabilitation strategies and may be important to predict outcomes way after surgery. This study aimed to determine preoperative patient-related risk factors that could adversely affect the postoperative clinical course of patients undergoing HT. METHODS: Twenty-one hospitalized patients with heart failure undergoing HT were evaluated according to respiratory muscle strength and functional capacity before HT. Mechanical ventilation (MV) time, reintubation rate, and intensive care unit (ICU) length of stay were recorded, and assessed postoperatively. RESULTS: Inspiratory muscle strength as absolute and percentpredicted values were strongly correlated with MV time (r=-0.61 and r=-0.70, respectively, at P<0.001). Concerning ICU length of stay, only maximal inspiratory pressure (MIP) absolute and percent-predicted values were significantly associated. The absolute |MIP| was significantly negatively correlated with ICU length of stay (r=-0.58 at P=0.006) and the percent-predicted MIP was also significantly negatively correlated with ICU length of stay (r=-0.68 at P=0.0007). No associations were observed between preoperative functional capacity, age, sex, and clinical characteristics and MV time and ICU length of stay in the cohort included in this study. Patients with respiratory muscle weakness had a higher prevalence of prolonged MV, reintubation, and delayed ICU length of stay. CONCLUSION: An impairment of preoperative MIP was associated with poorer short-term outcomes following HT. As such, inspiratory muscle strength is an important clinical preoperative marker in patients undergoing HT.

Indicações e seleção do paciente para transplante cardíaco / Indications and patient selection for cardiac transplantation

O transplante cardíaco está indicado para pacientes cominsuficiência cardíaca grave com sintomas incapacitantes, a despeitode estarem recebendo tratamento farmacológico otimizado e deterem se esgotado as possibilidades cirúrgicas de tratamento. Entreoutros fatores, as limitações referentes à disponibilidade de doadoresde coração efetivos, principalmente no Brasil, tornam a escolhacriteriosa do receptor cardíaco, além de um desafio, uma granderesponsabilidade para a prática diária do cardiologista clínico.Hiponatremia, insuficiência renal, caquexia cardíaca, anemia, baixosníveis de colesterol, queda dos níveis de hemoglobina e dependênciade inotrópicos são fatores clínico-laboratoriais associados a mauprognóstico em pacientes com insuficiência cardíaca (IC) avançada.Os escores de risco [HFSS (Heart Failure Survival Score) eSHFM (Seattle Heart Failure Model)] devem ser utilizados comoferramentas acessórias para avaliar a gravidade dos pacientes comIC avançada. VO2 pico < 10 ml/kg/min e VE/VCO2 > 34 no teste doexercício cardiopulmonar estão relacionados com mortalidade empacientes ambulatorialmente avaliados para transplante cardíaco. Ahemodinâmica pulmonar, assim como o perfil imunológico, deveser rotineiramente acessada em pacientes candidatos a transplantecardíaco. Os pacientes com hipertensão pulmonar fixa estão sobrisco de desenvolverem insuficiência cardíaca direita fatal apóso transplante cardíaco. Por sua vez, a presença de anticorposcirculantes contra os antígenos HLA (Human Leukocyte Antigen)é um fator de risco para rejeição do enxerto após o transplantede coração. Finalmente, a indicação do transplante cardíaco emsituações clínicas extremas vem aumentando e se tornando umdesafio na prática clínica cardiológica.

The heart transplantation is indicated for patients with severeheart failure and disabling symptoms despite being receivingoptimal pharmacological treatment and having exhausted thepossibilities of surgical treatment. Among other factors, thelimitations related to the availability of effective heart donor,mainly in Brazil, make a judicious choice of the heart receptorin addition to a challenge, a huge responsibility for the dailypractice of clinical cardiologists. Hyponatremia, renal failure,cardiac cachexia, anemia, low cholesterol levels, decrease inhemoglobin levels and dependence on inotropes are clinical andlaboratory factors associated with poor prognosis in patientswith advanced heart failure. The risk scores [HFSS (HeartFailure Survival Score) and SHFM (Seattle Heart FailureModel)] should be used as ancillary tools to assess the severityof patients with advanced HF. Peak of VO2 < 10 ml/kg/minand VE/VCO2 > 34 during the cardio-pulmonary exercise testare related to mortality in ambulatory patients evaluated forcardiac transplantation. Pulmonary hemodynamics as wellas the immunological profile should be routinely accessed inpatients who are candidates for cardiac transplantation. Patientswith fixed pulmonary hypertension are at risk for fatal rightheart failure after heart transplantation. In turn, the presenceof circulating antibodies to Human Leukocyte Antigen HLA)is a risk factor for graft rejection after heart transplantation.Finally, the indication of cardiac transplantation in extremeclinical situations are increasing and becoming a challenge incardiology clinical practice.

Summary of the II Brazilian Guideline update on Acute Heart Failure 2009/2011.

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda 2009/2011 / Summary of the II Brazilian Guideline Update on Acute Heart Failure 2009/2011

Nos últimos dois anos, observamos diversas modificações na abordagem diagnóstica e terapêutica dos pacientes com Insuficiência Cardíaca aguda (IC aguda), o que nos motivou quanto à necessidade da realização de um sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda de 2009. Na avaliação diagnóstica, o fluxograma diagnóstico foi simplificado e foi fortalecido o papel da avaliação clínica e ecocardiograma. Na avaliação clínico-hemodinâmica admissional, o ecocardiograma hemodinâmico ganhou destaque no auxilio da definição dessa condição no paciente com IC aguda na sala de emergência. Na avaliação prognóstica, os biomarcadores tiveram seu papel mais bem estabelecido, e a síndrome cardiorrenal teve seus critérios e valor prognóstico mais bem definidos. Os fluxogramas de abordagem terapêutica foram revistos, tornando-se mais simples e objetivos. Dentre os avanços na terapêutica medicamentosa destacam-se a segurança e a importância da manutenção ou introdução dos betabloqueadores na terapêutica admissional. A anticoagulação, de acordo com as novas evidências, ganha um espectro maior de indicações. O edema agudo de pulmão tem bem estabelecido os seus modelos hemodinâmicos de apresentação com suas distintas formas de abordagens terapêuticas, com novos níveis de indicação e evidência. No tratamento cirúrgico da IC aguda, a revascularização miocárdica, a abordagem das lesões mecânicas e o transplante cardíaco foram revistos e atualizados. Este sumário de atualização fortalece a II Diretriz Brasileira de Insuficiência Cardíaca Aguda por mantê-la atualizada e rejuvenescida. Todos os clínicos cardiologistas que lidam com pacientes com IC aguda encontrarão na diretriz e em seu sumário de atualização importantes instrumentos no auxílio da prática clínica para o melhor diagnóstico e tratamento de seus pacientes.

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Linfoma primário não Hodgkin em ventrículo esquerdo detectado ao ecocardiograma em pacientes submetido a transplante cardíaco / Primary non-Hodgkin lymphoma in the left ventricle detected by echocardiography in a patient after heart transplant

O caso ilustra o papel do ecocardiograma no diagnóstico e acompanhamento terapêutico de linfoma primário intracardíaco, em pacientesubmetido a transplante cardíaco há 11 anos. No ecocardiograma transtorácico foi visibilizada massa que ocupava a cavidade ventricular esquerda, confirmada por ecocardiograma transesofágico e tomografia computadorizada. Não havia disseminação do tumor em outrosórgãos. A massa foi ressecada cirurgicamente e enviada para análise histopatológica e imuno-histoquímica que revelou linfoma não Hodgkin. O ecocardiograma, após a cirurgia, comprovou ausência do tumor, com função ventricular esquerda preservada. O paciente veio a falecer, quatro meses após, por complicações infecciosas. Destacamos a raridade desta apresentação clínica do paciente transplantado, sobretudo a localização no ventrículo esquerdo e o diagnóstico em vida possibilitado pelo ecocardiograma.

Tratamento endovascular de ruptura traumática da aorta torácica descendente / Endovascular treatment of traumatic descending thoracic aortic rupture

Paciente do sexo feminino, 55 anos de idade, vítima de atropelamento, foi admitida em unidade de emergência, onde se realizou o diagnóstico clínico, radiológico e tomográfico de ruptura traumática da aorta torácica descendente. Diante do achado, a paciente foi encaminhada para tratamento endovascular com colocação de endoprótese auto-expansível (stent) pela artéria femoral. O tratamento obteve sucesso, evidenciado pela exclusão da lesão localizada previamente no istmo aórtico. O tratamento endovascular tem sido indicado nas afecções de aorta torácica descendente com bons resultados iniciais. Na ruptura traumática de aorta, a terapêutica endovascular representa uma alternativa aceitável, especialmente devido aos riscos do tratamento operatório convencional.

A 55-year-old, female patient who was run over by a motor vehicle was admitted at an emergency room. Clinical, radiological and tomographic diagnosis of traumatic descending aortic thoracic rupture was performed. The patient was referred for endovascular treatment with placement of a self-expandable stent through the femoral artery. Treatment was successful, with exclusion of the lesion previously located in the aortic isthmus. Endovascular treatment has been indicated in the treatment of descending thoracic aortic diseases, with good initial results. In case of traumatic aortic rupture, endovascular treatment is a feasible alternative, especially due to risks offered by the conventional surgical treatment.

A elevação da pressão arterial sistólica durante o teste ergométrico após transplante cardíaco: correlação com o quadro clínico e a função ventricular avaliada pela ecocardiografia sob estresse com dobutamina / Increase in systolic blood pressure during exercise testing after heart transplantation: correlation with the clinical condition and ventricular function assessed by dobutamine stress echocardiography

OBJETIVO: Em pacientes submetidos a transplante cardíaco (TxC) descreve-se redução da elevação da pressão arterial durante o teste ergométrico (TE). Este fenômeno, cuja origem é desconhecida, ocorre em freqüência e intensidade variáveis. O objetivo deste estudo foi verificar a relação entre o incremento da pressão arterial sistólica (deltaPAS) e aspectos clínicos, bem como as variáveis aferidas no TE e ecocardiograma sob estresse pela dobutamina (EED), em pacientes na fase tardia após TxC. MÉTODOS: Quarenta e cinco homens, 49,04±10,19 anos, 40,91±27,46 meses pós-TxC submeteram-se a avaliação clínica, TE e EED . Avaliou-se o índice de contratilidade segmentar e a fração de ejeção de ventrículo esquerdo. Consideraram-se anormais deltaPAS<35mmHg no TE (SBC,1995). RESULTADOS: Não houve correlação significativa entre deltaPAS e o tempo de evolução do transplante, tempo de isquemia do enxerto, antecedentes de rejeição, dose de diltiazem, consumo de oxigênio estimado, fração de ejeção e índice de contratilidade segmentar. O deltaPAS foi normal em 17 casos (Grupo I) e anormal em 28 pacientes (Grupo II). Não houve diferenças significativas entre os pacientes de ambos os grupos em relação aos aspectos clínicos e aos resultados do TE e EED. CONCLUSÃO: Ao contrário de outras populações, os autores não detectaram correlações entre deltaPAS e o quadro clínico e a função ventricular esquerda em pacientes com TxC. Os fatores associados à redução do deltaPAS no TE pós-TxC permanecem desconhecidos.

OBJECTIVE: Patients who underwent heart transplantation (HTX) experience a reduction in the elevation that is usual in systolic blood pressure during exercise testing. Of unknown origin, this phenomenon varies in frequency and intensity. The aim of this study was to analyze the relationship between systolic blood pressure increase (delta SBP) and clinical aspects, as well as variables measured during exercise testing (ET) and dobutamine stress echocardiography (DSE) in patients in the late post-transplantation course. METHODS: Forty-five men, mean age 49.04 ± 10.19, underwent clinical assessment, ET and DSE 40.91 ± 27.46 months after heart transplantation. Left ventricular wall motion score index and ejection fraction were assessed. Delta SBP < 35mmHg during ET was considered abnormal (SBC,1995). RESULTS: No significant correlation was found between delta SBP and post-transplantation time, graft ischemic time, history of rejection, diltiazem dosage, oxygen uptake, ejection fraction, and wall motion score index (WMSI). Delta SBP was normal in 17 patients (Group I) and abnormal in 28 (Group II). Patients of both groups did not differ significantly in regard to clinical features and ET and DSE results. CONCLUSION: Unlike other populations, no correlation was found between delta SBP during exercise testing and clinical condition or left ventricular function in heart transplant patients. Pathophysiological factors associated with delta SBP reduction during exercise testing remain unknown.

Benefícios potenciais dos novos agentes bloqueadores de sistemas neuro-hormonais / Potential benefits of the new neuro-hormonal system blocking agents

O crescente aumento da incidência da insuficiência cardíaca tem feito dessa síndrome um importante problema de saúde pública em medicina cardiovascular. Nos últimos anos, tem-se presenciado um avanço significativo nos conhecimentos fisiopatológicos envolvidos na gênese, na progressão e nos sintomas relacionados à doença. Dentre estes, destaca-se o mecanismo denominado ativação neuro-hormonal. A caracterização desses neuro-hormônios, de suas vias de produção e de seus respectivos receptores tem propiciado o desenvolvimento de drogas que interferem de forma benéfica na evolução dos pacientes com disfunção ventricular. Neste artigo serão abordados alguns aspectos da ativação neuro-hormonal que ocorrem na insuficiência cardíaca e seus respectivos bloqueios.