Multifaceted strategy based on automated text messaging after a recent heart failure admission: the MESSAGE-HF Randomized Clinical Trial

IMPORTANCE: Readmissions after an index heart failure (HF) hospitalization are a major contemporary health care problem. OBJECTIVE: To evaluate the feasibility and efficacy of an intensive telemonitoring strategy in the vulnerable period after an HF hospitalization. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted in 30 HF clinics in Brazil. Patients with left ventricular ejection fraction less than 40% and access to mobile phones were enrolled up to 30 days after an HF admission. Data were collected from July 2019 to July 2022. INTERVENTION: Participants were randomly assigned to a telemonitoring strategy or standard care. The telemonitoring group received 4 daily short message service text messages to optimize self-care, active engagement, and early intervention. Red flags based on feedback messages triggered automatic diuretic adjustment and/or a telephone call from the health care team. MAIN OUTCOMES AND MEASURES: The primary end point was change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 180 days. A hierarchical win-ratio analysis incorporating blindly adjudicated clinical events (cardiovascular deaths and HF hospitalization) and variation in NT-proBNP was also performed. RESULTS: Of 699 included patients, 460 (65.8%) were male, and the mean (SD) age was 61.2 (14.5) years. A total of 352 patients were randomly assigned to the telemonitoring strategy and 347 to standard care. Satisfaction with the telemonitoring strategy was excellent (net promoting score at 180 days, 78.5). HF self-care increased significantly in the telemonitoring group compared with the standard care group (score difference at 30 days, -2.21; 95% CI, -3.67 to -0.74; P = .001; score difference at 180 days, -2.08; 95% CI, -3.59 to -0.57; P = .004). Variation of NT-proBNP was similar in the telemonitoring group compared with the standard care group (telemonitoring: baseline, 2593 pg/mL; 95% CI, 2314-2923; 180 days, 1313 pg/mL; 95% CI, 1117-1543; standard care: baseline, 2396 pg/mL; 95% CI, 2122-2721; 180 days, 1319 pg/mL; 95% CI, 1114-1564; ratio of change, 0.92; 95% CI, 0.77-1.11; P = .39). Hierarchical analysis of the composite outcome demonstrated a similar number of wins in both groups (telemonitoring, 49 883 of 122 144 comparisons [40.8%]; standard care, 48 034 of 122 144 comparisons [39.3%]; win ratio, 1.04; 95% CI, 0.86-1.26). CONCLUSIONS and relevance: An intensive telemonitoring strategy applied in the vulnerable period after an HF admission was feasible, well-accepted, and increased scores of HF self-care but did not translate to reductions in NT-proBNP levels nor improvement in a composite hierarchical clinical outcome.

APOLLO-B, a study of patisiran in patients with transthyretin cardiac amyloidosis: primary long-term results from the open-label extension period

INTRODUCTION: The Phase 3 APOLLO-B study evaluates patisiran in patients (pts) with transthyretin (ATTR) cardiac amyloidosis over a 12-month (M) double-blind (DB) period, followed by an open-label extension (OLE) period when all pts receive patisiran (NCT03997383). Hypothesis: Patisiran provides long-term benefit in pts with ATTR cardiac amyloidosis. Aims: Describe safety and efficacy of patisiran during the APOLLO-B OLE (18M+). METHODS: Pts (18-85 yrs) with ATTR cardiac amyloidosis and heart failure history were randomized 1:1 to patisiran or placebo (pbo). Pts completing DB period were eligible to receive patisiran in the OLE for ≤36M. Results summarized based on DB treatment arm. Exploratory assessments include change from study baseline (CFB) in 6-minute walk test (6MWT), KCCQ-OS, NT-proBNP, and troponin I. RESULTS: In the DB period, 359 pts (pbo n=178; patisiran n=181) received study drug (median [range] age, 76.0 [41, 85] yrs; male, 89%; wtATTR, 80%; tafamidis at baseline, 25%); 334 (93%) entered the OLE. In patisiran arm, M12 and M18 results, respectively, were similar for each endpoint: 6MWT and KCCQ-OS (mean [SEM] CFB) −8.09 [5.73] vs −9.21 [6.04] meters (m) and 0.60 [1.36] vs 0.22 [1.48]; NT-proBNP and troponin I (geometric mean fold-CFB [95%CI]) 1.10 [1.03, 1.17] vs 1.17 [1.07, 1.27] and 1.11 [1.05, 1.18] vs 1.09 [1.01, 1.17]). In pbo arm, patisiran initiation in OLE was associated with a slower rate of worsening or relative stability across endpoints; CFB at M12 vs M18, respectively: 6MWT, −25.43 [5.61] vs −31.08 [5.45] m; KCCQ-OS, −3.41 [1.33] vs −4.02 [1.49]; NT-proBNP, 1.39 [1.28, 1.51] vs 1.53 [1.38, 1.71]; and troponin I, 1.29 [1.21, 1.38] vs 1.21 [1.13, 1.30]. Patisiran had an acceptable safety profile; no new concerns. OLE analyses are ongoing; updated data to be presented. CONCLUSIONS: The M18 results provide evidence that beneficial effects observed in DB period on functional capacity, health status, and quality of life were maintained by continued treatment with patisiran during the OLE. Pbo-treated pts initiating patisiran at M12 showed slowed worsening or stabilization in most endpoints at M18. Early treatment initiation is important: pbo-treated pts did not recover functional capacity or health lost prior to initiating OLE patisiran.

Discinergia ventricular esquerda reversível identificada por potenciação pós-extrassistólica em miocardiopatia chagásica crônica não é causada por hibernação miocárdica / Reversible dysynergy identified by post-extrasystolic potentiation in chronic chagas cardiomyopathy is not caused by myocardial hibernation

A alteração regional da mobilidade segmentar do ventrículo esquerdo é marcador precoce de miocardiopatia chagásica crônica. Demonstramos recentemente que a discinergia em algumas regiões ventriculares pode ser revertida pela potenciação pós-extrassistólica. Apesar de angiografia coronária normal, pacientes com miocardiopatia chagásica apresentam falhas de perfusão, corroborando a hipótese de que a hibernação miocárdica pode ser responsável pelas anormalidades de mobilidade segmentar revertidas durante a potenciação pós-extrassistólica. Método: Vinte e dois pacientes consecutivos portadores de miocardiopatia chagásica foram submetidos a angiografia coronária, ventriculografia e cintilografia miocárdica com tálio-201 com o protocolo estresse-redistribuição-reinjeção para avaliação da perfusão dos segmentos do ventrículo esquerdo...

Background: Regional left ventricular segmental wall motion impairment is an early marker of chronic Chagas cardiomyopathy. We have recently shown that dysynergy may be reversed in some ventricular regions by post-extrasystolic potentiation. Despite normal epicardial coronary arteries, patients with Chagas cardiomyopathy have perfusion defects, raising the possibility that myocardial hibernation could be responsible for the wall motion abnormalities reversed during post-extrasystolic potentiation. Methods: Twentytwo consecutive patients with chronic Chagas cardiomyopathy underwent coronary angiography, left ventricular contrast angiography and stress-redistribution-reinjection thallium-201 myocardial scintigraphy for the assessment of the perfusion status in left ventricular segments showing the presence of post-extrasystolic potentiation...

Persistência de distúrbios perfusionais miocárdicos após intervenção coronária percutânea com êxito: dependência de fatores microcirculatórios / Myocardial perfusion disturbances persisting after successful percutaneous coronary angioplasty: relationship to microcirculatory derangements

Introdução: A persistência transitória de defeitos perfusionais imediatamente após intervenção coronária percutânea bem sucedida para correção de estenoses coronárias é bem documentada. Método: Para testar a hipótese de que tais anormalidades perfusionais sejam associadas a distúrbios microcirculatórios causados por microembolização coronária, comparou-se a intensidade e extensão desses defeitos perfusionais detectados com cintilografia miocárdica em grupos randomicamente constituídos de pacientes tratados com angioplastia coronária por balão (AB) ou submetidos a aterectomia rotacional complementada por balão (AR + B). As características clínicas e angiográficas foram comparáveis nos dois grupos, assim como o sucesso do procedimento de angioplastia coronária. Resultados: Antes da intervenção coronária percutânea, o índice de defeito miocárdico, englobando a extensão e a gravidade da hipoperfusão, foi comparável nos dois grupos, na condição de estresse (AB = 7,72±1,91 vs AR + B = 8,61±3,38) e de repouso (AB = 3,11±1,22 vs AR + B = 2,40±1,63). Após o procedimento, o índice de defeito perfusional decresceu em ambos os grupos durante o estresse, mas com significância estatística apenas no grupo AB = 3,96±1,40 vs AR + B = 3,71 ±1,89. O contraste entre os dois grupos se acentuou na condição de repouso após a intervenção coronária: o índice de defeito decresceu de forma marginalmente significante no grupo AB para 1,46±0,66 e aumentou, embora sem significância estatística, no grupo AR + B, para 3,47±1,92. Conclusão: Esses resultados são compatíveis com o conceito de que a persistência transitória de defeitos perfusionais após angioplastia coronária bem sucedida seja dependente de distúrbios microcirculatórios associados à microembolização durante o procedimento.

Introduction: The transitory persistence of perfusion defects immediately after successful percutaneous coronary interventions to correct coronary stenosis is well known. Methods: To test the hypothesis that such perfusion abnormalities are associated with microcirculatory disorders caused by coronary microembolization we compared the intensity and extent of these perfusion defects detected using myocardial scintigraphy in groups of patients randomly assigned to coronary balloon angioplasty (BA) or to rotational atherectomy plus balloon angioplasty (RA + B). The clinical and angiography characteristics were comparable in both groups, as well as the successof the coronary angioplasty procedure. Results: Before the percutaneous coronary intervention the myocardium defect index, related to the extent and severity of hypoperfusion, was comparable for the two groups, both under stress (AB =7.72±1.91 vs. RA + B = 8.61±3.38) and at rest (AB = 3.11±1.22vs. RA + B = 2.40±1.63). After the procedure, the perfusion defect index decreased for both groups during stress, but with statistical significance only in the AB Group = 3.96±1.40 vs. RA + B = 3.71±1.89. The difference between the two groups was greater at rest after the coronary intervention procedure: the defect index decreased with marginal significance for the AB Group to 1.46±0.66 and increased, though without statistical significance, for the RA + B Group to 3.47±1.92. Conclusion: These results are compatible with the notion that transitory persistence of perfusion defects after successful coronary angioplasty are dependent on microcirculatory disorders associated to microembolization during the procedure

Perfil clínico, cinecoronariográfico e evolutivo precoce de pacientes jovens com infarto agudo do miocárdio na era trombolítica / Clinical Profile, Early Outcome and Coronary Angiography Findings in Young Patients with Acute Myocardial Infarction in the Thrombolytic Era

PURPOSE: To assess the clinical, angiographic and early follow-up findings of young patients suffering an acute myocardial infarction, in comparison with older patients with infarction, in the thrombolytic era. METHODS: A retrospective analysis of the medical records of 46 patients < 40 years-old (group I) at the time of an acute myocardial infarction was compared with that of 46 older patients, randomly selected, presenting with this syndrome between february, 1991 and february, 1996 (group II). In both groups a comparison was conducted regarding the proportions of gender, risk factors, type of infarction (Q vs non-Q), left ventricular function, coronary anatomy and early mortality (1 month). The medical treatment was comparable for both groups, including the utilization of thrombolytics. RESULTS: The groups were discriminated only by: higher prevalence of smoking, of angiographically normal coronary arteries, and of non-critical (< 75reduction of luminal diameter) coronary stenosis in group I; in the older group a higher proportion of patients had multivessel disease. Although not reaching statistical significance, a trend was observed to a more benign early course of the infarction in the patients less than < 40 years-old. CONCLUSION: The present findings are similar to those described in the pre-thrombolytic era, for young patients suffering an acute myocardial infarction.

Studies of the coronary circulation in Chagas' heart disease

Pathogenesis of chronic Chagas' heart disease may include various disturbances in the coronary circulation, that could be responsible for the myocardial lesions seen in human hearts and in experimental models of the disease. In this paper we critically reviewed the anatomical and functional abnormalities described in chronic chagasic patients, pertaining to the so-called vascular pathogenetic theory of Chagas' disease. The epicardial coronary arteries are usually tree of significant obstructive disease in nonselected groups of chagasic patients examined at autopsy or by coronary angiography. However, chagasic patients who were studied after an episode of acute myocardial infarction, show the same patterns of atherosclerotic coronary artery disease seen in the general nonchagasic population. Studies of chagasic patients with angiographically normal coronary arteries, by several scintigraphy methods, revealed myocardial perfusion abnormalities which may be caused by the microcirculatory derangements described in animals experimentally infected with the T. cruzi. Since hypoperfusion has been detected in regions with normal or mildly impaired wall motion, it is likely that the microvascular disturbances precede and may be a causative mechanism for the subsequent myocardial damage. We speculate that hibernating ventricular areas may occur in chagasic patients, on the basis of the evidence gathered from these studies. Recent investigations of chronic patients with Chagas' disease and chest pain showed attenuation of the vasomotor responses to physiological and pharmacological stimuli, in the epicardial coronary arteries.

Reagudizaçäo de cardite chagásica provocando insuficiência ventricular direita exclusiva / Reactivation of Myocarditis in Chagas' Disease Inducing Isolated Right Ventricular Failure

Woman, 42 years-old, receiving immunosuppressive therapy for a lymphoma, presented reagudization of Chagas' disease, from its indeterminate phase. Intense inflammatory visceral aggression, due to extensive intracellular proliferation of the Trypanosoma cruzi, was the likely mechanism for acute myocarditis leading to severe right ventricular failure. Antiparasite chemotherapy was effective in the control of visceral involvement and for the remission of cardiac failure. The clinical course in this case is compatible with the hypothesis of early right ventricular damage in Chagas' disease

A circulaçäo coronária na cardiopatia chagásica crônica / Coronary circulation in chronic Chagas' heart disease

Anormalidades anatômicas e funcionais da circulaçäo coronária têm sido descritas e englobadas na teoria vascular da patogênese da cardiopatia chagásica crônica. Neste artigo foram criticamente revistos resultados de estudos em humanos e modelos experimentais da infecçäo como o T.Cruzi sobre aspectos anatômicos e funcionais da circulaçäo coronária, no epicárdio e na microcirculaçäo. por evidências necroscópicas e cinecoronariográficas, as artérias epicárdicas näo exibem, em geral, lesöes obstrutivas consideradas capazes de induzir isquemia miocárdica. Constituem exceçäo aqueles pacientes chagásicos estudados após episódio de infarto agudo do miocárdio, que apresentam frequência de obstruçöes coronarianas superponível à encontrada na populaçäo näo-chagásica com infarto agudo do miocárdio. Distúrbios prefusionais, compatíveis com as alteraçöes microvasculares experimentalmente documentadas, säo observados em pacientes chagásicos crônicos com coronárias angiograficamente normais. Essas alteraçöes podem ter relaçäo causal com a disfuncçäo contrátil regional detectada em regioöes com hipoperfusäo crônica, sugerindo a ocorrência de possíveis áreas de hibernaçäo miocárdica, análoga à que se verifica na cardiopatia isquêmica aterosclerótica. Investigaçöes recentes em cardiopatas chagásicos com precordialgia sugerem anormalidades no controle vasomotor coronariano, havendo atenuaçäo das respostas arteriais epicárdicas aos estímulos constritor e dilatador.

Detecção de isquemia miocárdica em chagásicos crônicos com precordialgia atípica pelos testes de esforço e Holter / Detection of Myocardial Ischemia in Chagas' Disease Patients with Angina-Like Symptoms by the Effort Test and Holter Monitoring

Objetivo - Investigar a freqüência e as características de alteraçöes isquêmicas miocárdicas detectadas pela eletrocardiografia de esforço e monitorizaçäo eletrocardiográfica contínua (Holter) em pacientes chagásicos com dor precordial. Métodos - Trinta e um pacientes com diagnósticos clínicos e sorológico de doença de Chagas (54,4 ñ 9,6 anos, 51// homens) foram investigados para esclarecimento causal de angina de peito intensa e preocupante a ponto de afetar o padräo de vida e exigir exploraçäo agressiva. A detecçäo de isquemia miocárdica consistiu de 1 teste de esforço máximo e 2) Holter de 24h. Todos os pacientes foram submetidos a cinecoronariografia, ocasiäo em que se executava manobra de hiperventilaçäo controlada para constataçäo de espasmo arterial coronário. Os resultados obtidos com os dois testes (esforço e Holter) foram correlacionados e confrontados com os obtidos durante a cinecoronariografia. Resultados - alteraçöes basais do eletrocardiograma (ECG) impediram a análise do segmento ST em 11 pacientes. Dos restantes, 7(35//) apresentaram angina no teste de esforço. Dois deles (10//) tiveram isquemia miocárdica concomitante, detectando-se coronariopatia orgânica/funcional em ambos (associaçäo positiva, p=0,03): lesöes de 90// na artéria circunflexa e de 50// no trajeto intramiocárdico da descendente anterior esquerda. Nesta última, após hiperventilaçäo, ocorreu espasmo que reduziu em mais de 30// o diâmetro luminal do segmento estenótico, com dor precordial e elevaçäo de ST, que reverteram com nitrato. Durante o Holter (16 pacientes com traçados aproveitáveis), 25// dos indivíduos apresentaram angina do peito, sem qualquer distúrbio arrítmico ou isquêmico concomitante. Isquemia silente ocorreu em 1 paciente (5//) durante o esforço e, em outros (18//), durante o Holter. Sua presença näo foi preditiva de alteraçöes coronárias orgânicas ou funcionais. Näo foram documentadas lesöes significativas nos 11 pacientes cujo ECG näo era passível de análise. Conclusäo - Observou-se importante limitaçäo da aplicabilidade geral dos métodos eletrocardiográficos para detecçäo de isquemia miocárdica nos pacientes chagásicos em decorrência das alteraçöes basais do ECG. Contudo, quando o ECG basal é adequado, o teste de esforço positivo (ST isquêmico, acompanhado de dor precordial) apresentou 100// de valor preditivo para doença arterial coronária orgânica/funcional. Isto ocorreu em pequena, porém näo desprezivel proporçäo desta populaçäo chagásica específica (10//). O teste de Holter näo contribuiu para elucidaçäo da origem da angina do peito em qualquer um dos doentes estudados. Ante a inconsistência dos resultados, o significado o significado clínico e fisiopatológico da isquemia silente na cardiopatia chágasica demanda investigaçäo ulterior

Purpose - To determine the incidence and characteristics of myocardial ischemia, as detected by stress electrocardiography and Holter monitoring in Chagus' patients whose main complaint was precordial pain. Methods - Thirty-one consecutive patients with Chagas' disease diagnosed on the basis of clinical and serological tests, and precordial pain severe enough to warrant cardiac catheterization were studied. Mean age was 54.4 ± 9.6 years, and 51% were males. EKG changes indicative of myocardial ischemia were sought during maximul exercise and also during 24-hour Holter monitoring. The detection of myocardial ischemia by each one of these tests was compared by Fischer exact test, and also correlated to anatomical and functional results of coronary angiography at rest and after standardized hyperventilation for detecting coronary vasospasm. Results - Baseline EKG changes mainly associated with ventricular conduction defects precluded the analysis of the ST segment in 11 patients. Among the other 20 patients, 7(35%) had angina during the exercice test, of whom only 2(10%) showed concomitant ischemic ST changes: one had 90% stenosis in the circumflex branch and the other 50% reduction of luminal diameter in a intramyocardial segment of the leit anterior descending coronary artery, undergoing further 30% constriction after hyperventilation, with pain and ST-elevation that responded to nitrate administration. Thus, a positive correlation between a positive EKG exercise test with accompanying symptoms, and organic/functional coronary artery disease was found (p = 0.03). Holter tracings of good quality were obtained in 16 patients. Angina-like symptoms occurred in 25% of these patients, without concomitant ischemic or dysrhythmic EKG changes. Conversely, silent ischemia was detected in 1 (5%) patient during exercice and in 3 (18%) patients during the Holter monitoring None of these patients had any evidence of organic or functional alterations in the coronary arteries. The absence of significant (> 50%) narrowing of the coronary arteries, t baseline and after hyperventilation, was also documented in the 11 patients in whom no valid EKG tracings were obtained for analysis. Conclusion - EKG-based methods for detecting myocardial eschemia are of limited value in the general population with Chagas' disease presenting with precordial pain, due to the high prevalence of baseline ST changes. The overall incidence of significant coronary artery disease, as detected by angiography, was low but not negligible in this population of Chagas' patients with precordial pain (4%). Nevertheless, a positive EKG test based on ST changes and accompanying pain has a 100% positive predictive accuracy for the presence of organic or functional coronary abnormalities. No additional yield was obtained with Holter monitoring, for the elucidution of the pathophysiology of the precordial pain in Chagas' patients with atypical angina. The significance of episodes of silent ischemia in some of these patients, with angiographically normal coronary arteries, remains to be determined

Protocolo para o atendimento da parada cárdio-respiratória / Guidelines for cardiopulmonary resuscitation

Os autores apresentam de forma sintética e prática os passos para o atendimento da Parada Cárdio-Respiratória (PCR), estabelecidos como rotina pela Divisäo de Cardiologia do HC-FMRPUSP. Säo revistos, à luz das contribuiçöes mais recentes da literatura médica, os conceitos que fundamentam os procedimentos preconizados em cada uma das fases do atendimento da PCR