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BACKGROUND: Heart failure (HF) associated with atrial fibrillation increases patients' physical inactivity, worsening their clinical condition and mortality. Exercise training is safe and has clear benefits in HF. However, little is known about the effects of exercise training on patients with HF with reduced ejection fraction and permanent atrial fibrillation (HFAF). OBJECTIVE: The purpose of this study was to test the hypothesis that exercise training improves functional capacity, cardiac function, and quality of life in patients with HFAF. METHODS: This randomized clinical trial was conducted at the Heart Institute. Patients with HFAF, left ventricular ejection fraction ≤40%, and resting heart rate (HR) ≤80 beats/min were included in the study. Cardiopulmonary testing, echocardiography, nervous system, and quality of life assessment were performed before and after the 12-week protocol period. RESULTS: Twenty-six patients (mean age 58 ± 1 years) were randomized to exercise training (HFAF-trained group; n = 13) or no training (HFAF-untrained group; n = 13). At baseline, no differences between the groups were found. Exercise improved peak oxygen consumption, slope of ventilation per minute/carbon dioxide production, and quality of life. The HFAF-trained group had significantly decreased resting HR (from 73 ± 2 to 69 ± 2 beats/min; P = .02) and recovery HR (from 148 ± 11 to 128 ± 9 beats/min; P = .001). Concomitantly, left ventricular ejection fraction increased (from 31% ± 1% to 36% ± 0.9%; P = .01), left atrial dimension decreased (from 52 ± 1.2 to 47 ± 1 mm; P = .03), and left ventricular end-systolic volume and left ventricular end-diastolic volume deceased (from 69 ± 2 to 64 ± 1.8 mL/m2 and from 99 ± 2.1 to 91 ± 2 mL/m2, respectively; P < .05). No changes were observed in the HFAF-untrained group. CONCLUSION: Exercise training can improve exercise capacity, quality of life, and cardiac function in patients with HF with reduced ejection fraction and permanent atrial fibrillation.
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Fibrilação Atrial , Insuficiência Cardíaca , Disfunção Ventricular Esquerda , Fibrilação Atrial/terapia , Exercício Físico , Teste de Esforço , Tolerância ao Exercício/fisiologia , Humanos , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Qualidade de Vida , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologiaRESUMO
AIMS: This study aimed to analyse the clinical presentation and prognosis of patients with Chagas cardiomyopathy and decompensated heart failure (HF), as compared with other aetiologies. METHODS AND RESULTS: A prospective cohort of patients admitted with decompensated HF. We included 767 patients (63.9% male), with median age of 58 years [interquartile range 48.2-66.7 years]. Main aetiologies were non-Chagas/non-ischaemic cardiomyopathies in 389 (50.7%) patients, ischaemic disease in 209 (27.2%), and Chagas disease in 169 (22%). Median left ventricular ejection fraction was 26% (interquartile range 22-35%). Patients with Chagas differed from both patients with non-Chagas/non-ischaemic and ischaemic cardiomyopathies for a higher proportion of cardiogenic shock at admission (17.8%, 11.6%, and 11%, respectively, P < 0.001) and had lower blood pressure at admission (systolic blood pressure 90 [80-102.5], 100 [85-110], and 100 [88.2-120] mmHg, P < 0.001) and lower heart rate (heart rate 71 [60-80], 87 [70-102], and 79 [64-96.5] b.p.m., P < 0.001). Further, patients with Chagas had higher serum BNP level (1544 [734-3148], 1061 [465-239], and 927 [369-1455] pg/mL, P < 0.001), higher serum bilirubin (1.4 [0.922.44], 1.2 [0.77-2.19], and 0.84 [0.49-1.45] mg/dL, P < 0.001), larger left ventricular diameter (68 [63-73], 67 [58-74], and 62 [56.8-68.3] mm, respectively, P < 0.001), lower left ventricular ejection fraction (25 [21-30]%, 26 [22-35]%, and 30 [25-38]%, P < 0.001), and a higher proportion of patients with right ventricular function (48.8%, 40.7%, and 25.9%, P < 0.001). Patients with Chagas disease were more likely to receive inotropes than patients with non-Chagas/non-ischaemic and ischaemic cardiomyopathies (77.5%, 67.5%, and 62.5%, respectively, P = 0.007) and also to receive intra-aortic balloon pumping (30.8%, 16.2%, and 10.5%, P < 0.001). Overall, the rates of death or urgent transplant were higher among patients with Chagas than in other aetiologies, a difference that was driven mostly due to increased rate of heart transplant during hospital admission (20.2%, 10.3%, and 8.1%). The prognosis of patients at 180 days after hospital admission was worse for patients with Chagas disease as compared with other aetiologies. In patients with Chagas, age [odds ratio (OR) = 0.934, confidence interval (CI)95% 0.901-0.982, P = 0.005], right ventricular dysfunction by echocardiography (OR = 2.68, CI95% 1.055-6.81, P = 0.016), and urea (OR = 1.009, CI95% 1.001-1.018, P = 0.038) were significantly associated with prognosis. CONCLUSIONS: Patients with Chagas cardiomyopathy and decompensated HF have a distinct clinical presentation and worse prognosis compared with other aetiologies.
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Doença de Chagas , Insuficiência Cardíaca , Idoso , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Volume Sistólico , Função Ventricular EsquerdaRESUMO
AIMS: Patients with advanced heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) and concurrent coronavirus disease 2019 (COVID-19) might have a higher risk of severe events. METHODS AND RESULTS: We retrospectively studied 16 patients with advanced HFrEF who developed COVID-19 between 1 March and 29 May 2020. Follow-up lasted until 30 September. Ten patients previously hospitalized with decompensated HFrEF were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization. Six patients undergoing ambulatory care at initiation of COVID-19 symptoms were hospitalized because of advanced HFrEF. All patients who experienced worsening of HFrEF due to COVID-19 required higher doses or introduction of additional inotropic drugs or intra-aortic balloon pump in the intensive care unit. The mean intravenous dobutamine dose before SARS-CoV-2 infection in previously hospitalized patients (n = 10) and the median (inter-quartile range) peak intravenous dobutamine dose during SARS-CoV-2 infection in all patients (n = 16) were 2 (0-7) µg/kg/min and 20 (14-20) (P < 0.001), respectively. During follow-up, 56% underwent heart transplantation (n = 2) or died (n = 7). Four patients died during hospitalization from mixed shock consequent to severe acute respiratory syndrome with inflammatory storm syndrome associated with septic and cardiogenic shock during COVID-19. After COVID-19 recovery, two patients died from mixed septic and cardiogenic shock and one from sustained ventricular tachycardia and cardiogenic shock. Five patients were discharged from hospital to ambulatory care. Four were awaiting heart transplantation. CONCLUSION: Worsening of advanced HF by COVID-19 is associated with high mortality. This report highlights the importance of preventing COVID-19 in patients with advanced HF.
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COVID-19/complicações , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Adulto , Idoso , COVID-19/mortalidade , COVID-19/terapia , Fármacos Cardiovasculares/uso terapêutico , Cuidados Críticos , Feminino , Insuficiência Cardíaca/virologia , Transplante de Coração , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Volume Sistólico , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Objectives: The prognostic significance of transient use of inotropes has been sufficiently studied in recent heart failure (HF) populations. We hypothesised that risk stratification in these patients could contribute to patient selection for advanced therapies. Methods: We analysed a prospective cohort of adult patients admitted with decompensated HF and ejection fraction (left ventricular ejection fraction (LVEF)) less than 50%. We explored the outcomes of patients requiring inotropic therapy during hospital admission and after discharge. Results: The study included 737 patients, (64.0% male), with a median age of 58 years (IQR 48-66 years). Main aetiologies were dilated cardiomyopathy in 273 (37.0%) patients, ischaemic heart disease in 195 (26.5%) patients and Chagas disease in 163 (22.1%) patients. Median LVEF was 26 % (IQR 22%-35%). Inotropes were used in 518 (70.3%) patients. In 431 (83.2%) patients, a single inotrope was administered. Inotropic therapy was associated with higher risk of in-hospital death/urgent heart transplant (OR=10.628, 95% CI 5.055 to 22.344, p<0.001). At 180-day follow-up, of the 431 patients discharged home, 39 (9.0%) died, 21 (4.9%) underwent transplantation and 183 (42.4%) were readmitted. Inotropes were not associated with outcome (death, transplant and rehospitalisation) after discharge. Conclusions: Inotropic drugs are still widely used in patients with advanced decompensated HF and are associated with a worse in-hospital prognosis. In contrast with previous results, intermittent use of inotropes during hospitalisation did not determine a worse prognosis at 180-day follow-up. These data may add to prognostic evaluation in patients with advanced HF in centres where mechanical circulatory support is not broadly available.
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AIMS: Explore the association between clinical findings and prognosis in patients with acute decompensated heart failure (ADHF) and analyze the influence of etiology on clinical presentation and prognosis. METHODS AND RESULTS: Prospective cohort of 500 patients admitted with ADHF from Aug/2013-Feb/2016; patients were predominantly male (61.8%), median age was 58 (IQ25-75% 47-66 years); etiology was dilated cardiomyopathy in 141 (28.2%), ischemic heart disease in 137 (27.4%), and Chagas heart disease in 113 (22.6%). Patients who died (154 [30.8%]) or underwent heart transplantation (53[10.6%]) were younger (56 years [IQ25-75% 45-64 vs 60 years, IQ25-75% 49-67], P = 0.032), more frequently admitted for cardiogenic shock (20.3% vs 6.8%, P<0.001), had longer duration of symptoms (14 days [IQ25-75% 4-32.8 vs 7.5 days, IQ25-75% 2-31], P = 0.004), had signs of congestion (90.8% vs 76.5%, P<0.001) and inadequate perfusion more frequently (45.9% vs 28%, P<0.001), and had lower blood pressure (90 [IQ25-75% 80-100 vs 100, IQ25-75% 90-120], P<0.001). In a logistic regression model analysis, systolic blood pressure (P<0.001, OR 0.97 [95%CI 0.96-0.98] per mmHg) and jugular distention (P = 0.004, OR 1.923 [95%CI 1.232-3.001]) were significant. Chagas patients were more frequently admitted for cardiogenic shock (15%) and syncope/arrhythmia (20.4%). Pulmonary congestion was rare among Chagas patients and blood pressure was lower. The rate of in-hospital death or heart transplant was higher among patients with Chagas (50.5%). CONCLUSIONS: A physical exam may identify patients at higher risk in a contemporaneous population. Our findings support specific therapies targeted at Chagas patients in the setting of ADHF.
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Cardiomiopatia Chagásica/patologia , Insuficiência Cardíaca/patologia , Função Ventricular , Idoso , Cardiomiopatia Chagásica/mortalidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Análise de SobrevidaRESUMO
BACKGROUND: beta-adrenergic receptor antagonism with drugs like carvedilol slows the progression of heart failure by an undefined mechanism. (123)I-metaiodobenzylguanidine (MIBG) is an analog of norepinephrine used to study cardiac sympathetic function. METHODS AND RESULTS: In this double-blind randomized, placebo-controlled study, we used MIBG imaging to evaluate the effect of carvedilol (n=15) or placebo (n=7) on neuronal norepinephrine reuptake in patients with heart failure due to idiopathic dilated cardiomyopathy, with LVEF less than 35% and functional class II or III. The drug was begun at 6.25 mg b.i.d. and titrated up to 25 mg t.i.d, as tolerated. Thorax planar scintigraphy images were obtained 15 min (Initial) and 4 h (Late) after MIBG injection at baseline (t(0)) as well as 2 months (t(1)) and 6 months (t(2)) after drug initiation. The multifarious statistical technique of profile analysis was applied and p< or =0.05 was considered significant. The heart/mediastinum MIBG uptake (H/M ratio) was calculated from these images. On the Initial images, the H/M ratio was 1.64+/-0.24 (t(0)), 1.71+/-0.21 (t(1)), and 1.87+/-0.34 (t(2)) in the carvedilol group and 1.68+/-0.42 (t(0)), 1.81+/-0.45 (t(1)), and 1.69+/-0.44 (t(2)) in controls (p=0.0455). On the Late images, the H/M ratio was 1.39+/-0.24 (t(0)), 1.53+/-0.23 (t(1)), and 1.64+/-0.36 (t(2)) in the carvedilol group, and 1.49+/-0.45 (t(0)), 1.53+/-0.47 (t(1)), and 1.47+/-0.41 (t(2)) in controls (p=0.0513). CONCLUSION: Compared with placebo, the addition of carvedilol to existing heart failure treatment incites the reverse remodeling of cardiac sympathetic nervous system function.
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Antagonistas Adrenérgicos beta/uso terapêutico , Carbazóis/uso terapêutico , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/tratamento farmacológico , Propanolaminas/uso terapêutico , Sistema Nervoso Simpático/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/tratamento farmacológico , 3-Iodobenzilguanidina , Adulto , Cardiomiopatia Dilatada/complicações , Carvedilol , Método Duplo-Cego , Feminino , Insuficiência Cardíaca/complicações , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/efeitos dos fármacos , Ventrículos do Coração/inervação , Humanos , Masculino , Pessoa de Meia-Idade , Norepinefrina/sangue , Cintilografia , Compostos Radiofarmacêuticos , Sistema Nervoso Simpático/efeitos dos fármacos , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicaçõesRESUMO
BACKGROUND: Clinical and experimental conflicting data have questioned the relationship between infectious agents, inflammation and dilated cardiomyopathy (DCM). OBJECTIVES: The aim of this study was to determine the frequency of infectious agents and inflammation in endomyocardial biopsy (EMB) specimens from patients with idiopathic DCM, explanted hearts from different etiologies, including Chagas' disease, compared to donated hearts. METHODS: From 2008 to 2011, myocardial samples from 29 heart donors and 55 patients with DCMs from different etiologies were studied (32 idiopathic, 9 chagasic, 6 ischemic and 8 other specific etiologies). Inflammation was investigated by immunohistochemistry and infectious agents by immunohistochemistry, molecular biology, in situ hybridization and electron microscopy. RESULTS: There were no differences regarding the presence of macrophages, expression of HLA class II and ICAM-I in donors and DCM. Inflammation in Chagas' disease was predominant. By immunohistochemistry, in donors, there was a higher expression of antigens of enterovirus and Borrelia, hepatitis B and C in DCMs. By molecular biology, in all groups, the positivity was elevated to microorganisms, including co-infections, with a higher positivity to adenovirus and HHV6 in donors towards DCMs. This study was the first to demonstrate the presence of virus in the heart tissue of chagasic DCM. CONCLUSIONS: The presence of inflammation and infectious agents is frequent in donated hearts, in the myocardium of patients with idiopathic DCM, myocardial dysfunction related to cardiovascular diseases, and primary and secondary cardiomyopathies, including Chagas' disease. The role of co-infection in Chagas' heart disease physiopathology deserves to be investigated in future studies.
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Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/microbiologia , Doença de Chagas/diagnóstico , Doença de Chagas/microbiologia , Coração/microbiologia , Doadores de Tecidos , Adulto , Cardiomiopatias/diagnóstico , Cardiomiopatias/microbiologia , Feminino , Transplante de Coração/normas , Humanos , Inflamação/diagnóstico , Inflamação/microbiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto JovemRESUMO
OBJECTIVE: To assess left ventricular mass in patients with heart failure and its correlations with other clinical variables and prognosis. METHODS: The study comprised 587 patients aged from 13.8 years to 68.9 years, 461 (78.5%) being males and 126 (21.5%) females. Left ventricular mass was estimated by using M-mode echocardiography and was indexed by height. RESULTS: The left ventricular mass index ranged from 35.3 g/m to 333.5 g/m and increased with age. The left ventricular mass index was greater in males (mean, 175.7 g/m) than in females (mean, 165.7 g/m). The left ventricular mass index was greater in patients with hypertensive cardiomyopathy (mean of 188.1 g/m), with idiopathic dilated cardiomyopathy (mean, 177.7 g/m) and with cardiomyopathies of other etiologies (mean, 175.1 g/m) than in patients with chagasic (mean, 164.3 g/m) or ischemic (mean, 162 g/m) cardiomyopathy. The left ventricular mass index in patients with heart failure showed a correlation with age, sex, etiology, and left atrial diameter. The correlation with left ventricular ejection fraction was negative: the increase in the left ventricular mass index was associated with a reduction in ejection fraction. The relative risk of death was 1.22 for each 50-g/m increase in the left ventricular mass index. CONCLUSIONS: The estimate of left ventricular mass may contribute to the prognostic assessment of patients with heart failure.
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Insuficiência Cardíaca/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Adolescente , Adulto , Fatores Etários , Idoso , Pesos e Medidas Corporais , Ecocardiografia , Métodos Epidemiológicos , Feminino , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Hipertrofia Ventricular Esquerda/mortalidade , Hipertrofia Ventricular Esquerda/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores SexuaisRESUMO
BACKGROUND: Discrepancies between pre and post-mortem diagnoses are reported in the literature, ranging from 4.1 to 49.8 % in cases referred for necropsy, with important impact on patient treatment. OBJECTIVE: To analyze patients who died after cardiac transplantation and to compare the pre- and post-mortem diagnoses. METHODS: Perform a review of medical records and analyze clinical data, comorbidities, immunosuppression regimen, laboratory tests, clinical cause of death and cause of death at the necropsy. Then, the clinical and necroscopic causes of death of each patient were compared. RESULTS: 48 deaths undergoing necropsy were analyzed during 2000-2010; 29 (60.4 %) had concordant clinical and necroscopic diagnoses, 16 (33.3%) had discordant diagnoses and three (6.3%) had unclear diagnoses. Among the discordant ones, 15 (31.3%) had possible impact on survival and one (2.1%) had no impact on survival. The main clinical misdiagnosis was infection, with five cases (26.7 % of discordant), followed by hyperacute rejection, with four cases (20 % of the discordant ones), and pulmonary thromboembolism, with three cases (13.3% of discordant ones). CONCLUSION: Discrepancies between clinical diagnosis and necroscopic findings are commonly found in cardiac transplantation. New strategies to improve clinical diagnosis should be made, considering the results of the necropsy, to improve the treatment of heart failure by heart transplantation.
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Autopsia , Causas de Morte , Transplante de Coração/mortalidade , Adulto , Erros de Diagnóstico/estatística & dados numéricos , Feminino , Humanos , Masculino , Prontuários Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Sobrevida , Fatores de TempoRESUMO
AIMS: Trials of disease management programmes (DMP) in heart failure (HF) have shown controversial results regarding quality of life. We hypothesized that a DMP applied over the long-term could produce different effects on each of the quality-of-life components. METHODS AND RESULTS: We extended the prospective, randomized REMADHE Trial, which studied a DMP in HF patients. We analysed changes in Minnesota Living with Heart Failure Questionnaire components in 412 patients, 60.5% male, age 50.2 +/- 11.4 years, left ventricular ejection fraction 34.7 +/- 10.5%. During a mean follow-up of 3.6 +/- 2.2 years, 6.3% of patients underwent heart transplantation and 31.8% died. Global quality-of-life scores improved in the DMP intervention group, compared with controls, respectively: 57.5 +/- 3.1 vs. 52.6 +/- 4.3 at baseline, 32.7 +/- 3.9 vs. 40.2 +/- 6.3 at 6 months, 31.9 +/- 4.3 vs. 41.5 +/- 7.4 at 12 months, 26.8 +/- 3.1 vs. 47.0 +/- 5.3 at the final assessment; P < 0.01. Similarly, the physical component (23.7 +/- 1.4 vs. 21.1 +/- 2.2 at baseline, 16.2 +/- 2.9 vs. 18.0 +/- 3.3 at 6 months, 17.3 +/- 2.9 vs. 23.1 +/- 5.7 at 12 months, 11.4 +/- 1.6 vs. 19.9 +/- 2.4 final; P < 0.01), the emotional component (13.2 +/- 1.0 vs. 12.1 +/- 1.4 at baseline, 11.7 +/- 2.7 vs. 12.3 +/- 3.1 at 6 months, 12.4 +/- 2.9 vs. 16.8 +/- 5.9 at 12 months, 6.7 +/- 1.0 vs. 10.6 +/- 1.4 final; P < 0.01) and the additional questions (20.8 +/- 1.2 vs. 19.3 +/- 1.8 at baseline, 14.3 +/- 2.7 vs. 17.3 +/- 3.1 at 6 months, 12.4 +/- 2.9 vs. 21.0 +/- 5.5 at 12 months, 6.7 +/- 1.4 vs. 17.3 +/- 2.2 final; P < 0.01) were better (lower) in the intervention group. The emotional component improved earlier than the others. Post-randomization quality of life was not associated with events. CONCLUSION: Components of the quality-of-life assessment responded differently to DMP. These results indicate the need for individualized DMP strategies in patients with HF. Trial registration information www.clincaltrials.gov NCT00505050-REMADHE.
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Insuficiência Cardíaca/psicologia , Monitorização Ambulatorial/métodos , Educação de Pacientes como Assunto/métodos , Qualidade de Vida , Progressão da Doença , Feminino , Seguimentos , Insuficiência Cardíaca/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Inquéritos e Questionários , Fatores de TempoRESUMO
Fundamento: Discordâncias entre diagnóstico pre e post-mortem são relatadas na literatura, podendo variar de 4,1 a 49,8% dentre os casos encaminhados para exame necroscópico, com importante repercussão no tratamento dos pacientes. Objetivo: Analisar pacientes com óbito após o transplante cardíaco e confrontar os diagnósticos pre e post-mortem. Métodos: Por meio da revisão de prontuários, foram analisados dados clínicos, presença de comorbidades, esquema de imunossupressão, exames laboratoriais, causa clínica do óbito e causa do óbito à necrópsia. Foram confrontadas, então, a causa clínica e a causa necroscópica do óbito de cada paciente. Resultados: Foram analisados 48 óbitos submetidos à necrópsia no período de 2000 a 2010; 29 (60,4%) tiveram diagnósticos clínico e necroscópico concordantes, 16 (33,3%) tiveram diagnósticos discordantes e três (6,3%) tiveram diagnóstico não esclarecido. Entre os discordantes, 15 (31,3%) apresentaram possível impacto na sobrevida e um (2,1%) não apresentou impacto na sobrevida. O principal diagnóstico clínico feito equivocadamente foi o de infecção, com cinco casos (26,7% dos discordantes), seguido por rejeição hiperaguda, com quatro casos (20% dos discordantes), e tromboembolismo pulmonar, com três casos (13,3% dos discordantes). Conclusão: Discordâncias entre o diagnóstico clínico e achados da necrópsia são comumente encontradas no transplante cardíaco. Novas estratégias no aperfeiçoamento do diagnóstico clínico devem ser introduzidas, considerando-se os resultados da necrópsia para melhoria do tratamento da insuficiência cardíaca por meio do transplante cardíaco. .
Background: Discrepancies between pre and post-mortem diagnoses are reported in the literature, ranging from 4.1 to 49.8 % in cases referred for necropsy, with important impact on patient treatment. Objective: To analyze patients who died after cardiac transplantation and to compare the pre- and post-mortem diagnoses. Methods: Perform a review of medical records and analyze clinical data, comorbidities, immunosuppression regimen, laboratory tests, clinical cause of death and cause of death at the necropsy. Then, the clinical and necroscopic causes of death of each patient were compared. Results: 48 deaths undergoing necropsy were analyzed during 2000-2010; 29 (60.4 %) had concordant clinical and necroscopic diagnoses, 16 (33.3%) had discordant diagnoses and three (6.3%) had unclear diagnoses. Among the discordant ones, 15 (31.3%) had possible impact on survival and one (2.1%) had no impact on survival. The main clinical misdiagnosis was infection, with five cases (26.7 % of discordant), followed by hyperacute rejection, with four cases (20 % of the discordant ones), and pulmonary thromboembolism, with three cases (13.3% of discordant ones). Conclusion: Discrepancies between clinical diagnosis and necroscopic findings are commonly found in cardiac transplantation. New strategies to improve clinical diagnosis should be made, considering the results of the necropsy, to improve the treatment of heart failure by heart transplantation. .
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Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autopsia , Causas de Morte , Transplante de Coração/mortalidade , Erros de Diagnóstico/estatística & dados numéricos , Prontuários Médicos/estatística & dados numéricos , Estudos Retrospectivos , Sobrevida , Fatores de TempoRESUMO
BACKGROUND: The effectiveness of heart failure disease management programs in patients under cardiologists' care over long-term follow-up is not established. METHODS AND RESULTS: We investigated the effects of a disease management program with repetitive education and telephone monitoring on primary (combined death or unplanned first hospitalization and quality-of-life changes) and secondary end points (hospitalization, death, and adherence). The REMADHE [Repetitive Education and Monitoring for ADherence for Heart Failure] trial is a long-term randomized, prospective, parallel trial designed to compare intervention with control. One hundred seventeen patients were randomized to usual care, and 233 to additional intervention. The mean follow-up was 2.47+/-1.75 years, with 54% adherence to the program. In the intervention group, the primary end point composite of death or unplanned hospitalization was reduced (hazard ratio, 0.64; confidence interval, 0.43 to 0.88; P=0.008), driven by reduction in hospitalization. The quality-of-life questionnaire score improved only in the intervention group (P<0.003). Mortality was similar in both groups. Number of hospitalizations (1.3+/-1.7 versus 0.8+/-1.3, P<0.0001), total hospital days during the follow-up (19.9+/-51 versus 11.1+/-24 days, P<0.0001), and the need for emergency visits (4.5+/-10.6 versus 1.6+/-2.4, P<0.0001) were lower in the intervention group. Beneficial effects were homogeneous for sex, race, diabetes and no diabetes, age, functional class, and etiology. CONCLUSIONS: For a longer follow-up period than in previous studies, this heart failure disease management program model of patients under the supervision of a cardiologist is associated with a reduction in unplanned hospitalization, a reduction of total hospital days, and a reduced need for emergency care, as well as improved quality of life, despite modest program adherence over time.
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Administração de Caso/normas , Insuficiência Cardíaca/terapia , Pacientes Ambulatoriais , Cooperação do Paciente/estatística & dados numéricos , Educação de Pacientes como Assunto/métodos , Brasil/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Garantia da Qualidade dos Cuidados de Saúde/métodos , Qualidade de Vida , Inquéritos e Questionários , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
BACKGROUND: Hyponatremia and congestive phenomena indicate a bad prognosis in decompensated heart failure. The occurrence of renal failure is associated to an increased death risk. OBJECTIVE: To evaluate the safety and efficacy of the hypertonic saline solution in patients with decompensated heart failure for renal failure prevention. METHODS: Patients with decompensated heart failure, congestion and hyponatremia participated in the study. In addition to the standard treatment, the patients received hypertonic saline solution and were submitted to clinical as well as laboratory assessment. RESULTS: Nine patients were enrolled in the study. Mean age was 55 + 14.2 years, being 5 male (55.5%) and 4 (44.5%) female patients. All of them presented functional class III-IV of the New York Heart Association (NYHA), and 5 (55.5%) received dobutamine. All of them presented initial creatinine > 1.4 mg/dl. The mean tonicity of the solution was 4.39% + 0.018% (2.5% to 7.5%) and the duration of treatment was 4.9 days + 4.1 days (1-15 days). There were no severe adverse effects; none of the patients presented clinical worsening or neurologic disorders; hypokalemia occurred in 4 cases (44.5%). The comparison of the variables before and after treatment showed a decrease in urea (105 mg/dl + 74.8 mg/dl vs. 88 mg/dl + 79.4 mg/dl; p = 0.03) and increase in the urinary volume (1,183 ml/day vs. 1,778 ml/day; p = 0.03); there was no tendency to creatinine decrease (2.0 mg/dl + 0.8 mg/dl vs. 1.7 mg/dl + 1.0 mg/dl; p = 0.08). Despite the elevation in sodium levels (131 mEq/l + 2.8 mEq/l vs. 134 mEq/l + 4.9 mEq/l) and weight decrease (69.5 kg + 18.6 kg vs. 68.2 kg + 17.1 kg), there was no statistically significant difference. CONCLUSION: The use of hypertonic saline solution in patients with decompensated heart failure can be a safe therapeutic method and potentially related to clinical improvement and renal failure prevention.
Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Hiponatremia/tratamento farmacológico , Insuficiência Renal/prevenção & controle , Solução Salina Hipertônica/uso terapêutico , Biomarcadores/sangue , Cardiotônicos/uso terapêutico , Creatinina/sangue , Diuréticos/uso terapêutico , Dobutamina/uso terapêutico , Feminino , Furosemida/uso terapêutico , Insuficiência Cardíaca/sangue , Humanos , Hipopotassemia/etiologia , Hiponatremia/sangue , Masculino , Pessoa de Meia-Idade , Potássio/sangue , Solução Salina Hipertônica/efeitos adversos , Índice de Gravidade de Doença , Sódio/sangue , Fatores de Tempo , Resultado do Tratamento , Ureia/sangueRESUMO
OBJECTIVES: The inhibition of the rennin-angiotensin-aldosterone system (RAAS) and sympathetic autonomous nervous system has increased the perspective of survival in these patients, as well as allowing the improvement of the quality of life. The aim of this study was to evaluate the reality of the treatment employed and its impact on the disease in patients followed at a specialized heart failure (HF) outpatient clinic. METHODS: A sample of 96 patients followed at the HF and Transplant Outpatient Clinic of Heart Institute of the University of São Paulo School of Medicine (InCor -HCFMUSP) were evaluated. The data were collected during the ambulatory consultation from the medical files and through physical examination. Patients were randomly selected for the study. RESULTS: Most of the patients were Functional Class II (42.3%) and evolution stage C (94.9%). The medical prescription given to the patients was quite similar to the one recommended by the directives. Approximately 95% of them received RAAS inhibitors (ACE inhibitor--enalapril and captopril--or angiotensin receptor antagonist--losartan), whereas 85% of the patients additionally received beta blockers (carvedilol). The mean dose prescribed was also similar to the one used in large studies and reached more than 60% of the maximum dose for each medication. The hemodynamic data show that patients were stable, despite the intensity of the dysfunction and ventricular remodeling observed in these patients. CONCLUSION: Patients with HF followed by a specialized medical team receive a medical prescription that is closer to the recommended one. These patients, despite the marked characteristics of disease severity, achieve hemodynamic and clinical stability with an adequate therapeutic optimization.
Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Carbazóis/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Propanolaminas/administração & dosagem , Captopril/administração & dosagem , Carvedilol , Quimioterapia Combinada , Enalapril/administração & dosagem , Feminino , Humanos , Losartan/administração & dosagem , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de DoençaRESUMO
OBJETIVOS: A inibição dos sistemas renina-angiotensina-aldosterona (SRAA) e sistema nervoso autônomo simpático aumentou a perspectiva de sobrevida desses pacientes, além de permitir substancial melhora na qualidade de vida. O objetivo deste trabalho foi avaliar a realidade do tratamento aplicado e seu impacto sobre a doença em pacientes acompanhados em um ambulatório especializado em insuficiência cardíaca(IC). MÉTODOS: Foram estudados 96 pacientes acompanhados no ambulatório de Insuficiência Cardíaca e Transplante do Instituto do Coração, do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP). Os dados foram coletados durante a consulta ambulatorial a partir de prontuário médico e exame clínico. A escolha dos pacientes foi aleatória. RESULTADOS: A maior parte dos pacientes encontrava-se em classe funcional II (42,3 por cento) e em estágio C de evolução (94,9 por cento). A prescrição médica para os pacientes foi bastante próxima do preconizado pelas diretrizes. Aproximadamente 95 por cento recebem inibidores do SRAA (inibidor de ECA - enalapril e captopril - ou antagonista dos receptores de angiotensina-losartan), enquanto 85 por cento dos pacientes recebem, além desses, agentes betabloqueadores (carvedilol). A dose média prescrita também se aproxima das utilizadas nos grandes estudos, e atinge mais de 60 por cento da dose máxima de cada medicação. Os dados hemodinâmicos encontrados mostram pacientes estáveis, apesar da intensidade da disfunção e do remodelamento ventricular destes. CONCLUSÃO: Pacientes portadores de IC acompanhados por equipe médica especializada têm prescrição médica mais próxima do preconizado. Esses pacientes, embora com características marcadas de gravidade da doença, conseguem estabilidade hemodinâmica e clínica com a otimização terapêutica adequada.
OBJECTIVES: The inhibition of the rennin-angiotensin-aldosterone system (RAAS) and sympathetic autonomous nervous system has increased the perspective of survival in these patients, as well as allowing the improvement of the quality of life. The aim of this study was to evaluate the reality of the treatment employed and its impact on the disease in patients followed at a specialized heart failure (HF) outpatient clinic. METHODS: A sample of 96 patients followed at the HF and Transplant Outpatient Clinic of Heart Institute of the University of São Paulo School of Medicine (InCor -HCFMUSP) were evaluated. The data were collected during the ambulatory consultation from the medical files and through physical examination. Patients were randomly selected for the study. RESULTS: Most of the patients were Functional Class II (42.3 percent) and evolution stage C (94.9 percent). The medical prescription given to the patients was quite similar to the one recommended by the directives. Approximately 95 percent of them received RAAS inhibitors (ACE inhibitor - enalapril and captopril - or angiotensin receptor antagonist - losartan), whereas 85 percent of the patients additionally received beta blockers (carvedilol). The mean dose prescribed was also similar to the one used in large studies and reached more than 60 percent of the maximum dose for each medication. The hemodynamic data show that patients were stable, despite the intensity of the dysfunction and ventricular remodeling observed in these patients. CONCLUSION: Patients with HF followed by a specialized medical team receive a medical prescription that is closer to the recommended one. These patients, despite the marked characteristics of disease severity, achieve hemodynamic and clinical stability with an adequate therapeutic optimization.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas Adrenérgicos beta/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Carbazóis/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Propanolaminas/administração & dosagem , Captopril/administração & dosagem , Quimioterapia Combinada , Enalapril/administração & dosagem , Losartan/administração & dosagem , Índice de Gravidade de DoençaRESUMO
FUNDAMENTO: Hiponatremia e fenômenos congestivos indicam mau prognóstico na insuficiência cardíaca descompensada. A ocorrência de insuficiência renal está associada a aumento do risco de morte. OBJETIVO: Avaliar a segurança e a eficácia da solução hipertônica em pacientes com insuficiência cardíaca descompensada para prevenção de insuficiência renal. MÉTODOS: Participaram do estudo pacientes com insuficiência cardíaca descompensada, congestão e hiponatremia. Além do tratamento padrão, os pacientes receberam solução salina hipertônica, e foram submetidos a avaliação tanto clínica como laboratorial. RESULTADOS: Foram incluídos 9 pacientes. A média das idades dos pacientes foi de 55 + 14,2 anos, sendo 5 (55,5 por cento) do sexo masculino e 4 (44,5 por cento), do feminino. Todos apresentavam classe funcional III-IV da New York Heart Association (NYHA), e 5 (55,5 por cento) recebiam dobutamina. Todos apresentaram creatinina inicial acima de 1,4 mg/dl. A tonicidade média da solução foi de 4,39 por cento + 0,018 por cento (2,5 por cento a 7,5 por cento) e a duração do tratamento foi de 4,9 dias + 4,1 dias (1 dia a 15 dias). Não houve efeitos adversos graves; em nenhum caso houve piora clínica ou distúrbios neurológicos; hipocalemia ocorreu em 4 (44,5 por cento) casos. A comparação das variáveis pré- e pós-tratamento demonstrou queda da uréia (105 mg/dl + 74,8 mg/dl vs. 88 mg/dl + 79,4 mg/dl; p = 0,03) e aumento do volume urinário (1.183 ml/dia vs. 1.778 ml/dia; p = 0,03); houve tendência a redução da creatinina (2,0 mg/dl + 0,8 mg/dl vs. 1,7 mg/dl + 1,0 mg/dl; p = 0,08). Apesar da elevação do valor do sódio (131 mEq/l + 2,8 mEq/l vs. 134 mEq/l + 4,9 mEq/l) e da redução do peso (69,5 kg + 18,6 kg vs. 68,2 kg + 17,1 kg), não houve diferença estatisticamente significante. CONCLUSÃO: O uso de solução salina hipertônica em pacientes com insuficiência cardíaca descompensada pode ser método terapêutico seguro e potencialmente relacionado a melhora...
BACKGROUND: Hyponatremia and congestive phenomena indicate a bad prognosis in decompensated heart failure. The occurrence of renal failure is associated to an increased death risk. OBJECTIVE: To evaluate the safety and efficacy of the hypertonic saline solution in patients with decompensated heart failure for renal failure prevention. METHODS: Patients with decompensated heart failure, congestion and hyponatremia participated in the study. In addition to the standard treatment, the patients received hypertonic saline solution and were submitted to clinical as well as laboratory assessment. RESULTS: Nine patients were enrolled in the study. Mean age was 55 + 14.2 years, being 5 male (55.5 percent) and 4 (44.5 percent) female patients. All of them presented functional class III-IV of the New York Heart Association (NYHA), and 5 (55.5 percent) received dobutamine. All of them presented initial creatinine > 1.4 mg/dl. The mean tonicity of the solution was 4.39 percent + 0.018 percent (2.5 percent to 7.5 percent) and the duration of treatment was 4.9 days + 4.1 days (1-15 days). There were no severe adverse effects; none of the patients presented clinical worsening or neurologic disorders; hypokalemia occurred in 4 cases (44.5 percent). The comparison of the variables before and after treatment showed a decrease in urea (105 mg/dl + 74.8 mg/dl vs. 88 mg/dl + 79.4 mg/dl; p = 0.03) and increase in the urinary volume (1,183 ml/day vs. 1,778 ml/day; p = 0.03); there was no tendency to creatinine decrease (2.0 mg/dl + 0.8 mg/dl vs. 1.7 mg/dl + 1.0 mg/dl; p = 0.08). Despite the elevation in sodium levels (131 mEq/l + 2.8 mEq/l vs. 134 mEq/l + 4.9 mEq/l) and weight decrease (69.5 kg + 18.6 kg vs. 68.2 kg + 17.1 kg), there was no statistically significant difference. CONCLUSION: The use of hypertonic saline solution in patients with decompensated heart failure can be a safe therapeutic method and potentially related to clinical improvement and renal...
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Cardíaca/tratamento farmacológico , Hiponatremia/tratamento farmacológico , Insuficiência Renal , Solução Salina Hipertônica/uso terapêutico , Biomarcadores/sangue , Cardiotônicos/uso terapêutico , Creatinina/sangue , Diuréticos/uso terapêutico , Dobutamina/uso terapêutico , Furosemida/uso terapêutico , Insuficiência Cardíaca/sangue , Hipopotassemia/etiologia , Hiponatremia/sangue , Potássio/sangue , Índice de Gravidade de Doença , Solução Salina Hipertônica/efeitos adversos , Sódio/sangue , Fatores de Tempo , Resultado do Tratamento , Ureia/sangueRESUMO
A endomiocardiofibrose é uma doença comum em países tropicais, particularmente Uganda e Nigéria, e pode acometer tanto o ventrículo esquerdo como direito, gerando uma insuficiência cardíaca restritiva que, além dos sintomas clássicos, manifesta-se por ascite desproporcional ao edema periférico. Apresentamos o caso de uma portadora de endomiocardiofibrose refratária ao tratamento clínico, submetida ao tratamento cirúrgico com melhora clínica por curto período, voltando a apresentar sintomas incapacitantes três meses após a cirurgia de ressecção de fibrose endomiocárdica e plastia tricúspide. A paciente foi então submetida a transplante cardíaco ortotópico bicaval, com boa evolução clínica. É o primeiro caso de transplante cardíaco nesta doença, mostrando-se uma alternativa de tratamento promissora.
Assuntos
Feminino , Humanos , Pessoa de Meia-Idade , Fibrose Endomiocárdica/cirurgia , Transplante de Coração , Resultado do TratamentoRESUMO
To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Cooperação do Paciente , Doenças Cardiovasculares/tratamento farmacológico , Idoso de 80 Anos ou mais , Brasil , Modelos Lineares , Seguimentos , Ambulatório Hospitalar , Análise Multivariada , Distribuição de Qui-Quadrado , Fatores SocioeconômicosRESUMO
Objetivo - Comparar pacientes atendidos em centro de referência em cardiologia com pacientes atendidos em centro de saúde comunitário. Casuística e Métodos - 564 (5,3%) de 10667 pacientes atendidos no Instituto do Coraçäo (InCor) e 105 (58,6%) de 169 atendidos no Centro de Saúde do Bairro de Santo Amaro (CSSA, Säo Paulo, no período de abril a julho de 1989. Resultados - A idade foi inferior a 40 anos em 212 (35,8%) casos InCor) e em 27 (25,5%) casos (CSSA). Predominaram pacientes do sexo feminino: 316 (56%) - InCor e 70 (66,7%) - CSSA. No InCor, 317 (56,2%) residiam em Säo Paulo e no CSSA todos no mesmo bairro. Procuraram o InCor por iniciativa própria 43% dos pacientes. No InCor, foi feito o diagnóstico de cardiopatia em 81% dos casos e no CSSA em 92,5%. Exames adicionais ao eletrocardiograma e a radiografia de tórax foram considerados necessários em 35% dos casos no InCor. Os diagnósticos prováveis foram: a) insuficiência coronariana em 92 (20,1%) casos (InCor) e em 8 (8,2%) casos (CSSA); b) valvopatias em 46 (10,1%) casos (InCor) e em 9 (9,2%) casos (CSSA); c) prolapso da valva mitral em 31 (6,8%) casos (InCor) e em 7 (7,1%) casos (CSSA); d) cardiopatia congênita em 10 (2,2%) casos (InCor) e em 1 (1%) casos (CSSA); e hipertensäo arterial sistêmica em 161 (35,2%) casos (InCor) e em 55 (56,1%) casos (CSSA); f) infecçäo ou doença de Chagas em 44 (9,6%) casos (InCor) e em 8 (8,2%) casos (CSSA); g) disritmia cardíaca em 38 (8,3%) casos (InCor) e em 8 (8,2%) casos (CSSA);...
Purpose Comparison between patients from a cardiology referral center and thosefrom community health facility. Patients and Methods 564 (5.3%) of 10667 patients from the referral center Instituto do Coração (InCor) and 105 (58.6%) of 169 from community health facility Centro de de Santo Amaro (CSSA), São Paulo. Results 217 (35.8% ) patients in InCor and 27 (25.5%) in CSSA were younger than 40 years of age. Female patients were more frequent: 316 (56%) in InCor and 70 (66.7%) in CSSA. In InCor,317 (56.2%) patients lived in São Paulo City and in CSSA all the patients live in the surroundings. Forty-three percent of the patients sought for medical attention in InCor by themselves, without medical referral. The diagnosis of heart disease was established in 81% of the patients in InCor and in 92.5% of the patients in CSSA. Other tests (besides electrocardiogram and chest roentgenogram) were considered to be indicated in 35% of the patientsfrom InCor. The diagnoses were: a) coronary heart disease in 92 (20.1%) cases (InCor) and in 8 (8.2%) cases (CSSA); b) valvular heart diseas in 46 (10.1%) cases (InCor) and in 9 (9.2%) cases (CSSA); c) mitral valve prolapse in 31 (6.8%) cases (InCor) and in 7 (7.1%) cases (CSSA); d) congenital heart disease in 10 (2.2%) cases (InCor) and in 1 (1%) case (CSSA); e) systemic arterial hypertension in 161 (35.2%) cases (InCor) and in 55 (56.1%) cases (CSSA); f) Chagas'infection or Chagas'heart disease in 44 (9.6%) cases (InCor) and in 8 (8.2%) cases (CSSA); g) cardiac rhythm disorders in 38 (8.3% ) cases (InCor) and in 8 (8.2%) cases (CSSA); h) other diseases in 33 (7.2%) cases (InCor) and in 1 (1%) (CSSA); i) diseases of the aorta in 2 (0.4%) cases (InCor) and in 1 (1%) (CSSA). Medical treatment was recommended to 71.5% of the patients from the InCor and to 92.5% of the patients from CSSA...