Síndrome cardiorrenal: diagnóstico y tratamiento / Cardiorenal syndrome: diagnosis and treatment

Introducción: Las enfermedades cardíacas y renales coexisten con frecuencia. El síndrome cardiorrenal es una entidad compleja; en ella, la disfunción primaria cardíaca produce daño renal (tipos 1 y 2) y viceversa (tipos 3 y 4) o efecto de una enfermedad sistémica que afecta a ambos órganos (tipo 5). Objetivo: Actualizar el diagnóstico y tratamiento de los pacientes con síndrome cardiorrenal. Métodos: Se utilizan métodos teóricos y empíricos para realizar análisis del conocimiento actualizado sobre el tema. Se ha definido la existencia de un síndrome cardiorrenal que compromete a ambos órganos, con interacción bidireccional. En su detección, el diagnóstico clínico es insuficiente y requiere marcadores bioquímicos; estas herramientas, junto con la medición del sodio urinario, permite vigilar la efectividad terapéutica. Otro recurso es la ultrafiltración, según complicaciones. Conclusiones: Se debe indicar tratamiento con base en la evidencia para mejorar la calidad de vida, reducir la mortalidad y retrasar el deterioro de la función renal y cardíaca a largo plazo; el trasplante renal se debe considerar en pacientes en diálisis con disfunción ventricular severa. Idealmente, deberían recibir un trasplante combinado: cardíaco y renal, lo cual es difícil; algunos pacientes sometidos exclusivamente a trasplante renal presentan una mejoría notable en su fracción de eyección y en la sobrevida.

Introduction: heart and kidney diseases frequently coexist. Cardiorenal syndrome is a complex entity in which primary cardiac dysfunction causes a kidney damage (types 1 and 2) and vice versa (types 3 and 4) or an effect of a systemic disease that affects both organs (type 5). Objective: to update the diagnosis and treatment of patients with cardiorenal syndrome. Methods: theoretical and empirical methods are used to carry out the analysis of updated knowledge on the subject. The existence of a cardiorenal syndrome that compromises both organs has been defined with bidirectional interaction. In its detection, clinical diagnosis is insufficient and requires biochemical markers; these tools, together with the measurement of urinary sodium, allow us to monitor therapeutic effectiveness. Another resource is ultrafiltration, according to complications. Conclusions: evidence-based treatment should be indicated to improve quality of life, reduce mortality, and delay the deterioration of renal and cardiac function in the long term; kidney transplantation should be considered in dialysis patients with severe ventricular dysfunction. Ideally, they should receive a combined transplant: heart and kidney, which is difficult; some patients undergoing exclusively a renal transplantation show a notable improvement in their ejection fraction and survival.

Uso de carboximaltose férrica no tratamento de deficiência de ferro em pacientes com insuficiência cardíaca na perspectiva da saúde suplementar: análise de custo-efetividade e impacto orçamentário / Ferric carboxymaltose for treatment of iron deficiency in heart failure patients from the supplementary health care system perspective: cost-effectiveness and budgetary impact analysis

Objetivo: Avaliar a relação de custo-efetividade e impacto orçamentário (AIO) do tratamento de deficiência de ferro (DF), com ou sem anemia, em pacientes com insuficiência cardíaca (IC) com fração de ejeção reduzida NYHA II e III, com uso de carboximaltose férrica (CMF), comparada ao placebo (não intervenção), sob a perspectiva pagadora da saúde suplementar (SS). Métodos: No modelo econômico, foi utilizada a árvore de decisão, no horizonte temporal de 52 semanas, na perspectiva da SS, sendo mensurados os benefícios clínicos e os custos associados à intervenção. Também foram executadas análises de sensibilidade determinística e probabilística para avaliar possíveis incertezas futuras. A elaboração da AIO foi realizada considerando o horizonte temporal de cinco anos, a população a ser tratada, os diferentes cenários de market share e os custos diretos envolvidos no tratamento atual e no tratamento proposto. Resultados: A razão de custo-efetividade incremental (RCEI) foi de -R$ 20.517,07 para um ano de vida ajustado pela qualidade (QALYs). O impacto da incorporação da CMF na SS gerou uma economia em cinco anos de -R$ 43.945.225. Conclusões: A análise apresentada mostrou que o tratamento com CMF reduziu o custo de hospitalização, o número de consultas ambulatoriais e o custo de outros medicamentos relacionados à IC e proporcionou uma economia anual. Considerando um horizonte de tempo de 52 semanas, a terapia intravenosa com CMF resultou em uma estratégia de redução de custos, quando comparada ao tratamento proposto para a DF em pacientes com IC.

Objective: This study aims to evaluate the cost-effectiveness and budget impact (AIO) of iron carboxymaltose (CMF) for treatment of iron deficiency (ID), with or without anemia, in patients with heart failure (HF) and reduced ejection fraction NYHA II and III compared to placebo (non-intervention), from the perspective of paying supplementary health (SS). Methods: In the economic model, the decision tree was used, with a time horizon of 52 weeks, from the SS perspective, measuring the clinical benefits and costs associated with the intervention. Deterministic and probabilistic sensitivity analyzes were also performed to assess possible future uncertainties. The elaboration of the AIO was carried out considering a time horizon of five years, population to be treated, different market share scenarios and direct costs involved in the current treatment and in the proposed treatment. Results: The incremental cost effectiveness ratio (ICER) was -R$ 20,517.07 for 1 quality-adjusted life year (QALY). The budget impact of incorporation of the CMF in SSprovided savings in five years of -R$ 43,945,225. Conclusions: The presented analysis showed that treatment with CMF reduced the cost of hospitalization, the number of outpatient visits and the cost of other HF-related medications and provided annual savings. Considering a time horizon of 52 weeks, intravenous therapy with CMF resulted in a cost-saving strategy when compared to the proposed treatment for DF in patients with HF.

La cardio-oncología como una visión multidisciplinaria en el enfoque y tratamiento de la patología oncológica contemporánea / Cardio-oncology as a multidisciplinary vision in approaching and treating contemporary oncological pathology

Introducción: Las enfermedades cardiovasculares son la principal causa de muerte en el mundo, y las enfermedades oncológicas están aumentando en prevalencia. Los medicamentos oncológicos pueden tener efectos secundarios cardiovasculares, y la cardiooncología es una subespecialidad de la cardiología que se ocupa de la prevención y el tratamiento de las complicaciones cardiovasculares relacionadas con el cáncer. Puntos importantes del editorial: Las antraciclinas son un grupo de medicamentos oncológicos que pueden causar cardiotoxicidad, lo que puede causar una variedad de síntomas, incluyendo fatiga, disnea, edema y dolor en torácico. En casos graves, la cardiotoxicidad puede provocar insuficiencia cardíaca. Otros medicamentos oncológicos que pueden causar cardiotoxicidad incluyen los anticuerpos anti-HER2, el fluorouracilo y la gemcitabina. Los inhibidores de la tirosinkinasa y los inhibidores del factor de crecimiento derivado del endotelio también pueden causar problemas cardiovasculares, como hipertensión, formación de coágulos sanguíneos y arritmia. Los pacientes con cáncer también tienen un mayor riesgo de desarrollar complicaciones tromboembólicas venosas en miembros inferiores. Conclusión: El diagnóstico temprano y el tratamiento de las complicaciones cardiovasculares relacionadas con el cáncer son esenciales para mejorar la supervivencia de los pacientes con cáncer. La cardiooncología es una especialidad emergente y multidisciplinaria que requiere la participación de oncólogos, hematólogos, radiooncólogos y cardiólogos. El equipo de cardiooncología trabaja en conjunto para evaluar el riesgo cardiovascular de los pacientes con cáncer, prevenir las complicaciones cardiovasculares y tratar las complicaciones cardiovasculares que ocurren.

Introduction: Cardiovascular diseases are the main cause of death in the world, and oncological diseases are increasing in prevalence. Cancer drugs can have cardiovascular side effects, and cardio-oncology is a subspecialty of cardiology concerned with preventing and treating cardiovascular complications related to cancer. Important points from the editorial: Anthracyclines are a group of cancer drugs that can cause cardiotoxicity, which can cause various symptoms, including fatigue, dyspnea, edema, and chest pain. In severe cases, cardiotoxicity can lead to heart failure. Other cancer drugs that can cause cardiotoxicity include anti-HER2 antibodies, fluorouracil, and gemcitabine. Tyrosine kinase and endothelium-derived growth factor inhibitors can also cause cardiovascular problems, such as high blood pressure, blood clot formation, and arrhythmia. Cancer patients are also at increased risk of developing lower limb venous thromboembolic complications. Conclusion: Early diagnosis and treatment of cancer-related cardiovascular complications are essential to improve the survival of cancer patients. Cardio-oncology is an emerging, multidisciplinary specialty that requires the participation of oncologists, hematologists, radiation oncologists, and cardiologists. The cardio-oncology team works together to assess cardiovascular risk in cancer patients, prevent cardiovascular complications, and treat cardiovascular complications that do occur.

La Insuficiencia Cardíaca Aguda como Manifestación de la Tirotoxicosis. A Propósito de un Caso / Acute heart failure as a manifestation of thyrotoxicosis. A case report

Introducción: La tirotoxicosis se considera una emergencia endocrinológica. Suele ser la complicación más grave y menos frecuente de una patología relativamente frecuente como es el hipertiroidismo. Tiene afectación a nivel sistémico, con especial hincapié en el sistema cardiovascular, por lo que una de las manifestaciones prevalentes y a considerar en este trabajo, es la insuficiencia cardiaca aguda. Caso clínico: Paciente femenina de 40 años con antecedente de tabaquismo e hipertiroidismo, con abandono de medicación (Metimazol) y de controles en contexto de pandemia. Consultó en reiteradas ocasiones por evento sincopal asociado a palpitaciones, agregando en esta consulta episodio tos con expectoración hemoptoica y náuseas. Laboratorio con TSH<0.01mU/L y T4 7.77pmol/L. Troponinas 19.3ng/L. Evolucionó con hipotensión sin respuesta a cristaloides y mayor disnea. Se decidió intubación orotraqueal. Se realizó ecocardiograma que informaba función sistólica con deterioro severo. Realizó tratamiento con Metimazol y solución de Lugol con mejoría de los parámetros de laboratorio. A los diez días evolucionó con abdomen agudo perforado con posterior shock séptico refractario y falleció. Discusión y conclusiones: Luego de examinar la bibliografía disponible, y contrastarla de forma retrospectiva con la evolución de la paciente, se puede observar la relación entre el hipertiroidismo y los cambios hemodinámicos. En el caso presentado, la paciente tuvo como antecedente el diagnóstico de hipertiroidismo y se consideró que el factor desencadenante fue la suspensión del metimazol; a su vez, la insuficiencia cardíaca aguda que presentó durante los primeros días de internación fue consecuencia del efecto cardiovascular directo de las hormonas tiroideas.

Introduction: Thyrotoxicosis is considered an endocrinological emergency; It is usually the most serious and least frequent complication of a relatively frequent pathology such as hyperthyroidism. It has systemic involvement, with special emphasis on the cardiovascular system, which is why one of the most prevalent manifestations to be considered in this work is acute heart failure. Clinical case: A 40-year-old female patient with a history of smoking and hyperthyroidism, with abandonment of medication (Methimazole) and controls in the context of a pandemic. She consulted repeatedly due to a syncopal event associated with palpitations, adding to this consultation an episode of coughing with bloody sputum and nausea. Laboratory with TSH <0.01mU/L and T4 7.77pmol/L. Troponins 19.3ng/L. He evolved with hypotension without response to crystalloids and increased dyspnea. Orotracheal intubation was decided. An echocardiogram was performed, which reported severely impaired systolic function. She underwent treatment with Methimazole and Lugol's solution with improvement in laboratory parameters. Ten days later, he developed an acute perforated abdomen with subsequent refractory septic shock and died. Discusion. Conclusion: After examining the available bibliography, and contrasting it retrospectively with the evolution of the patient, the relationship between hyperthyroidism and hemodynamic changes can be observed. In the case presented, the patient had a history of a diagnosis of hyperthyroidism, and it was considered that the triggering factor was the suspension of methimazole; In turn, the acute heart failure that she presented during the first days of hospitalization was a consequence of the direct cardiovascular effect of thyroid hormones.

Intervención de la telemedicina en pacientes peruanos con insuficiencia cardíaca en tiempos de COVID-19 / Telemedicine Intervention in Peruvian Patients with Heart Failure in Times of COVID-19

Introducción: La insuficiencia cardíaca tiene un gran impacto epidemiológico, no solo por su alta morbilidad y mortalidad, sino también por el alto costo en servicios hospitalarios. Las tasas de hospitalización por reagudizaciones y readmisiones luego del alta se han incrementado los últimos años, lo que constituye en la actualidad un problema de salud pública. Objetivo: Evaluar el efecto de la intervención de la telemedicina en pacientes peruanos con insuficiencia cardíaca en tiempos de COVID-19. Métodos: Se utilizó un diseño cuasi experimental con evaluación antes y después de la intervención en 32 pacientes provenientes de Chimbote (Perú), entre los meses de enero a junio del 2021, que aceptaron participar en el estudio y cumplieron con los criterios de inclusión y exclusión. Se utilizó una ficha de recolección de datos que registró las características clínicas de los pacientes, frecuencia de hospitalización y clase funcional, así como el cuestionario de Kansas City que midió la calidad de vida relacionada a salud. En la intervención, se implementaron actividades de telemedicina que comprendió teleconsulta médica de cardiología, telemonitoreo y teleorientación de enfermería, y teleorientación de nutrición. Resultados: Se redujo la frecuencia de hospitalización de 9,4 por ciento a 0 por ciento en los pacientes categorizados en clase funcional III disminuyó de 28,1 por ciento a 15,6 por ciento, y el score general se mejoró de 65,8 a 69,6 puntos. Conclusiones: La intervención de la telemedicina mejoró los resultados sanitarios de los pacientes peruanos con insuficiencia cardíaca(AU)

Introduction: Heart failure has a great epidemiological impact, not only because of its high morbidity and mortality, but also because of the high cost in hospital services. Hospitalization rates for exacerbations and readmissions after discharge have increased in recent years, which is currently a public health problem. Objective: To evaluate the effect of telemedicine intervention in Peruvian patients with heart failure in COVID-19 times. Methods: A quasi-experimental design was used with evaluation before and after the intervention in 32 patients from Chimbote (Peru), between January and June 2021, who agreed to participate in the study and met the inclusion and exclusion criteria. A data collection form was used to record the clinical characteristics of the patients, frequency of hospitalization and functional class, as well as the Kansas City questionnaire that measured health-related quality of life. Telemedicine activities were implemented in the intervention, including cardiology medical teleconsultation, telemonitoring and nursing tele-guidance, and nutrition tele-guidance. Results: The frequency of hospitalization was reduced from 9.4 to 0 percent, while in patients categorized in functional class III it decreased from 28.1 to 15.6 percent. The overall score was improved from 65.8 to 69.6 points. Conclusions: The telemedicine intervention improved health outcomes in Peruvian patients with heart failure(AU)

Sarcopenia em pacientes de 40 a 64 anos hospitalizados por insuficiência cardíaca / Sarcopenia in patients aged 40­64 years hospitalized for heart failure

Introdução: a insuficiência cardíaca (IC) e a sarcopenia são condições prevalentes e inter-relacionadas, figurando como importantes causas de limitações funcionais. Objetivo: avaliar critérios de sarcopenia, e suas relações com parâmetros cardiometabólicos, em pacientes de 40 a 64 anos hospitalizados por IC. Metodologia: estudo de corte transversal com caráter analítico envolvendo indivíduos com IC confirmada. A massa muscular apendicular (MMA) foi avaliada através da absorciometria por raios-X de dupla energia (DXA), considerando-se baixa MMA mulheres com MMA/altura² <5,5 kg/m² ou MMA/índice de massa corporal (IMC) <0,512 e homens com MMA/altura² <7,0 kg/m² ou MMA/IMC <0,789. Baixa força de preensão manual (FPM) foi considerada quando <16 kg em mulheres e <27 kg em homens. Resultados: avaliou-se 109 pacientes (50,5% mulheres), com mediana de idade de 58 anos. Constatou-se baixa MMA em 41,3% e baixa FPM em 64,2%, não havendo correlação significativa entre FPM e MMA em nenhum dos gêneros. Baixa MMA se associou ao gênero masculino (68,9% versus 35,9%; p=0,001), a maiores idades (60,0 [53,0-63,0] versus 57,0 [51,3-60,0] anos; p=0,039) e maiores níveis séricos de paratormônio (48,0 [30,5-94,4] versus 29,9 [23,0-54,1] pg/mL; p=0,009). Baixa FPM se associou a maior sintomatologia cardíaca (75,7% com baixa FPM tinham classificação funcional da New York Heart Association III-IV, versus 51,3% daqueles com FPM normal; p=0,009). Conclusões: há uma relevante prevalência de sarcopenia em pacientes de 40 a 64 anos hospitalizados por IC, observando-se maior frequência de baixa MMA nos homens, associação entre baixa FPM e sintomatologia cardíaca, e maiores níveis de paratormônio naqueles com perda muscular.

Introduction: heart failure (HF) and sarcopenia are prevalent and interrelated conditions, being important causes of functional limitations. Objective: to evaluate sarcopenia criteria, and their relationship with cardiometabolic parameters, in patients aged 40­64 years hospitalized for HF. Methodology: Cross-sectional study including patients with established HF. Appendicular skeletal muscle mass (ASMM) was assessed using dual-energy X-ray absorptiometry (DXA), considering low ASMM women with ASMM/height² <5.5 kg/m² or ASMM/body mass index (BMI) <0.512 and men with ASMM/height² <7.0 kg/m² or ASMM/BMI <0.789. Low handgrip strength (HGS) was considered when <16 kg in women and <27 kg in men. Results: we evaluated 109 patients (50.5% women), with a median age of 58 years. Low ASMM was found in 41.3% and low HGS in 64.2%, with no significant correlation between HGS and ASMM in either gender. Low ASMM was associated with male gender (68.9% versus 35.9%; p=0.001), older age (60.0 [53.0-63.0] versus 57.0 [51.3-60, 0] years; p=0.039) and higher serum parathyroid hormone (48.0 [30.5-94.4] versus 29.9 [23.0-54.1] pg/mL; p=0.009). Low HGS was associated with greater cardiac symptoms (75.7% with low HGS had a New York Heart Association III-IV functional classification, versus 51.3% of those with normal HGS; p=0.009). Conclusions: there is a relevant prevalence of sarcopenia in patients aged 40­64 years hospitalized for HF, observing a higher frequency of low ASMM in men, an association between low HGS and cardiac symptoms, and higher levels of parathyroid hormone in those with muscle wasting.

Laboratorio de Insuficiencia Cardíaca: experiencia en un hospital universitario / Heart failure laboratory: experience in an university hospital

Introducción: La mayor parte del manejo del paciente con insuficiencia cardíaca (IC) se logra de manera ambulatoria. La adhesión a los estándares de tratamiento recomendados y el acceso al sistema de salud determinan su evolución. Se describe nuestra experiencia en pacientes con IC ambulatoria en un Hospital Universitario. Material y métodos: Se incluyeron pacientes derivados para interconsulta al Laboratorio de IC entre los meses de enero de 2021 y octubre de 2022. Se realizó una intervención estructurada, que incluyó visitas presenciales y seguimiento por email y/o telefónico y asesoramiento nutricional. Resultados: Se incluyeron 98 pacientes. La media de edad fue 64,05 años. El promedio total de FEVI fue 36,26%. Se observó asociación significativa entre los mayores de 60 años (n=65; 66,33%) y dislipemia, hipertensión arterial, enfermedad oncológica y enfermedad coronaria, en comparación con los individuos más jóvenes. La FEVI baja se correlacionó con los portadores de enfermedad coronaria y oncológica. En ellos se observó mayor utilización de betabloqueantes, ARNI, iSGLT2 y ácido acetil salicílico. El sexo masculino, la FEVI disminuida y la edad, fueron predictores de peor pronóstico. Conclusión: La utilización del tratamiento farmacológico en la IC depende de múltiples factores. A pesar de ello, se observó una distribución de la terapéutica instaurada acorde a la recomendación de guía y registros nacionales e internaciones de pacientes con IC

Introduction: Most of the management of the patient with heart failure (HF) is accomplished on an outpatient basis. Adherence to the recommended treatment standards and access to the health system determine their evolution. We describe our experience in patients with ambulatory HF in a University Hospital. Material and methods: Patients referred for interconsultation to the HF Laboratory between the months of January 2021 and October 2022 were included. A structured intervention was carried out, which included face-to-face visits and follow-up by email and/or telephone and nutritional advice. Results: 98 patients were included. Mean age was 64.05 years. Total mean LVEF was 36.26%. A significant association was observed between those over 60 years of age (n=65; 66.33%) and dyslipidemia, arterial hypertension, oncological disease, and coronary disease, compared to younger individuals. The low LVEF was correlated with coronary and oncological disease. In them was observed greater use of beta-blockers, ARNI, iSGLT2 and acetylsalicylic acid. Male sex, decreased LVEF and age were predictors of worse prognosis. Conclusion: The use of pharmacological treatment in HF depends on multiple factors. Despite this, a distribution of the established therapy according to the guideline recommendation and national registries and hospitalizations of patients with HF was observed.

Como eu faço avaliação ecocardiográfica de pericardite constritiva / My approach to echocardiographic assessment for constrictive pericarditis

A pericardite constritiva (PC) é uma condição na qual a cicatrização e perda de elasticidade do pericárdio resultam em enchimento ventricular prejudicado, disfunção diastólica e insuficiência cardíaca direita. O diagnóstico dessa patologia é desafiador, sendo frequente a necessidade de técnicas de imagem multimodal, dentre as quais a ecocardiografia representa a modalidade de imagem inicial para a avaliação diagnóstica, além de permitir a diferenciação da PC da cardiomiopatia restritiva (CMR) e outras condições que mimetizam constrição. (AU)

Constrictive pericarditis (CP) is a condition in which scarring and loss of elasticity of the pericardium result in impaired ventricular filling, diastolic dysfunction, and right heart failure. The diagnosis of this pathology is challenging, with frequent need for multimodal imaging techniques, among which echocardiography represents the initial imaging modality for the diagnostic evaluation, in addition to allowing the differentiation of CP from restrictive cardiomyopathy (RCM) and other conditions that mimic constriction. (AU)

Como eu faço o strain longitudinal do ventrículo direito com softwares automatizados 2D e 3D / My approach to right ventricular longitudinal strain with automated 2D and 3D software

A análise da deformação miocárdica ventricular direita tem surgido como uma ferramenta diagnóstica importante na detecção de disfunção sistólica ventricular direita inicial não detectada pelas técnicas ecocardiográficas convencionais. Além disso, é capaz de trazer informações diagnósticas e prognósticas adicionais aos parâmetros tradicionais de avaliação da função sistólica ventricular direita em diversas patologias. O método ecocardiográfico de escolha para sua avaliação é o strain longitudinal derivado do speckletracking. Ele tem se mostrado mais sensível para pequenas mudanças na função sistólica quando comparado à excursão sistólica do plano do anel tricúspide, estudo da onda s´ ao Doppler tecidual do anel tricúspide e variação da área fracional do ventrículo direito. O avanço da inteligência artificial e a presença de softwares com análise automatizada entram neste cenário visando tornar a aplicabilidade do método mais simples, rápida e com menor variabilidade inter e intraobservador. O objetivo deste artigo de revisão é demonstrar o passo a passo da técnica, desde a otimização e aquisição de imagens até a interpretação dos resultados, com figuras ilustrativas de casos selecionados.(AU)

Right ventricular strain analysis has emerged as an important diagnostic tool in the detection of early right ventricular systolic dysfunction not detected by conventional echocardiography techniques. Furthermore, it is capable of providing additional diagnostic and prognostic information to the traditional parameters for evaluating right ventricular systolic function in various pathologies. The echocardiography method of choice for its assessment is longitudinal strain derived from speckletracking. This method has been shown to be more sensitive for small changes in systolic function when compared to tricuspid annular plane systolic excursion, tissue Doppler imaging of the tricuspid annular s' wave, and right ventricular fractional area change. Advances in artificial intelligence and software with automated analysis have been introduced to this scenario with the aim of making the method simpler and quicker to apply, with lower inter- and intra-observer variability. The objective of this review article is to demonstrate the technique step by step, from image optimization and acquisition to interpretation of results, with illustrative figures of selected cases.(AU)

Desenvolvimento e validação de material educacional para pacientes com insuficiência cardíaca / Development and validation of educational material for patients with heart failure / Desarrollo y validación de material educativo para pacientes con insuficiencia cardíaca

Objetivo: Desenvolver e validar um folder educativo para uso em pessoas com Insuficiência Cardíaca. Métodos: Estudo metodológico para elaboração de folder educativo e validação por especialistas. Os juízes técnicos foram enfermeiros especialistas em cardiologia, que validaram conteúdo e aparência, e designers gráfico validaram a aparência, estética e a comunicação visual. O Índice de Validade de Conteúdo (IVC) foi calculado, as respostas foram consistentes quando Alfa de Cronbach> 0,60 e o índice de concordância entre avaliadores (IRA) foi calculado. Resultados: Alta concordância entre enfermeiros (IRA = 1), consistência interna quase perfeita (Alfa de Cronbach = 0,84), IVC total e isolado acima de 0,8. A cartilha foi considerada válida. Para os designers gráficos, o IVC geral obteve um valor que garantiu a validade de aparência. Conclusão: A cartilha educativa foi validada pelos juízes e apresenta-se como instrumento para auxiliar no preparo para alta e acompanhamento em longo prazo de pacientes com IC. (AU)

Objective: To develop and validate an educational folder for use in people with Heart Failure. Methods: Study with a methodological approach for the elaboration of an educational folder and validation by experts. Technical specialists were nurses, cardiology specialists, who validated content and appearance; Specialist designers validated appearance, aesthetics and visual communication. The content validity index (IVC) was calculated; responses were consistent when Cronbach's alpha > 0.60 and the inter-rater agreement index (IRA) was calculated. Results: High agreement among nurses (ARI = 1), almost perfect internal consistency (Cronbach's alpha = 0.84), total and isolated CVI above 0.8. The booklet was considered valid. For graphic designers, the overall IVC achieved a value that guaranteed appearance validity. Conclusion: The educational booklet was validated by the judges and is presented as an instrument to assist in the preparation for discharge and long-term follow-up of patients with HF. (AU)

Objetivo: Desarrollar y validar una carpeta educativa para su uso en personas con Insuficiencia Cardíaca. Métodos: Estudio con enfoque metodológico para la elaboración de una carpeta educativa y validación por expertos. Los técnicos especialistas fueron enfermeros, especialistas en cardiología, quienes validaron el contenido y la apariencia; Diseñadores especializados validaron apariencia, estética y comunicación visual. Se calculó el índice de validez de contenido (IVC); las respuestas fueron consistentes cuando se calculó el alfa de Cronbach> 0,60 y el índice de acuerdo entre evaluadores. Resultados: Alto acuerdo entre enfermeras (ARI = 1), consistencia interna casi perfecta (alfa de Cronbach = 0,84), IVC total y aislado por encima de 0,8. El folleto se consideró válido. Para los diseñadores gráficos, el IVC general logró un valor que garantizaba la validez de la apariencia. Conclusion: El folleto educativo fue validado por los jueces y se presenta como un instrumento para ayudar en la preparación para el alta y el seguimiento a largo plazo de los pacientes con IC. (AU)

Effect of home-based cardiac rehabilitation for patients with heart failure: a systematic review and meta-analysis / Rehabilitación para pacientes con insuficiencia cardíaca: una revisión sistemática y metanálisis

SUMMARY: This study is to investigate the effect of home-based cardiac rehabilitation (HBCR) on quality of life, functional capacity, and readmission rates in patients with heart failure. Randomized controlled trials (RCTs) were screened from Cochrane Library, CINAHL, EMBASE, and MEDLINE. The intervention group received a standardized HBCR or a comprehensive rehabilitation strategy that included HBCR. The participants in the control group received CR at a medical center or usual care without CR intervention. The main outcome measurements included quality of life, exercise capacity, mortality and re-hospitalization. This meta-analysis included 20 RCTs, in which 16 studies compared HBCR with usual care, and 4 studies compared HBCR with center-based CR. In comparison with the usual care, HBCR improved the total quality of life score [MD=-5.85, 95 % CI (-9.76, - 1.94), P=0.003, I2=75 %]. Patients with HBCR and usual care were significantly different in VO2max [MD=1.05 mL/kg/min, 95 % CI (0.35, 1.75), P=0.003, I2=46 %]. However, VO2max of patients with HBCR was not significantly different from those with center-based CR [MD=0.08 mL/kg/min, 95 % CI (-1.29, 1.44), P=0.91, I2=0 %]. There was statistically significant difference in the 6-min Walk Distance between usual care and HBCR (for distance [MD=11.84, 95 % CI (7.41, 16.28), P<0.00001, I2=0 %]; and for feet [MD=98.93, 95 % CI (26.79, 171.08), P=0.007, I2=56 %]). However, there was no significant difference in 6-min Walk Distance between patients with HBCR and center-based CR [MD=12.45, 95 % CI (-9.81, 34.72), P=0.27, I2=0 %] , or in anxiety and depression between patients with usual care and HBCR (for anxiety, [MD=-0.25, 95 % CI (-0.56, 0.05), P=0.11, I2=0 %]; for depression, [MD=-0.18, 95 % CI (-0.51, 0.16), P=0.30, I2=0 %] . No significant difference was found in death number [RR=1.04, 95 % CI (0.55, 1.98), P=0.90, I2=0 %] or in the number of re-hospitalization [RR=0.88, 95 % CI (0.66, 1.18), P=0.40, I2=0 %] between usual care and HBCR. For patients with heart failure, compare with usual care and center-based CR, HBCR can improve the total quality of life. Compare with usual care, HBCR can improve VO2max and 6-min Walk Distance, but compare with center- based CR, there are no differences in mortality, re-hospitalization rate or incidence of anxiety and depression. Additionally, center- based CR and HBCR showed similar outcomes and medical costs.

El objetivo de este estudio fue investigar el efecto de la rehabilitación cardíaca domiciliaria (HBCR) sobre la calidad de vida, la capacidad funcional y las tasas de reingreso en pacientes con insuficiencia cardíaca. Se seleccionaron ensayos controlados aleatorios (ECA) de la Biblioteca Cochrane, CINAHL, EMBASE y MEDLINE. El grupo de intervención recibió un HBCR estandarizado o una estrategia de rehabilitación integral que incluía HBCR. Los participantes del grupo de control recibieron RC en un centro médico o atención habitual sin intervención de RC. Las principales medidas de resultado incluyeron la calidad de vida, la capacidad de ejercicio, la mortalidad y la rehospitalización. Este metanálisis incluyó 20 ECA, en los que 16 estudios compararon HBCR con la atención habitual y 4 estudios compararon que mejoró la puntuación total de calidad de vida [DM=-5,85, IC del 95 % (-9,76, -1,94), P=0,003, I2=75 %]. Los pacientes con HBCR y atención habitual fueron significativamente diferentes en el VO2máx [DM = 1,05 ml/kg/ min, IC del 95 % (0,35, 1,75), P = 0,003, I2 = 46 %]. Sin embargo, el VO2max de los pacientes con HBCR no fue significativamente diferente de aquellos con CR basada en el centro [DM = 0,08 ml/kg/min, IC del 95 % (-1,29, 1,44), P = 0,91, I2 = 0 %]. Hubo una diferencia estadísticamente significativa en la distancia de caminata de 6 minutos entre la atención habitual y HBCR (para la distancia [DM=11,84, IC del 95 % (7,41, 16,28), P<0,00001, I2=0 %]; y para los pies [DM= 98,93, IC 95 % (26,79, 171,08), P=0,007, I2=56 %]). Sin embargo, no hubo una diferencia significativa en la distancia de caminata de 6 minutos entre los pacientes con HBCR y CR basada en el cen- tro [DM = 12,45, IC del 95 % (-9,81, 34,72), P = 0,27, I2 = 0 %], o en la ansiedad y depresión entre pacientes con atención habitual y HBCR (para ansiedad, [DM=-0,25, IC del 95 % (-0,56, 0,05), P=0,11, I2=0 %]; para depresión, [DM=-0,18, 95 % IC (- 0,51, 0,16), P=0,30, I2=0 %] No se encontraron diferencias significativas en el número de muertes [RR=1,04, IC del 95 % (0,55, 1,98), P=0,90, I2=0 %] o en el número de reingresos [RR=0,88, IC 95 % (0,66, 1,18), P=0,40, I2=0 %] entre atención habitual y HBCR. Para los pacientes con insuficiencia cardíaca, en comparación con la atención habitual y la CR en un centro, la HBCR puede mejorar la calidad de vida total. En comparación con la atención habitual, la HBCR puede mejorar el VO2máx y la distancia recorrida en 6 minutos, pero en comparación con la CR basada en un centro, no hay diferencias en la mortalidad, la tasa de rehospitalización o la incidencia de ansiedad y depresión. Además, CR y HBCR basados en el centro mostraron resultados y costos médicos similares.

Fibrilación auricular una arritmia y un sindrome / Atrial fibrillation, an arrhythmia and a syndrome

Atrial Fibrillation (AF) is the most common sustained arrhythmia and is highly prevalent in elderly patients. It confers a higher risk for ischemic stroke, heart failure and death. The diagnosis and treatment of AF has been extensively studied and remain under constant revision. This article reviews the recent European guidelines and the advances observed with the introduction of direct oral anticoagulants in the last ten years. This new family of drugs has clear benefits in terms of efficacy and safety compared with traditional vitamin K antagonists. Treatment of most common comorbidities in patients with AF such as advanced age, heart failure, diabetes, renal failure, and others are also analyzed. New therapies for AF will be shortly available.

Similarities and differences of myocardial metabolic characteristics between HFpEF and HFrEF mice based on LC-MS/MS metabolomics / 中华心血管病杂志

Objective: To reveal the similarities and differences in myocardial metabolic characteristics between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) mice using metabolomics. Methods: The experimental mice were divided into 4 groups, including control, HFpEF, sham and HFrEF groups (10 mice in each group). High fat diet and Nω-nitroarginine methyl ester hydrochloride (L-NAME) were applied to construct a"two-hit"HFpEF mouse model. Transverse aortic constriction (TAC) surgery was used to construct the HFrEF mouse model. The differential expression of metabolites in the myocardium of HFpEF and HFrEF mice was detected by untargeted metabolomics (UHPLC-QE-MS). Variable importance in projection>1 and P<0.05 were used as criteria to screen and classify the differentially expressed metabolites between the mice models. KEGG functional enrichment and pathway impact analysis demonstrated significantly altered metabolic pathways in both HFpEF and HFrEF mice. Results: One hundred and nine differentially expressed metabolites were detected in HFpEF mice, and 270 differentially expressed metabolites were detected in HFrEF mice. Compared with the control group, the most significantly changed metabolite in HFpEF mice was glycerophospholipids, while HFrEF mice presented with the largest proportion of carboxylic acids and their derivatives. KEGG enrichment and pathway impact analysis showed that the differentially expressed metabolites in HFpEF mice were mainly enriched in pathways such as biosynthesis of unsaturated fatty acids, ether lipid metabolism, amino sugar and nucleotide sugar metabolism, glycerophospholipid metabolism, arachidonic acid metabolism and arginine and proline metabolism. The differentially expressed metabolites in HFrEF mice were mainly enriched in arginine and proline metabolism, glycine, serine and threonine metabolism, pantothenate and CoA biosynthesis, glycerophospholipid metabolism, nicotinate and nicotinamide metabolism and arachidonic acid metabolism, etc. Conclusions: HFpEF mice have a significantly different myocardial metabolite expression profile compared with HFrEF mice. In addition, biosynthesis of unsaturated fatty acids, arachidonic acid metabolism, glycerophospholipid metabolism and arginine and proline metabolism are significantly altered in both HFpEF and HFrEF mice, suggesting that these metabolic pathways may play an important role in disease progression in both types of heart failure.

Long-term outcome of EVAHEART I implantable ventricular assist device for the treatment of end stage heart failure: clinical 3-year follow-up results of 15 cases / 中华心血管病杂志

Objective: To evaluate the long-term efficacy and safety of the implantable ventricular assist system EVAHEART I in clinical use. Methods: Fifteen consecutive patients with end-stage heart failure who received left ventricular assist device therapy in Fuwai Hospital from January 2018 to December 2021 were enrolled in this study, their clinical data were retrospectively analyzed. Cardiac function, liver and kidney function, New York Heart Association (NYHA) classification, 6-minute walk distance and quality of life were evaluated before implantation and at 1, 6, 12, 24 and 36 months after device implantation. Drive cable infection, hemolysis, cerebrovascular events, mechanical failure, abnormally high-power consumption and abnormal pump flow were recorded during follow up. Results: All 15 patients were male, mean average age was (43.0±7.5) years, including 11 cases of dilated cardiomyopathy, 2 cases of ischemic cardiomyopathy, and 2 cases of valvular heart disease. All patients were hemodynamically stable on more than one intravenous vasoactive drugs, and 3 patients were supported by preoperative intra aortic balloon pump (IABP). Compared with before device implantation, left ventricular end-diastolic dimension (LVEDD) was significantly decreased ((80.93±6.69) mm vs. (63.73±6.31) mm, P<0.05), brain natriuretic peptide (BNP), total bilirubin and creatinine were also significantly decreased ((3 544.85±1 723.77) ng/L vs. (770.80±406.39) ng/L; (21.28±10.51) μmol/L vs. (17.39±7.68) μmol/L; (95.82±34.88) μmol/L vs. (77.32±43.81) μmol/L; P<0.05) at 1 week after device implantation. All patients in this group were in NYHA class Ⅳ before implantation, and 9 patients could recover to NYHA class Ⅲ, 3 to class Ⅱ, and 3 to class Ⅰ at 1 month after operation. All patients recovered to class Ⅰ-Ⅱ at 6 months after operation. The 6-minute walk distance, total quality of life and visual analogue scale were significantly increased and improved at 1 month after implantation compared with those before operation (P<0.05). All patients were implanted with EVAHEART I at speeds between 1 700-1 950 rpm, flow rates between 3.2-4.5 L/min, power consumption of 3-9 W. The 1-year, 2-year, and 3-year survival rates were 100%, 87%, and 80%, respectively. Three patients died of multiple organ failure at 412, 610, and 872 d after surgery, respectively. During long-term device carrying, 3 patients developed drive cable infection on 170, 220, and 475 d after surgery, respectively, and were cured by dressing change. One patient underwent heart transplantation at 155 d after surgery due to bacteremia. Three patients developed transient ischemic attack and 1 patient developed hemorrhagic stroke events, all cured without sequelae. Conclusion: EVAHEART I implantable left heart assist system can effectively treat critically ill patients with end-stage heart failure, can be carried for long-term life and significantly improve the survival rate, with clear clinical efficacy.

Predictive value of the proportion of hibernating myocardium in total perfusion defect on reverse remodeling in patients with HFrEF underwent coronary artery bypass graft / 中华心血管病杂志

Objective: To evaluate the predictive value of the proportion of hibernating myocardium (HM) in total perfusion defect (TPD) on reverse left ventricle remodeling (RR) after coronary artery bypass graft (CABG) in patients with heart failure with reduced ejection fraction (HFrEF) by 99mTc-methoxyisobutylisonitrile (MIBI) single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) combined with 18F-flurodeoxyglucose (FDG) gated myocardial imaging positron emission computed tomography (PET). Methods: Inpatients diagnosed with HFrEF at the Cardiac Surgery Center, Anzhen Hospital of Capital Medical University from January 2016 to January 2022 were prospectively recruited. MPI combined with 18F-FDG gated PET was performed before surgery for viability assessment and the patients received follow-up MPI and 18F-FDG gated PET at different stages (3-12 months) after surgery. Δ indicated changes (post-pre). Left ventricular end-systolic volume (ESV) reduced at least 10% was defined as RR, patients were divided into reverse remodeling (RR+) group and the non-reverse group (RR-). Binary logistic regression analysis was used to identify predictors of RR. Receiver operating characteristic (ROC) curve analysis was performed and the area under the curve (AUC) was calculated to assess the cut-off value for predicting RR. Additionally, we retrospectively enrolled inpatients with HFrEF at the Cardiac Surgery Center, Anzhen Hospital of Capital Medical University from January 2021 to January 2022 as the validation group, who underwent MPI and 18F-FDG gated PET before surgery. Echocardiography was performed before CABG and after CABG (3-12 months). In the validation group, the reliability of obtaining the cut-off value for the ROC curve was verified. Results: A total of 28 patients with HFrEF (26 males; age (56.9±8.7) years) were included in the prospective cohort. HM/TPD was significantly higher in the RR+ group than in the RR- group ((51.8%±17.9%) vs. (35.7%±13.9%), P=0.016). Binary logistic regression analysis revealed that HM/TPD was an independent predictor of RR (Odds ratio=1.073, 95% Confidence interval: 1.005-1.145, P=0.035). ROC curve analysis revealed that HM/TPD=38.3% yielded the highest sensitivity, specificity, and accuracy (all 75%) for predicting RR and the AUC was 0.786 (P=0.011). Meanwhile, a total of 100 patients with HFrEF (90 males; age (59.7±9.6) years) were included in the validation group. In the validation group, HM/TPD=38.3% predicted RR in HFrEF patients after CABG with the highest sensitivity, specificity and accuracy (82%, 60% and 73% respectively). Compared with the HFrEF patients in the HM/TPD<38.3% group (n=36), RR and cardiac function improved more significantly in the HM/TPD≥38.3% group (n=64) (all P<0.05). Conclusions: Preoperative HM/TPD ratio is an independent factor for predicting RR in patients with HFrEF after CABG, and HM/TPD≥38.3% can accurately predict RR and the improvement of cardiac function after CABG.

Associations of all-cause mortality with admission blood pressure variability during multiple hospitalizations in acute decompensated heart failure / 中华心血管病杂志

Objective: To investigate whether admission blood pressure (BP) variability during multiple hospitalizations is associated with all-cause mortality independent of baseline BP in acute decompensated heart failure (ADHF). Methods: Patients with ADHF admitted to the Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University from September 2013 to December 2017 were retrospectively enrolled. The risk of all-cause mortality associated with indices of BP variability, including mean admission BPs, standard deviation of BP and coefficient of variation of BP during multiple hospitalizations was assessed, using Cox regression model. Results: A total of 1 006 ADHF patients (mean aged (69.3±13.5) years; 411 (40.8%) female; 670 (66.6%) with preserved ejection fraction) were enrolled. During a median follow-up of 1.54 years, 47.0% of patients died. In all ADHF patients, after adjusting for confounding factors, for every 1-standard deviation (SD) increase in SD and coefficient of variation (CV) of systolic BP, the risk of all-cause mortality increased by 10% and 11%, respectively (SD: HR, 1.10, 95%CI, 1.01-1.21, P=0.029, CV: HR, 1.11, 95%CI, 1.02-1.21, P=0.017); for every 1-SD increase in the mean of diastolic BP, the risk of all cause mortality decreased by 25% (HR, 0.75; 95%CI, 0.65-0.87; P<0.001). In ADHF patients with preserved ejection fraction, after accounted for potential confounders, higher SD and CV of admitted systolic and diastolic BP were significantly associated with higher risk of all-cause mortality, regardless of whether confounding factors were adjusted (P≤0.049); After adjusting for confounding factors, the risk of all-cause mortality increased by 18% and 19% for every 1-SD increase in SD and CV of systolic BP, while the risk of all-cause mortality increased by 11% and 15% for every 1-SD increase in SD and CV of diastolic BP. In ADHF patients with reduced ejection fraction, after adjusting for confounding factors, the higher the mean admission systolic BP during multiple hospitalizations, the lower the risk of total mortality (HR, 0.68; 95%CI, 0.47-1.00; P=0.049). Conclusions: In patients with ADHF, independent of baseline BP, BP variability during multiple hospitalizations was strong predictor of all-cause mortality.

Setting up a telenursing training program for heart failure self-care education

@#Given the complex nature of heart failure (HF), nurses in clinical practice and nurse educators should employ a methodical approach in providing effective health education to the patient and their families even remotely. However, the limited training programs available and unprecedented nature of COVID-19 has rendered nurses less prepared to deliver heart failure self-care education. The purpose of this article is to describe the development, implementation, and evaluation of a training program which aim to equip nurses with specific skills in delivering heart failure self-care education using information and communication technologies (telenursing) in the context of the physical restrictions brought by the COVID-19 pandemic. Four phases of program development and implementation were done: (1) Phase I: Planning Phase; (2) Phase II: Needs Assessment; (3) Phase III: Designing the Health Program; and (4) Phase IV- Implementation and Evaluation. Twenty-three nurses from a tertiary private hospital participated via video conferencing in the pilot implementation of the program led by doctorate students. Using Kaufman’s approach in qualitative evaluation, participants reported the training content, materials, and the method of delivery which were valuable, meaningful, and acceptable to them. They perceived the program further enhanced their competencies, and improved patient and organizational outcomes. Taking on a proactive role, nurses should explore measures of enhancing nurses’ knowledge and skills in self-care education through information and communication technologies (ICT). This training program based on participative planning and collaboration between academia and practice proves to be feasible and requires further empirical studies to test its effectiveness in real-word settings.

Correlation between serum cystatin C and lipid level in patients with chronic heart failure / 中南大学学报(医学版)

OBJECTIVES@#Serum cystatin C (Cys C) and blood lipid levels are related to the occurrence and development of chronic heart failure (CHF). However, there are few reports on the correlation between blood lipid level and serum Cys C level in patients with CHF. The aim of this study is to explore the correlation between serum Cys C level and blood lipid level in patients with CHF, and to provide valuable reference for clinical diagnosis and treatment of CHF.@*METHODS@#A total of 336 CHF patients who were hospitalized in the Department of Cardiovascular Medicine of Shaanxi Provincial People's Hospital from October 2017 to July 2018 were included and they were divided into a Cys C normal group (n=180) and a Cys C abnormal group (n=156) according to serum Cys C level of the patients. The general data, laboratory indicators, and cardiac ultrasound results were compared between the 2 groups. Pearson correlation analysis was used to detect the correlation between serum Cys C level and blood lipid level and other factors, and the data related to Cys C were further analyzed by multivariate logistic regression.@*RESULTS@#Compared with the Cys C normal group, patients in the Cys C abnormal group had lower left ventricular ejection fraction (LVEF) (P<0.001), older age (P=0.030), higher incidence rate of diabetes and smoking index (P=0.002 and P=0.003, respectively). The levels of serum creatinine (SCr), blood urea nitrogen (BUN), and total bilirubin (TBIL) were higher (all P<0.001), while the levels of high density lipoprotein (HDL), apolipoprotein (Apo) A, and albumin (ALB) were lower (P<0.001, P=0.001, and P=0.003, respectively) in the Cys C abnormal group. Pearson correlation analysis showed that serum Cys C level was negatively correlated with platelet count, HDL, Apo A, ALB, and LVEF. It was positively correlated with smoking index, mean platelet volume, neutrophil ratio, BUN, and TBIL (all P<0.05). The results of multivariate logistic regression analysis showed that the decreased HDL level was a risk factor for the abnormality of serum Cys C in patients with CHF (OR=0.119, P=0.003), while Apo A was not a risk factor for its abnormality (P=0.337).@*CONCLUSIONS@#HDL might be the only blood lipid index associated with abnormal serum Cys C in patients with CHF.