Effect of adding hydrochlorothiazide to usual treatment of patients with acute decompensated heart failure: a randomized clinical trial.

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in patients aged 65 years or older, and most of them present with congestion. The use of hydrochlorothiazide (HCTZ) may increase the response to loop diuretics. To evaluate the effect of adding HCTZ to furosemide on congestion and symptoms in patients with ADHF. This randomized clinical trial compared HCTZ 50 mg versus placebo for 3 days in patients with ADHF and signs of congestion. The primary outcome of the study was daily weight reduction. Secondary outcomes were change in creatinine, need for vasoactive drugs, change in natriuretic peptides, congestion score, dyspnea, thirst, and length of stay. Fifty-one patients were randomized-26 to the HCTZ group and 25 to the placebo group. There was an increment of 0.73 kg/day towards additional weight reduction in the HCTZ group (HCTZ: - 1.78 ± 1.08 kg/day vs placebo: - 1.05 ± 1.51 kg/day; p = 0.062). In post hoc analysis, the HCTZ group demonstrated significant weight reduction for every 40 mg of intravenous furosemide (HCTZ: - 0.74 ± 0.47 kg/40 mg vs placebo: - 0.33 ± 0.80 kg/40 mg; p = 0.032). There was a trend to increase in creatinine in the HCTZ group (HCTZ: 0.50 ± 0.37 vs placebo: 0.27 ± 0.40; p = 0.05) but no significant difference in onset of acute renal failure (HCTZ: 58% vs placebo: 41%; p = 0.38). No differences were found in the remaining outcomes. Adding hydrochlorothiazide to usual treatment of patients with acute decompensated heart failure did not cause significant difference in daily body weight reduction compared to placebo. In analysis adjusted to the dose of intravenous furosemide, adding HCTZ 50 mg to furosemide resulted in a significant synergistic effect on weight loss.Trial registration: The Brazilian Clinical Trials Registry (ReBEC), a publically accessible primary register that participates in the World Health Organization International Clinical Trial Registry Platform; number RBR-5qkn8h. Registered in 23/07/2019 (retrospectively), http://www.ensaiosclinicos.gov.br/rg/RBR-5qkn8h/ .

Cardiac Surgery in Jehovah's Witness Patients: Experience of a Brazilian Tertiary Hospital.

INTRODUCTION: The outcomes of Jehovah's Witness (JW) patients submitted to open heart surgery may vary across countries and communities. The aim of this study was to describe the morbidity and mortality of JW patients undergoing cardiac surgery in a tertiary hospital center in Southern Brazil. METHODS: A case-control study was conducted including all JW patients submitted to cardiac surgery from 2008 to 2016. Three consecutive surgical non-JW controls were matched to each selected JW patient. The preoperative risk of death was estimated through the mean EuroSCORE II. RESULTS: We studied 16 JW patients with a mean age of 60.6±12.1 years. The non-JW group included 48 patients with a mean age of 63.3±11.1 years (P=0.416). Isolated coronary artery bypass graft surgery was the most frequent surgery performed in both groups. Median EuroSCORE II was 1.29 (IQR: 0.66-3.08) and 1.43 (IQR: 0.72-2.63), respectively (P=0.988). The mortality tended to be higher in JW patients (18.8% vs. 4.2%, P=0.095), and there was a higher difference between the predicted and observed mortality in JW patients compared with controls (4.1 and 18.8% vs. 2.1 and 4.2%). More JW patients needed hemodialysis in the postoperative period (20.0 vs. 2.1%, P=0.039). CONCLUSION: We showed a high rate of in-hospital mortality in JW patients submitted to cardiac surgery. The EuroSCORE II may underestimate the surgical risk in these patients.

Predictors of serious arrhythmic events in patients with nonischemic heart failure.

PURPOSE: Risk stratification of serious arrhythmic events in patients with nonischemic heart failure (HF), beyond estimates of left ventricular ejection fraction (LVEF), remains an important clinical challenge. This study aims to determine the clinical value of different noninvasive and invasive tests as predictors of serious arrhythmic events in patients with nonischemic HF. METHODS: A prospective observational study was conducted including 106 nonischemic HF patients who underwent a comprehensive clinical and laboratory evaluation including two-dimensional echocardiography, 24-h Holter monitoring, cardiopulmonary exercise testing (CPX), and an invasive electrophysiological study. The study's primary end-point was either syncope, appropriate therapy by implantable cardioverter-defibrillators, or sudden cardiac death. RESULTS: During a mean follow-up of 704 ± 320 days, the primary end-point occurred in 15 patients (14.2%). In multivariable analysis, LV end-diastolic diameter >73 mm (hazard ratio [HR] 3.7; p = 0.016), exercise periodic breathing (EPB) on CPX (HR 2.88; p = 0.045), and non-sustained ventricular tachycardia (NSVT) ≥10 beats (HR 8.2; p < 0.01) remained independently associated with serious arrhythmic events. The positive predictive value of the presence of two of these predictors ranged from 44 to 100%. The absence of all three factors (n = 65, 61% of the sample) identified a subset of patients with low risk of future arrhythmic events, with a negative predictive value of 96.9%. CONCLUSIONS: In this cohort study of nonischemic HF patients, LV dimension, EPB, and NSVT ≥10 beats were independent predictors of serious arrhythmic events. The presence or absence of these characteristics identified sub-groups of high and low risk of serious arrhythmic events, respectively.

Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study.

BACKGROUND: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. OBJECTIVE: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. METHODS: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. RESULTS: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. CONCLUSION: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.

Short-term Effects of High-Dose Caffeine on Cardiac Arrhythmias in Patients With Heart Failure: A Randomized Clinical Trial.

IMPORTANCE: The presumed proarrhythmic action of caffeine is controversial. Few studies have assessed the effect of high doses of caffeine in patients with heart failure due to left ventricular systolic dysfunction at high risk for ventricular arrhythmias. OBJECTIVE: To compare the effect of high-dose caffeine or placebo on the frequency of supraventricular and ventricular arrhythmias, both at rest and during a symptom-limited exercise test. DESIGN, SETTING, AND PARTICIPANTS: Double-blinded randomized clinical trial with a crossover design conducted at the heart failure and cardiac transplant clinic of a tertiary-care university hospital. The trial included patients with chronic heart failure with moderate-to-severe systolic dysfunction (left ventricular ejection fraction <45%) and New York Heart Association functional class I to III between March 5, 2013, and October 2, 2015. INTERVENTIONS: Caffeine (100 mg) or lactose capsules, in addition to 5 doses of 100 mL decaffeinated coffee at 1-hour intervals, for a total of 500 mg of caffeine or placebo during a 5-hour protocol. After a 1-week washout period, the protocol was repeated. MAIN OUTCOMES AND MEASURES: Number and percentage of ventricular and supraventricular premature beats assessed by continuous electrocardiographic monitoring. RESULTS: We enrolled 51 patients (37 [74%] male; mean [SD] age, 60.6 [10.9] years) with predominantly moderate-to-severe left ventricular systolic dysfunction (mean [SD] left ventricular ejection fraction, 29% [7%]); 31 [61%] had an implantable cardioverter-defibrillator device. No significant differences between the caffeine and placebo groups were observed in the number of ventricular (185 vs 239 beats, respectively; P = .47) and supraventricular premature beats (6 vs 6 beats, respectively; P = .44), as well as in couplets, bigeminal cycles, or nonsustained tachycardia during continuous electrocardiographic monitoring. Exercise test-derived variables, such as ventricular and supraventricular premature beats, duration of exercise, estimated peak oxygen consumption, and heart rate, were not influenced by caffeine ingestion. We observed no increases in ventricular premature beats (91 vs 223 vs 207 beats, respectively) in patients with higher levels of plasma caffeine concentration compared with lower plasma levels (P = .91) or with the placebo group (P = .74). CONCLUSIONS AND RELEVANCE: Acute ingestion of high doses of caffeine did not induce arrhythmias in patients with systolic heart failure and at high risk for ventricular arrhythmias. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02045992.

Os indicadores de intersubjetividade e sua potência na clínica de crianças / The intersubjectivity indicators and its potentiality in the children's clinic / Los indicadores de intersubjetividad y su potencia en la clinica de niños

Os indicadores de intersubjetividade são uma espécie de guia, reunindo fenômenos que vêm sendo destacados pela literatura psicanalítica e indicam que a constituição psíquica da criança está se desenvolvendo no encontro com seu ambiente subjetivante. Tais fenômenos foram reunidos pelo psicanalista uruguaio Victor Guerra. Neste artigo, as autoras sustentam que esses indicadores podem se consolidar como uma ferramenta teórica e técnica na clínica de crianças que apresentam entraves em seu processo de subjetivação. É apresentado um resumo desses indicadores e cenas clínicas, visando compreender de que modo eles podem amparar o trabalho analítico, iluminando um caminho rumo à subjetivação.(AU)

The intersubjectivity indicators are a kind of guide to countless phenomena that have been highlighted by psychoanalytic literature over the years, which indicates that the child is developing its psychic constitution by the encounter with its subjective environment. Such phenomena were collected and consistently arranged by the Uruguayan psychoanalyst Victor Guerra. In this article, the authors advocate the idea that these indicators can be consolidated as a theoretical and technical tool in the clinic of children that present obstacles in their process of subjectivation. Initially, a summary of these indicators is presented and then some clinical scenes are analised to comprehend how these indicators can support analytical work, illuminating a path towards subjectivation.(AU)

Los indicadores de intersubjetividad son una especie de guía acerca de innumerables fenómenos que vienen siendo destacado por la literatura psicoanalítica a los quales indican que la constitución psíquica del niño se está desarrollando en el encuentro con su ambiente subjetivante. Tales fenómenos fueron reunidos y arreglados de forma consistente por el psicoanalista uruguayo Victor Guerra. En este artículo las autoras sostienen que esos indicadores pueden consolidarse como una herramienta teórica y técnica en la clínica de niños que presentan obstáculos en su proceso de subjetivación. Se presenta un resumen de estos indicadores y se analisan algunas escenas clínicas para compreender de qué modo los indicadores pueden amparar el trabajo analítico, iluminando camino potente hacia la subjetivación.(AU)

A função subjetivante do ritmo em um contexto de atendimento psicanalítico / The subjectfying role of rhythm in a psychoanalytical setting

Neste trabalho, as autoras abordam a função subjetivante do ritmo na constituição psíquica a partir da teoria da intersubjetividade, valendo-se, principalmente, das contribuições do psicanalista Victor Guerra. Partimos de um caso atendido no contexto de um tratamento psicoterápico em grupo para crianças, ancorado na teoria psicanalítica. Discute-se o papel do ritmo co-criado com o paciente no processo de subjetivação. Entende-se a trama rítmica como um embalar seguro que regula as experiências. Priorizamos para discussão a face do ritmo que compreende as variações de presença e ausência do objeto. Consideramos que a dimensão delimitante do ritmo tem grande valor na criação dos contornos do self, numa crescente diferenciação eu/não-eu e na construção de um espaço interno para representar. Para que tenham tal efeito subjetivante, contudo, os momentos que denunciam a descontinuidade devem estar inseridos em certa previsibilidade rítmica, em que as ausências podem ser antecipadas e cuja duração varie conforme a capacidade da criança de tolerá-las. Deste modo, ressalta-se que o ritmo só será terapêutico se puder ser co-criado com o paciente, em uma ritmicidade conjunta.(AU)

In this paper, the authors approach the subjectfying role rhythm plays in the psychic constitution as understood by the intersubjectivity theory, mainly psychoanalyst Victor Guerra's contributions in this regard. We discuss a clinical case of a child in a group psychoanalytic-based psychotherapy to better analyze the role of a shared rhythmicity in the therapeutic setting. We understand rhythm as a tread that "holds" safely the subject and regulates how they experience different interactions with others. We discuss primarily the variation between presence and absence of the rhythm, since we consider that it plays an important delimiting function in the constituting of internal and external boundaries of the self, helping in the differentiation between self and others and in the ability to represent. To play such subjectfying function, however, the moments that show a discontinuity between self and environment must be introduced in a foreseeable rhythm, with absences that can be anticipated and that only last as long as the child can tolerate them. Finally, we consider that rhythm can be used therapeutically if created with the pacient, in an experience of a shared rhythmicity.(AU)

Cardiac surgery in Jehovah's witness patients: experience of a Brazilian Tertiary Hospital

Abstract Introduction: The outcomes of Jehovah's Witness (JW) patients submitted to open heart surgery may vary across countries and communities. The aim of this study was to describe the morbidity and mortality of JW patients undergoing cardiac surgery in a tertiary hospital center in Southern Brazil. Methods: A case-control study was conducted including all JW patients submitted to cardiac surgery from 2008 to 2016. Three consecutive surgical non-JW controls were matched to each selected JW patient. The preoperative risk of death was estimated through the mean EuroSCORE II. Results: We studied 16 JW patients with a mean age of 60.6±12.1 years. The non-JW group included 48 patients with a mean age of 63.3±11.1 years (P=0.416). Isolated coronary artery bypass graft surgery was the most frequent surgery performed in both groups. Median EuroSCORE II was 1.29 (IQR: 0.66-3.08) and 1.43 (IQR: 0.72-2.63), respectively (P=0.988). The mortality tended to be higher in JW patients (18.8% vs. 4.2%, P=0.095), and there was a higher difference between the predicted and observed mortality in JW patients compared with controls (4.1 and 18.8% vs. 2.1 and 4.2%). More JW patients needed hemodialysis in the postoperative period (20.0 vs. 2.1%, P=0.039). Conclusion: We showed a high rate of in-hospital mortality in JW patients submitted to cardiac surgery. The EuroSCORE II may underestimate the surgical risk in these patients.

Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study / Preditores de Mortalidade Total e de Resposta Ecocardiográfica à Terapia de Ressincronização Cardíaca: Um Estudo de Coorte

Abstract Background: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. Objective: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. Methods: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. Results: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. Conclusion: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.

Resumo Fundamento: Estudos Clínicos demonstram que até 40% dos pacientes não respondem à terapia de ressincronização cardíaca (TRC), assim a seleção apropriada dos pacientes é fundamental para o sucesso da TRC na insuficiência cardíaca. Objetivo: Avaliação de preditores de mortalidade e resposta à TRC no cenário brasileiro. Métodos: Estudo de coorte retrospectivo incluindo os pacientes submetidos à TRC em hospital terciário no Sul do Brasil entre 2008-2014. A sobrevida foi avaliada através de banco de dados da Secretaria Estadual de Saúde (RS). Os preditores de resposta ecocardiográfica foram avaliados utilizando método de regressão de Poisson. A análise de sobrevida foi feita por regressão de Cox e curvas de Kaplan Meyer. Um valor de p bicaudal inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Foram incluídos 170 pacientes com seguimento médio de 1011 ± 632 dias. A mortalidade total foi de 30%. Os preditores independentes de mortalidade identificados foram idade (hazzard ratio [HR] de 1,05; p = 0,027), infarto agudo do miocárdio (IAM) prévio (HR de 2,17; p = 0,049) e doença pulmonar obstrutiva crônica (DPOC) (HR de 3,13; p = 0,015). O percentual de estimulação biventricular em 6 meses foi identificado com fator protetor de mortalidade ([HR] 0,97; p = 0,048). Os preditores independentes associados à reposta ecocardiográfica foram ausência de insuficiência mitral, presença de bloqueio de ramo esquerdo e percentual de estimulação biventricular. Conclusão: A mortalidade nos pacientes submetidos à TRC em hospital terciário foi independentemente associada à idade, presença de DPOC e IAM prévio. O percentual de estimulação biventricular avaliado 6 meses após o implante do ressincronizador foi independentemente associado a melhora da sobrevida e resposta ecocardiográfica.