Normal myocardial perfusion despite a very high coronary calcium score.

An exceptionally high coronary calcium score, greater than 10,000 UA, superior to any other found in the literature reviewed, was reported in an asymptomatic, adult man with hypertension, obesity and dyslipidemia, without myocardial ischemia and no significative coronary stenosis, associated to Glagov's phenomenon in the left coronary artery and an abdominal aortic aneurysm.

New Approaches in the Management of Sudden Cardiac Death in Patients with Heart Failure-Targeting the Sympathetic Nervous System.

Cardiovascular diseases (CVDs) have been considered the most predominant cause of death and one of the most critical public health issues worldwide. In the past two decades, cardiovascular (CV) mortality has declined in high-income countries owing to preventive measures that resulted in the reduced burden of coronary artery disease (CAD) and heart failure (HF). In spite of these promising results, CVDs are responsible for ~17 million deaths per year globally with ~25% of these attributable to sudden cardiac death (SCD). Pre-clinical data demonstrated that renal denervation (RDN) decreases sympathetic activation as evaluated by decreased renal catecholamine concentrations. RDN is successful in reducing ventricular arrhythmias (VAs) triggering and its outcome was not found inferior to metoprolol in rat myocardial infarction model. Registry clinical data also suggest an advantageous effect of RDN to prevent VAs in HF patients and electrical storm. An in-depth investigation of how RDN, a minimally invasive and safe method, reduces the burden of HF is urgently needed. Myocardial systolic dysfunction is correlated to neuro-hormonal overactivity as a compensatory mechanism to keep cardiac output in the face of declining cardiac function. Sympathetic nervous system (SNS) overactivity is supported by a rise in plasma noradrenaline (NA) and adrenaline levels, raised central sympathetic outflow, and increased organ-specific spillover of NA into plasma. Cardiac NA spillover in untreated HF individuals can reach ~50-fold higher levels compared to those of healthy individuals under maximal exercise conditions. Increased sympathetic outflow to the renal vascular bed can contribute to the anomalies of renal function commonly associated with HF and feed into a vicious cycle of elevated BP, the progression of renal disease and worsening HF. Increased sympathetic activity, amongst other factors, contribute to the progress of cardiac arrhythmias, which can lead to SCD due to sustained ventricular tachycardia. Targeted therapies to avoid these detrimental consequences comprise antiarrhythmic drugs, surgical resection, endocardial catheter ablation and use of the implantable electronic cardiac devices. Analogous NA agents have been reported for single photon-emission-computed-tomography (SPECT) scans usage, specially the 123I-metaiodobenzylguanidine (123I-MIBG). Currently, HF prognosis assessment has been improved by this tool. Nevertheless, this radiotracer is costly, which makes the use of this diagnostic method limited. Comparatively, positron-emission-tomography (PET) overshadows SPECT imaging, because of its increased spatial definition and broader reckonable methodologies. Numerous ANS radiotracers have been created for cardiac PET imaging. However, so far, [11C]-meta-hydroxyephedrine (HED) has been the most significant PET radiotracer used in the clinical scenario. Growing data has shown the usefulness of [11C]-HED in important clinical situations, such as predicting lethal arrhythmias, SCD, and all-cause of mortality in reduced ejection fraction HF patients. In this article, we discussed the role and relevance of novel tools targeting the SNS, such as the [11C]-HED PET cardiac imaging and RDN to manage patients under of SCD risk.

Inspiratory Muscle Training Improves Intercostal and Forearm Muscle Oxygenation in Patients With Chronic Heart Failure: Evidence of the Origin of the Respiratory Metaboreflex.

BACKGROUND: The impact of inspiratory muscle training (IMT) on respiratory and peripheral muscle oxygenation and perfusion during inspiratory muscle fatigue in patients with chronic heart failure (HF) has not been established. METHODS AND RESULTS: Twenty-six patients with chronic HF were randomly assigned to either 8 weeks of IMT or a control group. Inspiratory fatigue was induced by means of a progressive inspiratory resistive loading protocol until there was an inability to sustain inspiratory pressure, when the inspiratory muscle metaboreflex should be activated. The main outcomes were intercostal and forearm muscle oxygen saturation and deoxygenation as measured by means of near-infrared spectroscopy (NIRS) and blood lactate levels. Inspiratory muscle strength was increased by 78% (P <.001) after 8 weeks of participation in the IMT group. IMT attenuated the reduction of oxygen saturation in intercostal and forearm muscles and the increase in blood lactate during respiratory fatigue (P <.001 and P <.05, respectively). These changes were different from the control group (P <.01, P <.05, and P <.05, respectively). After 8 weeks, similar increases in oxygen consumption, mean arterial pressure, heart rate, stroke volume, and cardiac output were observed in both groups during respiratory fatigue. CONCLUSIONS: This randomized controlled clinical trial demonstrates that IMT attenuates the respiratory muscle oxygen demand-delivery mismatch during respiratory fatigue in patients with chronic HF.

Biomarkers and prediction of anthracyclic cardiotoxicity in breast cancer.

BACKGROUND: Chemotherapy with doxorubicin may lead to left ventricular dysfunction. There is a controversial recommendation that biomarkers can predict ventricular dysfunction, which is one of the most feared manifestations of anthracycline cardiotoxicity. OBJECTIVE: The aim of this study was to evaluate the behavior of biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin in predicting cardiotoxicity in a cohort of women with breast cancer undergoing chemotherapy with anthracycline. METHODS: This is an observational, prospective, longitudinal, unicentric study, which included 40 women with breast cancer, whose therapeutic proposal included treatment with doxorubicin. The protocol had a clinical follow-up of 12 months. Biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin were measured pre-chemotherapy and after the first, third, fourth, and sixth cycles of chemotherapy. RESULTS: There was a progressive increase in type B natriuretic peptide and myoglobin values in all chemotherapy cycles. Although creatine phosphokinase fraction MB showed a sustained increase, this increase was not statistically significant. Troponin, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB were the cardiotoxicity markers with the earliest changes, with a significant increase after the first chemotherapy session. However, they were not able to predict cardiotoxicity. CONCLUSION: Troponin I, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB are elevated during chemotherapy with doxorubicin, but they were not able to predict cardiotoxicity according to established clinical and echocardiographic criteria. The incidence of subclinical cardiotoxicity resulting from the administration of doxorubicin was 12.5%.

A Personalized Approach to the Management of Congestion in Acute Heart Failure.

Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.

Catheter ablation of accessory pathway in the treatment of pacemaker-mediated tachycardia.

Pacemaker-mediated tachycardia (PMT) remains a clinical problem in patients with dual-chamber pacemaker despite technological advances. The onset mechanism of this tachycardia is sensing of retrograde atrial activation after ventricular stimulation. Repeated retrograde conduction perpetuates tachycardia. Postventricular atrial refractory period prolongation has been used for prevention of PMT, but this is not the solution in all cases. We present a case with PMT where the retrograde limb is a left accessory pathway, which is treated with radiofrequency ablation successfully.

Natriuretic Peptide-guided Therapy for Heart Failure.

Heart failure (HF) is a complex syndrome with high mortality and hospitalization rates. Conventional care in patients with HF is usually based on clinical history and physical examination. Natriuretic peptides (NPs), B-type NP (BNP) and N-terminal proBNP, are the gold-standard biomarkers in HF. They are recommended for diagnosing HF, when the physician is uncertain of the diagnosis, and for estimating the prognosis. NPs also guide therapy in HF, as serial NP measurements inform medication adjustments to achieve targets independently of symptoms. In this regard, the data are conflicting. In patients with HF and reduced left ventricular ejection fraction (HFrEF) there is a suggestion that NP-guided therapy is helpful. The studies STARS-BNP and PROTECT demonstrated a reduction in cardiac events with NP-guided therapy. Additionally, mortality in patients aged <75 years reduced in the BATTLESCARRED and TIME-CHF studies, and in a meta-analysis. On the contrary, no differences were observed in the studies PRIMA and GUIDE-IT. In HF with preserved ejection fraction (HFpEF) and in the acute setting, no differences were detected with NP-guided therapy compared with conventional care. In patients at risk of developing HF, NP can be useful to guide therapy and prevent HF. In summary, NP-guided therapy seems to be useful in patients with HFrEF, especially in those aged <75 years, but has no use in HFpEF or in acute HF.

Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease. / Tortuosidade das Artérias Coronárias como um Novo Fenótipo para Isquemia sem Doença Arterial Coronariana.

BACKGROUND: Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia. OBJECTIVE: To assess the association between CorT and myocardial ischemia. METHODS: Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level. RESULTS: A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021). CONCLUSION: This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

FUNDAMENTO: As artérias coronárias tendem a ser mais tortuosas que outras artérias e acompanham os movimentos repetidos de flexão e relaxamento que ocorrem durante o ciclo cardíaco. A Tortuosidade das artérias Coronárias (TCor) causa alterações no fluxo coronariano, com uma redução na pressão de perfusão distal, o que pode levar à isquemia miocárdica. OBJETIVO: Avaliar a associação entre TCor e isquemia miocárdica. MÉTODOS: Entre janeiro de 2015 e dezembro de 2017, 57 pacientes com angina e doença arterial coronariana não obstrutiva pela angiografia coronária invasiva (ACI) foram incluídos retrospectivamente. Variáveis angiográficas foram analisadas para avaliar a presença e grau de tortuosidade e correlacionadas com seus respectivos territórios vasculares na cintilografia de perfusão miocárdica com estresse. A TCor foi definida como artérias coronárias com três ou mais curvaturas com ângulos ≤ 90o, medidos durante diástole. Um nível de 5% foi estabelecido como estatisticamente significativo. Um nível de 5% foi definido como estatisticamente significativo. RESULTADOS: Um total de 17 homens e 40 mulheres foram incluídos (idade média de 58,3 anos). A TCor foi observada em 16 pacientes (28%) e em 24 das 171 artérias. Observou-se uma associação significativa entre TCor e isquemia na análise por artéria (p<0,0001). O fator angiográfico mais associado com isquemia foi o número de curvaturas em uma artéria epicárdica medido na sístole (p=0,021). CONCLUSÃO: Este estudo mostrou uma associação da TCor com isquemia miocárdica em pacientes com artérias coronárias não obstruídas e angina. Observou-se uma relação entre número aumentado de curvaturas na artéria coronária medido por angiografia durante sístole e isquemia.

High-output Cardiac Failure: A Forgotten Phenotype in Clinical Practice.

INTRODUCTION: The knowledge on High-Output Cardiac Failure (HOCF) has greatly improved in the last two decades. One of the advances was the identification of a new phenotype of HOCF, characterized by the absence of ventricular dilation, already associated with liver disease, Arteriovenous Fistulas (AVF), lung disease, myelodysplastic syndromes, and obesity. However, it has been noted that any aetiology can present with one of the two phenotypes, depending on the evolution. OBJECTIVE: The study aims to describe, through an integrative review, the physiopathology and aetiologies of HOCF and to discuss phenotypes associated with this condition. METHODS: Revisions, guidelines, case-controls, cohort studies and clinical studies were searched in MEDLINE and LILACS, using the connectives in the "cardiac output, high" database (MeSH Terms) OR "high cardiac output" (All Fields). DISCUSSION: Two distinct phenotypes are currently described in the HOCF, regardless of the aetiology: 1) one with enlarged cardiac chambers; and 2) with normal heart chambers. The mechanisms related to HOCF are vasodilation, arteriovenous shunts that cause increased microvascular density, Reduced Systemic Vascular Resistance (RSVR), and high metabolism. These mechanisms lead to activation of the renin-angiotensin-aldosterone system, sodium and water retention, activation of neprilysin, of the sodium-glucose-2 transporter, which promote interstitial fibrosis, ventricular remodeling and a consequent increase in cardiac output >8L/min. CONCLUSION: Many aetiologies of HOCF have been described, and some of them are potentially curable. Prompt recognition of this condition and proper treatment may lead to better outcomes.

The MAGGIC risk score in the prediction of death or hospitalization in patients with heart failure: Comparison with natriuretic peptides.

BACKGROUND: The MAGGIC risk score has been validated to predict mortality in patients with heart failure (HF). OBJECTIVES: To assess the score ability to predict hospitalization and death and to compare with natriuretic peptides. METHODS: Ninety-three consecutive patients (mean age 62±10 years) with chronic HF and left ventricular ejection fraction (EF) <50% were studied. The MAGGIC score was applied at baseline and the patients were followed for 219±86 days. MAGGIC score was compared with NT-proBNP in the prediction of events. The primary end point was the time to the first event, which was defined as cardiovascular death or hospitalization for HF. RESULTS: There were 23 (24.7%) events (3 deaths and 20 hospitalizations). The median score in patients with and without events was, respectively, 20 [interquartile range 14.2-22] vs. 15.5 [11/21], p=0.16. A ROC curve was performed and a cutoff point of 12 points showed a sensitivity of 87% and specificity of 37% with an area under the curve of 0.59 (95% CI 0.48-0.69) which was lower than that of NT-proBNP (AUC 0.67; 95% CI 0.56-0.76). The mean event-free survival time for patients above and below this cutpoint was 248.8±13 vs. 290±13.7 days (log rank test with p=0.044). Using the COX proportional hazard model, age (p=0.004), NT-proBNP >1000 pg/mL (p=0.014) and the MAGGIC score (p=0.025) were independently associated with the primary outcome. CONCLUSION: The MAGGIC risk score was an independent predictor of events, including heart failure hospitalization. The addition of biomarkers improved the accuracy of the score.

Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study.

AIM: To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE). METHODS AND RESULTS: We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives. CONCLUSION: A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

Growth differentiation factor-15, a novel systemic biomarker of oxidative stress, inflammation, and cellular aging: Potential role in cardiovascular diseases.

Growth differentiation factor-15 (GDF-15) is a cytokine upregulated in multiple pathological conditions where oxidative stress, endothelial dysfunction, tissue aging, and chronic inflammation are the hallmarks. GDF-15 has many sources of production, including cardiac and vascular myocytes, endothelial cells, adipocytes and macrophages in response to metabolic stress, oncogenic transformation and the burden of proinflammatory cytokines or reactive oxygen species. Although the main sources of GDF-15 are extracardiac tissues, it has been shown to be elevated in many cardiac disorders. In experimental models of heart disease, GDF-15 release is induced after an ischemic insult and in pressure overload scenarios. Likewise, in recent years, an increasing body of evidence has emerged linking GDF-15 to the risk of mortality in acute coronary syndromes, atrial fibrillation and heart failure. Additionally, GDF-15 has been shown to add prognostic information beyond other conventional biomarkers such as natriuretic peptides and cardiac troponins. Further studies are needed to assess whether the incorporation of GDF-15 into clinical practice can improve cardiovascular outcomes.

Post-COVID-19 Tachycardia Syndrome: A Distinct Phenotype of Post-Acute COVID-19 Syndrome.

In this paper we highlight the presence of tachycardia in post-acute COVID-19 syndrome by introducing a new label for this phenomenon-post-COVID-19 tachycardia syndrome-and argue that this constitutes a phenotype or sub-syndrome in post-acute COVID-19 syndrome. We also discuss epidemiology, putative mechanisms, treatment options, and future research directions in this novel clinical syndrome.

Worsening Renal Function and Congestion in Patients with Acute Heart Failure: A Study with Bioelectrical Impedance Vector Analysis (BIVA) and Neutrophil Gelatinase-Associated Lipocalin (NGAL). / Agravamento da Função Renal e Congestão em Pacientes com Insuficiência Cardíaca Aguda: Estudo com Análise Vetorial de Bioimpedância Elétrica (BIVA) e Lipocalina Associada à Gelatinase Neutrofílica (NGAL).

BACKGROUND: Worsening renal function (WRF) is frequently observed in the setting of aggressive diuresis for the treatment of acute decompensated heart failure (ADHF) and is associated with poor outcomes in some studies. OBJECTIVE: We sought to assess the relationship of WRF and congestion at discharge with events (cardiac death or heart failure hospitalization). METHODS: Eighty patients with ADHF were studied. WRF was defined by an absolute increase in serum creatinine of ≥0.5 mg/dL from the values measured at the time of admission. B-type natriuretic peptide (BNP) and plasma neutrophil gelatinase-associated lipocalin (NGAL) were measured at admission and at discharge. Congestive state at discharge was assessed using bioelectrical impedance vector analysis (BIVA). Primary endpoint was time to first event defined as a combination of cardiac death or heart failure hospitalization. Receiver operating characteristic (ROC) curve analysis was used to determine the best hydration index cutoff to predict events. Kaplan-Meier event-free survival curves were constructed and compared using the log-rank test. Cox proportional hazards models were used to investigate the association with events. The criterion for determining statistical significance was p<0.05. RESULTS: Mean age was 60.6±15 years, and 48 (60%) were male. Mean ejection fraction was 35.3±7.8%. WRF occurred in 37.5% of the sample. Baseline creatinine was associated with WRF (p<0.001), but neither admission BNP (p=0.35) nor admission NGAL (p=0.18) was predictor of WRF. Using Cox proportional hazard models, hydration index at discharge calculated with BIVA was significantly associated with events (HR 1.39, 95% CI 1.25-1.54, p<0.0001) but not WRF (HR 2.14, 95% CI 0.62-7.35, p=0.22). CONCLUSION: Persistent congestion at discharge was associated with worse outcomes. WRF seems to be related to hemodynamic changes during the decongestion process but not to kidney tubular injuries.

FUNDAMENTO: O agravamento da função renal (AFR) é frequentemente observado na terapia agressiva com diuréticos para o tratamento de insuficiência cardíaca aguda descompensada (ICAD) e está associado com piores desfechos em alguns estudos. OBJETIVO: Avaliar a relação de AFR e congestão na alta hospitalar com ocorrência de eventos (morte cardíaca ou internação por insuficiência cardíaca). MÉTODOS: Oitenta pacientes com ICAD foram estudados. O AFR foi definido por um aumento absoluto (≥0,5 mg/dL) nos níveis séricos de creatinina a partir dos valores obtidos na admissão. Concentrações de peptídeo natriurético do tipo B (BNP) e lipocalina associada à gelatinase neutrofílica (NGAL) foram medidas na admissão e na alta hospitalar. Congestão foi avaliada na alta utilizando a análise vetorial de bioimpedância elétrica (BIVA). O desfecho primário foi o tempo para o primeiro evento, definido como uma combinação de morte cardíaca ou hospitalização por insuficiência cardíaca. Análise de curva Característica de Operação do Receptor (curva ROC) foi realizada para determinar o ponto de corte de IH mais adequado para predição de eventos. Curvas Kaplan-Meier de sobrevida livre de eventos foram construídas e comparadas usando o teste de log-rank. Modelos de riscos proporcionais de Cox foram usados para investigar a associação com eventos. O critério para se estabelecer significância estatística foi um p<0.05. RESULTADOS: A idade média foi 60,6 ± 15,0 anos, e 48 (60%) pacientes eram do sexo masculino. A fração de ejeção média foi 35,3±7,8%. O AFR ocorreu em 37,5% da amostra. A creatinina basal associou-se com AFR (p<0,001), mas nem BNP (p=0,35) nem NGAL (p=0,18) na admissão foram preditores de AFR. Usando modelos de riscos proporcionais de Cox, o índice de hidratação na alta, estimado por BIVA, associou-se significativamente com ocorrência de eventos (HR 1,39; IC95% 1,25-1,54, p<0,0001), mas não com AFR (HR 2,14; IC95% 0,62-7,35, p=0,22). CONCLUSÃO: A congestão persistente na alta associou-se com piores desfechos. O AFR parece estar relacionado com alterações hemodinâmicas durante o processo de descongestionamento, mas não com lesões renais.

Liver stiffness as measured by transient elastography is a predictor of outcomes in patients with chronic heart failure with reduced, mid-range, and recovered left-ventricular ejection fraction.

Background: Transient elastography is a noninvasive method for assessing liver stiffness (LS), which can reflect right-sided filling pressure associated with passive liver congestion in patients with HF. Methods: A prospective, single-center observational study in which LS was measured in consecutive ambulatory patients with heart failure with reduced, mid-range, and recovered left ventricular ejection fraction, between March 2018 and June 2019. Mean follow up was 219 ± 86 days. The primary endpoint was time to first event, which was defined as a composite of cardiovascular death or HF hospitalization. Results: Eighty-five patients were included in the final analysis. Mean age was 62 ± 10 and 68% were male. Mean ejection fraction and median NT-proBNP were, respectively, 38.7 ± 14.3% and 1140 pg/mL (interquartile range 224.3-2810.3). The median LS for the entire population was 6.3 (2.5-41.2) kPa. LS correlated with NT-proBNP (r = 0.46; p < 0.0001), total bilirubin (r = 0.47; p < 0.001), direct bilirubin (r = 0.43; p = 0.0001), gama-glutamyl-transpeptidase (r = 0.54; p < 0.0001), and alkaline phosphatase (r = 0.39; p = 0.0004). A Receiver Operating Characteristic (ROC) curve was performed and a cut point of 5.9 kPa showed sensitivity of 80% and specificity of 64.1% with area under the curve of 0.73. Using Cox proportional hazard model (independent variables: LS as a continuous variable, age, gender, NT-proBNP, LVEF, and creatinine), only LS was independently associated with the primary endpoint (hazard ratio 1.05, 95% confidence interval 1.01-1.09; for each increment of one unit of LS). Conclusion: LS correlates with biomarkers of myocardial stretch and several liver function tests and is an independent predictor of outcomes in ambulatory patients with HF.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.