RESUMEN
AIMS: Patients with advanced heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) and concurrent coronavirus disease 2019 (COVID-19) might have a higher risk of severe events. METHODS AND RESULTS: We retrospectively studied 16 patients with advanced HFrEF who developed COVID-19 between 1 March and 29 May 2020. Follow-up lasted until 30 September. Ten patients previously hospitalized with decompensated HFrEF were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization. Six patients undergoing ambulatory care at initiation of COVID-19 symptoms were hospitalized because of advanced HFrEF. All patients who experienced worsening of HFrEF due to COVID-19 required higher doses or introduction of additional inotropic drugs or intra-aortic balloon pump in the intensive care unit. The mean intravenous dobutamine dose before SARS-CoV-2 infection in previously hospitalized patients (n = 10) and the median (inter-quartile range) peak intravenous dobutamine dose during SARS-CoV-2 infection in all patients (n = 16) were 2 (0-7) µg/kg/min and 20 (14-20) (P < 0.001), respectively. During follow-up, 56% underwent heart transplantation (n = 2) or died (n = 7). Four patients died during hospitalization from mixed shock consequent to severe acute respiratory syndrome with inflammatory storm syndrome associated with septic and cardiogenic shock during COVID-19. After COVID-19 recovery, two patients died from mixed septic and cardiogenic shock and one from sustained ventricular tachycardia and cardiogenic shock. Five patients were discharged from hospital to ambulatory care. Four were awaiting heart transplantation. CONCLUSION: Worsening of advanced HF by COVID-19 is associated with high mortality. This report highlights the importance of preventing COVID-19 in patients with advanced HF.
Asunto(s)
COVID-19/complicaciones , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Adulto , Anciano , COVID-19/mortalidad , COVID-19/terapia , Fármacos Cardiovasculares/uso terapéutico , Cuidados Críticos , Femenino , Insuficiencia Cardíaca/virología , Trasplante de Corazón , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Volumen Sistólico , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
JUSTIFICATIVA E OBJETIVOS: Pericardite é uma rara manifestação de tuberculose, sendo esta etiologia descrita em 1% a 4% dos casos de pericardite. O objetivo deste estudo foi apresentar um caso de pericardite por tuberculose com sintomas inespecíficos. RELATO DO CASO: Paciente do sexo feminino, 38 anos, com quadro de síndrome consuptiva e tuberculose pericárdica, diagnosticado através do exame histopatológico da biópsia do pericárdio. CONCLUSÃO: Por se tratar de uma manifestação rara de tuberculose e de sintomatologia inespecífica, a alta suspeição clínica e a realização precoce dos métodos diagnósticos invasivos são de extrema importância para evitar a evolução de uma doença potencialmentefatal.
BACKGROUND AND OBJECTIVES: Pericarditis is a rare manifestation of tuberculosis, and this etiology is described in 1%-4% of the cases of pericarditis. The aim of this study was to present a case of tuberculous pericarditis with nonspecific symptoms. CASE REPORT: Female patient, 38 years old, with clinical picture of consumptive syndrome and tuberculous pericarditis, diagnosed through the histopathological examination of the pericardium biopsy. CONCLUSION: Because it is a rare manifestation of tuberculosis and with nonspecific symptoms, the high clinical suspicion and the early performance of invasive diagnostic methods are extremely important to prevent the evolution of a potentially fatal disease.
Asunto(s)
Humanos , Femenino , Adulto , Pericarditis/diagnóstico , Tuberculosis/complicaciones , Tuberculosis/diagnósticoRESUMEN
FUNDAMENTO: A depressão é uma comorbidade frequente na insuficiência cardíaca (IC), mas os mecanismos relacionados a pior evolução de pacientes deprimidos com IC ainda não estão esclarecidos. OBJETIVO: Avaliar o papel da depressão grave na evolução dos pacientes com IC descompensada. MÉTODOS: Estudamos consecutivamente 43 pacientes com IC avançada e FE < 40,0 por cento, hospitalizados para compensação cardíaca. Os pacientes, após história e exame físico, foram submetidos a exames laboratoriais, incluindo a dosagem de BNP. Após o diagnóstico de depressão, aplicou-se a escala de Hamilton-D. Depressão grave foi definida por escore igual ou maior que 18. As variáveis clínico-laboratoriais, segundo a presença ou não de depressão grave, foram analisadas pela regressão logística. A curva ROC definiu o ponto de corte para o BNP. RESULTADOS: Depressão grave ou muito grave foi identificada em 24 (55,8 por cento) pacientes. Os pacientes deprimidos graves não diferiram dos não deprimidos quanto à idade, sexo e função renal, mas apresentaram menor comprometimento cardíaco (FE 23,4 ± 7,2 por cento vs 19,5 ± 5,2 por cento; p = 0,046) e valores mais elevados do BNP (2.582,8 ± 1.596,6 pg/ml vs 1.206,6 ± 587,0 pg/ml; p < 0,001). Entretanto, os pacientes com BNP maior que 1.100 pg/ml tiveram 12,0 (odds ratio [IC 95 por cento] = 2,61 - 55,26) vezes mais chance de desenvolverem quadros de depressão grave. CONCLUSÃO: Os pacientes com depressão grave apresentaram maior grau de estimulação neuro-hormonal, apesar do grau de disfunção ventricular ser menor. As alterações fisiopatológicas relacionadas à depressão, aumentando a estimulação neuro-hormonal e as citocinas, provavelmente contribuíram para essa maior manifestação clínica, mesmo em presença de menor dano cardíaco.
BACKGROUND: Depression is a common comorbidity in heart failure (HF); however, the mechanisms related to a poorer outcome of depressed patients with HF remain unclear. OBJECTIVE: To evaluate the role of severe depression in the outcome of patients with decompensated HF. METHODS: A total of 43 patients with advanced HF, EF < 40.0 percent, and hospitalized for cardiac compensation were consecutively studied. After history taking and physical examination, the patients underwent laboratory tests including BNP determination. After the diagnosis of depression was made, the Hamilton-D scale was applied. Severe depression was defined by a score equal to or greater than 18. The clinical and laboratory variables according to the presence or absence of severe depression were analyzed using logistic regression. The ROC curve defined the cut-off point for BNP. RESULTS: Severe or very severe depression was identified in 24 (55.8 percent) patients. Severely depressed patients did not differ from non-depressed patients as regards age, gender and renal function, but showed less cardiac impairment (EF 23.4 ± 7.2 percent vs 19.5 ± 5.2 percent; p = 0.046) and higher BNP levels (2,582.8 ± 1,596.6 pg/ml vs 1,206.6 ± 587.0 pg/ml; p < 0.001). However, patients with BNP levels higher than 1,100 pg/ml had a 12.0-fold higher chance (odds ratio [95 percent CI] = 2.61 - 55.26) of developing severe depression. CONCLUSION: Patients with severe depression showed a higher degree of neurohormonal stimulation despite their lower degree of ventricular dysfunction. The pathophysiological changes related to depression, leading to increased neurohormonal stimulation and cytokines, probably contributed to this more intense clinical manifestation even in the presence of less cardiac damage.
FUNDAMENTO: La depresión es una comorbilidad frecuente en la insuficiencia cardíaca (IC), pero los mecanismos relacionados a peor evolución de pacientes deprimidos con IC aun no están aclarados. OBJETIVO: Evaluar el papel de la depresión grave en la evolución de los pacientes con IC descompensada. MÉTODOS: Estudiamos consecutivamente 43 pacientes con IC avanzada y FE < 40,0 por ciento, hospitalizados para compensación cardíaca. Los pacientes, después de historia y examen físico, fueron sometidos a exámenes de laboratorio, incluyendo el dosaje de BNP. Después del diagnóstico de depresión, se aplicó la escala de Hamilton-D. Depresión grave fue definida por escore igual o mayor que 18. Las variables clínicas-de laboratorio, según la presencia o no de depresión grave, fueron analizadas por la regresión logística. La curva ROC definió el punto de corte para el BNP. RESULTADOS: Depresión grave o muy grave fue identificada en 24 (55,8 por ciento) pacientes. Los pacientes deprimidos graves no difirieron de los no deprimidos en cuanto a la edad, sexo y función renal, pero presentaron menor compromiso cardíaco (FE 23,4 ± 7,2 por ciento vs. 19,5 ± 5,2 por ciento; p = 0,046) y valores más elevados del BNP (2.582,8 ± 1.596,6 pg/ml vs. 1.206,6 ± 587,0 pg/ml; p < 0,001). Mientras tanto, los pacientes con BNP mayor que 1.100 pg/ml tuvieron 12,0 (odds ratio [IC 95 por ciento] = 2,61 - 55,26) veces más chance de desarrollar cuadros de depresión grave. CONCLUSÍON: Los pacientes con depresión grave presentaron mayor grado de estimulación neurohormonal, a pesar del grado de disfunción ventricular ser menor. Las alteraciones fisiopatológicas relacionadas a la depresión, aumentando la estimulación neurohormonal y las citocinas, probablemente contribuyeron a esa mayor manifestación clínica, aun en presencia de menor daño cardíaco.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Depresión/epidemiología , Insuficiencia Cardíaca/epidemiología , Péptido Natriurético Encefálico/sangre , Disfunción Ventricular/epidemiología , Biomarcadores/sangre , Depresión/diagnóstico , Métodos Epidemiológicos , Valores de ReferenciaRESUMEN
FUNDAMENTO: Há evidências de que a suspensão do betabloqueador (BB) na descompensação cardíaca pode aumentar mortalidade. A dobutamina (dobuta) é o inotrópico mais utilizado na descompensação, no entanto, BB e dobuta atuam no mesmo receptor com ações antagônicas, e o uso concomitante dos dois fármacos poderia dificultar a compensação. OBJETIVO: Avaliar se a manutenção do BB associado à dobuta dificulta a compensação cardíaca. MÉTODOS: Estudados 44 pacientes com FEVE < 45 por cento e necessidade de inotrópico. Divididos em três grupos de acordo com o uso de BB. Grupo A (n=8): os que não usavam BB na admissão; Grupo B (n=25): os que usavam BB, porém foi suspenso para iniciar a dobuta; Grupo C (n=11): os que usaram BB concomitante à dobuta. Para comparação dos grupos, foram utilizados os testes t de Student, exato de Fisher e qui-quadrado. Considerado significante p < 0,05. RESULTADOS: FEVE média de 23,8 ± 6,6 por cento. O tempo médio do uso de dobuta foi semelhante nos três grupos (p=0,35), e o uso concomitante da dobuta com o BB não aumentou o tempo de internação (com BB 20,36 ± 11,04 dias vs sem BB 28,37 ± 12,76 dias, p=NS). Na alta, a dose do BB foi superior nos pacientes em que a medicação não foi suspensa (35,8 ± 16,8 mg/dia vs 23,0 ± 16,7 mg/dia, p=0,004). CONCLUSÃO: A manutenção do BB associado à dobuta não aumentou o tempo de internação e não foi acompanhada de pior evolução. Os pacientes que não suspenderam o BB tiveram alta com doses mais elevadas do medicamento.
BACKGROUND: There is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE: To evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS: We studied 44 patients with LVEF < 45 percent and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS: Mean LVEF 23.8 ± 6.6 percent. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION: Maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.
FUNDAMENTO: Hay evidencias de que la suspensión del betabloqueante (BB) en la descompensación cardíaca puede aumentar la mortalidad. La dobutamina (dobuta) es el inotrópico más utilizado en la descompensación, mientras tanto, BB y dobuta actúan en el mismo receptor con acciones antagónicas, y el uso concomitante de los dos fármacos podría dificultar la compensación. OBJETIVO: Evaluar si la manutención del BB asociado a la dobuta dificulta la compensación cardíaca. MÉTODOS: Estudiados 44 pacientes con FEVI < 45 por ciento y necesidad de inotrópico. Divididos en tres grupos de acuerdo con el uso de BB. Grupo A (n=8): los que no usaban BB en la admisión; Grupo B (n=25): los que usaban BB, sin embargo fue suspendido para iniciar la dobuta; Grupo C (n=11): los que usaron BB concomitantemente a la dobuta. Para comparación de los grupos, fueron utilizados los test t de Student, exacto de Fisher y qui-cuadrado. Considerado significante P < 0,05. RESULTADOS: FEVI media de 23,8±6,6 por ciento. El tiempo medio de uso de dobuta fue semejante en los tres grupos (p=0,35), y el uso concomitante de la dobuta con el BB no aumentó el tiempo de internación (con BB 20,36 ± 11,04 días vs sin BB 28,37 ± 12,76 días, p=NS). En el alta, la dosis del BB fue superior en los pacientes en que la medicación no fue suspendida (35,8 ± 16,8 mg/día vs 23,0 ± 16,7 mg/día, p=0,004). CONCLUSIÓN: La manutención del BB asociado a la dobuta no aumentó el tiempo de internación y no fue acompañada de peor evolución. Los pacientes que no suspendieron el BB tuvieron alta con dosis más elevadas del medicamento.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Adrenérgicos beta/efectos adversos , Cardiotónicos/uso terapéutico , Dobutamina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Privación de Tratamiento , Antagonistas Adrenérgicos beta/administración & dosificación , Antagonistas Adrenérgicos beta/metabolismo , Gasto Cardíaco Bajo/complicaciones , Gasto Cardíaco Bajo/tratamiento farmacológico , Quimioterapia Combinada/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Estudios ProspectivosRESUMEN
BACKGROUND: Depression is a common comorbidity in heart failure (HF); however, the mechanisms related to a poorer outcome of depressed patients with HF remain unclear. OBJECTIVE: To evaluate the role of severe depression in the outcome of patients with decompensated HF. METHODS: A total of 43 patients with advanced HF, EF < 40.0%, and hospitalized for cardiac compensation were consecutively studied. After history taking and physical examination, the patients underwent laboratory tests including BNP determination. After the diagnosis of depression was made, the Hamilton-D scale was applied. Severe depression was defined by a score equal to or greater than 18. The clinical and laboratory variables according to the presence or absence of severe depression were analyzed using logistic regression. The ROC curve defined the cut-off point for BNP. RESULTS: Severe or very severe depression was identified in 24 (55.8%) patients. Severely depressed patients did not differ from non-depressed patients as regards age, gender and renal function, but showed less cardiac impairment (EF 23.4 ± 7.2% vs 19.5 ± 5.2%; p = 0.046) and higher BNP levels (2,582.8 ± 1,596.6 pg/ml vs 1,206.6 ± 587.0 pg/ml; p < 0.001). However, patients with BNP levels higher than 1,100 pg/ml had a 12.0-fold higher chance (odds ratio [95% CI] = 2.61 - 55.26) of developing severe depression. CONCLUSION: Patients with severe depression showed a higher degree of neurohormonal stimulation despite their lower degree of ventricular dysfunction. The pathophysiological changes related to depression, leading to increased neurohormonal stimulation and cytokines, probably contributed to this more intense clinical manifestation even in the presence of less cardiac damage.
Asunto(s)
Depresión/epidemiología , Insuficiencia Cardíaca/epidemiología , Péptido Natriurético Encefálico/sangre , Disfunción Ventricular/epidemiología , Biomarcadores/sangre , Depresión/diagnóstico , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valores de ReferenciaRESUMEN
BACKGROUND: there is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE: to evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS: we studied 44 patients with LVEF < 45% and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS: mean LVEF 23.8 ± 6.6%. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION: maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.
Asunto(s)
Antagonistas Adrenérgicos beta/efectos adversos , Cardiotónicos/uso terapéutico , Dobutamina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Privación de Tratamiento , Antagonistas Adrenérgicos beta/administración & dosificación , Antagonistas Adrenérgicos beta/metabolismo , Gasto Cardíaco Bajo/complicaciones , Gasto Cardíaco Bajo/tratamiento farmacológico , Quimioterapia Combinada/efectos adversos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE: To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS: 52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS: Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION: The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.
Asunto(s)
Insuficiencia Cardíaca/fisiopatología , Músculo Esquelético/inervación , Sistema Nervioso Simpático/fisiopatología , Adolescente , Adulto , Anciano , Electrofisiología/métodos , Métodos Epidemiológicos , Antebrazo/irrigación sanguínea , Insuficiencia Cardíaca/mortalidad , Humanos , Persona de Mediana Edad , Músculo Esquelético/irrigación sanguínea , Nervio Peroneo/fisiología , Pletismografía , Pronóstico , Flujo Sanguíneo Regional/fisiología , Adulto JovenRESUMEN
FUNDAMENTO: Microneurografia e pletismografia de oclusão venosa podem ser considerados métodos de avaliação da atividade simpática. OBJETIVO: Avaliar a intensidade da atividade simpática através da microneurografia e da pletismografia de oclusão venosa em pacientes com insuficiência cardíaca, e correlacionar essa intensidade com prognóstico. MÉTODOS: 52 pacientes com insuficiência cardíaca (FE <45 por cento ao ecocardiograma), sendo 12 em CFII e quarenta em CFIV. Após compensação avaliou-se a atividade nervosa simpática muscular (ANSM) no nervo peronero (microneurografia), e o fluxo sanguíneo muscular (FSM) no antebraço (pletismografia de oclusão venosa). Após seguimento de 18 meses os pacientes foram divididos em três grupos: 12 em CFII, 19 em CFIV que não morreram e 21 em CFIV que morreram. A intensidade da atividade da simpática foi comparada nos três diferentes grupos. RESULTADOS: CFII apresentaram menor ANSM (Atividade Nervosa Simpática Muscular) (p=0,026) e maior FSM (p=0,045) que os CFIV que não morreram. CFIV que morreram apresentaram maior ANSM (p<0.001) e menor FSM (p=0,002) que os CFIV que não morreram. Curva ROC: valor de corte >53,5 impulsos/min para ANSM (S=90,55. E=73,68 por cento) e <1,81 ml/mn/100gr para FSM (S=90,4 por cento. E=73,7 por cento). Curva Kaplan-Meier: sobrevida maior com ANSM <53,5 impulsos/min (p<0,001), e ou FSM >1,81 ml/min/100gr (P<0,001). Análise de regressão logística: quanto maior a ANSM e menor o FSM, maior é a probabilidade de morte. CONCLUSÃO: A intensidade da ANSM e do FSM podem ser considerados marcadores prognósticos na insuficiência cardíaca avançada.
BACKGROUND: Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity. OBJECTIVE: To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis. METHODS: 52 patients with HF (ejection fraction < 45 percent at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups. RESULTS: Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68 percent) and < 1.81 ml/min/100gr for MBF (S=90.4 percent. E=73.7 percent). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death. CONCLUSION: The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.
FUNDAMENTO: Microneurografía y pletismografía de oclusión venosa se pueden considerar como métodos de evaluación de la actividad simpática. OBJETIVO: Evaluar la intensidad de la actividad simpática a través de la microneurografía y de la pletismografía de oclusión venosa en pacientes con insuficiencia cardiaca, y correlacionar esa intensidad con pronóstico. MÉTODOS: Un total de 52 pacientes con insuficiencia cardiaca (FE <45 por ciento al ecocardiograma), 12 de ellos en clase funcional II (CFII) y 40 en clase funcional IV (CFIV). Tras la compensación, se evaluaron la actividad nerviosa simpática muscular (ANSM) en el nervio peronero (microneurografía), y el flujo sanguíneo muscular (FSM) en el antebrazo (pletismografía de oclusión venosa). Tras el seguimiento de 18 meses, se dividieron a los pacientes en tres grupos: 12 individuos en CFII, 19 en CFIV que no murieron y 21 en CFIV que murieron. La intensidad de la actividad simpática se la comparó en los tres diferentes grupos. RESULTADOS: Los pacientes en CFII presentaron menor actividad nerviosa simpática muscular (p=0,026) y mayor FSM (p=0,045) que los en CFIV que no murieron. Los individuos en CFIV que murieron presentaron mayor ANSM (p<0.001) y menor FSM (p=0,002) que los en CFIV que no murieron. Curva ROC: valor de corte >53,5 impulsos/min para ANSM (S=90,55. E=73,68 por ciento) y <1,81 ml/mn/100gr para FSM (S=90,4 por ciento. E=73,7 por ciento). Curva Kaplan-Meier: sobrevida mayor con ANSM <53,5 impulsos/min (p<0,001), y/ó FSM >1,81 ml/min/100gr (P<0,001). Análisis de regresión logística: cuanto mayor sea la ANSM y menor el FSM, mayor será la probabilidad de muerte. CONCLUSIONES: La intensidad de la ANSM y del FSM puede considerarse como marcadores pronósticos en la insuficiencia cardiaca avanzada.
Asunto(s)
Adolescente , Adulto , Anciano , Humanos , Persona de Mediana Edad , Adulto Joven , Insuficiencia Cardíaca/fisiopatología , Músculo Esquelético/inervación , Sistema Nervioso Simpático/fisiopatología , Métodos Epidemiológicos , Electrofisiología/métodos , Antebrazo/irrigación sanguínea , Insuficiencia Cardíaca/mortalidad , Músculo Esquelético/irrigación sanguínea , Pletismografía , Pronóstico , Nervio Peroneo/fisiología , Flujo Sanguíneo Regional/fisiología , Adulto JovenRESUMEN
BACKGROUND: The incidence of hyperkalemia related to spironolactone use is low in stable heart failure; however, it has not been studied during decompensation. OBJECTIVE: To evaluate the influence of spironolactone on serum potassium in decompensated heart failure (HF). METHODS: In a cohort study, patients that had been hospitalized due to decompensated HF, with left ventricular ejection fraction (LVEF) < 0.45 and serum potassium between 3.5 and 5.5 mEq/l were selected. The patients were divided according to spironolactone use (Group S) or no use (Group C). The outcome was potassium increase (> 6.0 mEq/l) and the use of calcium polystyrene. A multivariate analysis through logistic regression was carried out and values of p < 0.05 were considered significant. RESULTS: A total of 186 patients (group S: 56; group C: 130) were studied; LVEF of 0.25, aged 55.5 years and 65.2% of them males. The incidence of hyperkalemia was 10.7% in group S and 5.4% in group C (p = 0.862). The multivariate analysis showed that serum urea > 60.5 mg/dl during the hospitalization presents a relative risk of 9.6 (95%CI 8.03 - 11.20; p = 0.005) for the occurrence of hyperkalemia. CONCLUSION: The incidence of hyperkalemia was two-fold higher with spironolactone use, but it was not statistically significant. The increase in urea levels was associated to the hyperkalemia. Randomized studies are necessary to clarify this issue.
Asunto(s)
Insuficiencia Cardíaca/tratamiento farmacológico , Hiperpotasemia/inducido químicamente , Antagonistas de Receptores de Mineralocorticoides/efectos adversos , Espironolactona/efectos adversos , Brasil/epidemiología , Métodos Epidemiológicos , Femenino , Humanos , Hiperpotasemia/sangre , Hiperpotasemia/epidemiología , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Potasio/sangre , Espironolactona/uso terapéutico , Urea/sangreRESUMEN
FUNDAMENTO: A incidência de hiperpotassemia relacionada à espironolactona é baixa na insuficiência cardíaca estável, entretanto não foi estudada durante a descompensação. OBJETIVO: Avaliar a influência da espironolactona na insuficiência cardíaca descompensada sobre o potássio sérico. MÉTODOS: Em um estudo de coorte, selecionamos pacientes hospitalizados por descompensação da insuficiência cardíaca, FEVE < 0,45 e potássio sérico entre 3,5 e 5,5 mEq/l. Os pacientes foram divididos segundo o uso da espironolactona (grupo E) ou não (grupo C). O desfecho foi aumento do potássio (> 6,0 mEq/l) e uso de poliestireno de cálcio. Realizou-se a análise multivariada pela regressão logística, e p < 0,05 foi considerado significante. RESULTADOS: Foram estudados 186 pacientes (grupo E: 56; grupo C: 130), FEVE 0,25, idade 55,5 anos e 65,2 por cento de homens. A incidência de hiperpotassemia foi de 10,7 por cento no grupo E e de 5,4 por cento no grupo C (p = 0,862). A análise multivariada mostrou que a uréia sérica > 60,5 mg/dl, durante a internação, apresenta risco relativo de 9,6 (IC 95 por cento 8,03 - 11,20; p = 0,005) para a ocorrência de hiperpotassemia. CONCLUSÃO: A incidência de hiperpotassemia foi duas vezes maior com espironolactona, mas não estatisticamente significante. Elevação da uréia foi associada à hiperpotassemia. Estudos randomizados são necessários para esclarecer o assunto.
BACKGROUND: The incidence of hyperkalemia related to spironolactone use is low in stable heart failure; however, it has not been studied during decompensation. OBJECTIVE: To evaluate the influence of spironolactone on serum potassium in decompensated heart failure (HF). METHODS: In a cohort study, patients that had been hospitalized due to decompensated HF, with left ventricular ejection fraction (LVEF) < 0.45 and serum potassium between 3.5 and 5.5 mEq/l were selected. The patients were divided according to spironolactone use (Group S) or no use (Group C). The outcome was potassium increase (> 6.0 mEq/l) and the use of calcium polystyrene. A multivariate analysis through logistic regression was carried out and values of p < 0.05 were considered significant. RESULTS: A total of 186 patients (group S: 56; group C: 130) were studied; LVEF of 0.25, aged 55.5 years and 65.2 percent of them males. The incidence of hyperkalemia was 10.7 percent in group S and 5.4 percent in group C (p = 0.862). The multivariate analysis showed that serum urea > 60.5 mg/dl during the hospitalization presents a relative risk of 9.6 (95 percentCI 8.03 - 11.20; p = 0.005) for the occurrence of hyperkalemia. CONCLUSION: The incidence of hyperkalemia was two-fold higher with spironolactone use, but it was not statistically significant. The increase in urea levels was associated to the hyperkalemia. Randomized studies are necessary to clarify this issue.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides/efectos adversos , Insuficiencia Cardíaca/tratamiento farmacológico , Hiperpotasemia/inducido químicamente , Espironolactona/efectos adversos , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Brasil/epidemiología , Métodos Epidemiológicos , Hiperpotasemia/sangre , Hiperpotasemia/epidemiología , Potasio/sangre , Espironolactona/uso terapéutico , Urea/sangreRESUMEN
A 38-year-old male underwent coronary artery bypass grafting (CABG). A saphenous vein graft was attached to the left marginal branch. The left internal thoracic artery was anastomosed to the left anterior descending artery (LAD). The early recovery was uneventful and the patient was discharged on the 5th postoperative day. After three months, he came back to the hospital complaining of weight loss, weakness, and dyspnea on mild exertion. Chest X-rays showed left pleural effusion. On physical examination, a decreased vesicular murmur was detected. After six days, the diagnosis of chylothorax was made after a milky fluid was detected in the plural cavity and total pulmonary expansion did not occur. On the next day, both anterior and posterior pleural drainage were performed by videothoracoscopy, and prolonged parenteral nutrition (PPN) was instituted for ten days. After seven days the patient was put on a low-fat diet for 8 days. The fluid accumulation ceased, the drains were removed and the patient was discharged with normal pulmonary expansion