Telemedicine Support for Primary Care Providers versus Usual Care in Patients with Heart Failure: Protocol of a Pragmatic Cluster Randomised Trial within the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) Study.

Heart failure is a prevalent condition and a frequent cause of hospital readmissions and poor quality of life. Teleconsultation support from cardiologists to primary care physicians managing patients with heart failure may improve care, but the effect on patient-relevant outcomes is unclear. We aim to evaluate whether collaboration through a novel teleconsultation platform in the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) project, tested on a previous feasibility study, can improve patient-relevant outcomes. We will conduct a parallel-group, two-arm, cluster-randomised superiority trial with a 1:1 allocation ratio, with primary care practices from Rio de Janeiro as clusters. Physicians from the intervention group practices will receive teleconsultation support from a cardiologist to assist patients discharged from hospitals after admission for heart failure. In contrast, physicians from the control group practices will perform usual care. We will include 10 patients per each of the 80 enrolled practices (n = 800). The primary outcome will be a composite of mortality and hospital admissions after six months. Secondary outcomes will be adverse events, symptoms frequency, quality of life, and primary care physicians' compliance with treatment guidelines. We hypothesise that teleconsulting support will improve patient outcomes.

Correction: Cardiovascular Risk Factors and Clinical Outcomes among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 Study.

[This corrects the article DOI: 10.5334/gh.1128.].

Cardiovascular Risk Factors and Clinical Outcomes among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 Study.

Background and aims: Limited data exist on the cardiovascular manifestations and risk factors in people hospitalized with COVID-19 from low- and middle-income countries. This study aims to describe cardiovascular risk factors, clinical manifestations, and outcomes among patients hospitalized with COVID-19 in low, lower-middle, upper-middle- and high-income countries (LIC, LMIC, UMIC, HIC). Methods: Through a prospective cohort study, data on demographics and pre-existing conditions at hospital admission, clinical outcomes at hospital discharge (death, major adverse cardiovascular events (MACE), renal failure, neurological events, and pulmonary outcomes), 30-day vital status, and re-hospitalization were collected. Descriptive analyses and multivariable log-binomial regression models, adjusted for age, sex, ethnicity/income groups, and clinical characteristics, were performed. Results: Forty hospitals from 23 countries recruited 5,313 patients with COVID-19 (LIC = 7.1%, LMIC = 47.5%, UMIC = 19.6%, HIC = 25.7%). Mean age was 57.0 (±16.1) years, male 59.4%, pre-existing conditions included: hypertension 47.3%, diabetes 32.0%, coronary heart disease 10.9%, and heart failure 5.5%. The most frequently reported cardiovascular discharge diagnoses were cardiac arrest (5.5%), acute heart failure (3.8%), and myocardial infarction (1.6%). The rate of in-hospital deaths was 12.9% (N = 683), and post-discharge 30 days deaths was 2.6% (N = 118) (overall death rate 15.1%). The most common causes of death were respiratory failure (39.3%) and sudden cardiac death (20.0%). The predictors of overall mortality included older age (≥60 years), male sex, pre-existing coronary heart disease, renal disease, diabetes, ICU admission, oxygen therapy, and higher respiratory rates (p < 0.001 for each). Compared to Caucasians, Asians, Blacks, and Hispanics had almost 2-4 times higher risk of death. Further, patients from LIC, LMIC, UMIC versus. HIC had 2-3 times increased risk of death. Conclusions: The LIC, LMIC, and UMIC's have sparse data on COVID-19. We provide robust evidence on COVID-19 outcomes in these countries. This study can help guide future health care planning for the pandemic globally.

Comparação entre avaliação de isquemia miocárdica pela reserva de fluxo fracionada e cintilografia de perfusão miocárdica / Comparison between myocardial ischemia evaluation by fractional flow reserve and myocardial perfusion scintigraphy

Lesões coronárias moderadas podem ser, ou não, responsáveis pela isquemia miocárdica. A análise funcional das lesões pode ser realizada por métodos invasivos e não invasivos. Comparar a análise funcional das lesões coronarianas moderadas pela reserva de fluxo fracionado e pela cintilografia de perfusão miocárdica. Foram estudados prospectivamente 47 pacientes com doença arterial coronária estável com pelo menos uma lesão coronariana moderada obstrutiva. Eles foram submetidos à reserva de fluxo fracionado e à cintilografia de perfusão miocárdica com intervalo médio de 24,5 dias, entre janeiro de 2013 e dezembro de 2015. Não houve alteração no estado clínico e nem no procedimento de revascularização entre exames. As variáveis populacionais foram descritas como mediana e interquartil. A reserva de fluxo fracionado foi realizada em um de tronco de coronária esquerda; 37 artérias coronárias descendentes; 12 artérias circunflexas e quatro artérias coronárias direitas. Reserva de fluxo fracionado < 0,8 foi considerada positiva. A análise comparativa entre os resultados dos testes foi feita pelo teste de Fisher bicaudal, sendo considerado significativo valor de p < 0,05. A reserva de fluxo fracionado < 0,8 foi encontrada no tronco de coronária esquerda (100%); 13 na artéria coronária descendente (35,14%); seis na artéria circunflexa (50%) e duas na artéria coronária direita (50%). Dentre os pacientes com reserva de fluxo fracionado positiva, 83% tinham isquemia miocárdica demonstrada na cintilografia de perfusão miocárdica (p = 0,058). Analisando especificamente o território da artéria coronária descendente, 83% dos pacientes com reserva de fluxo fracionado negativa não tinham isquemia na cintilografia de perfusão miocárdica, mas 69% dos pacientes com reserva de fluxo fracionado positiva não tinham isquemia na cintilografia de perfusão miocárdica (p = 0,413). Pode ocorrer discordância entre os resultados de análise funcional de lesões coronárias moderadas por testes invasivos e não invasivos

Moderate coronary artery lesions can be, or not, responsible for myocardial ischemia. The functional analysis of these lesions can be performed by invasive and noninvasive methods.To compare the functional analysis of moderate coronary lesions by fractional flow reserve and myocardial perfusion scintigraphy. 47 patients with stable coronary artery disease and at least one moderate coronary artery obstruction were prospectively studied. They were submitted to fractional flow reserve and myocardial perfusion scintigraphy with a median interval of 24.5 days between January 2013 and December 2015. There was no change in clinical status or revascularization procedure between the exams. The population variables were described as medians and interquartile range. Fractional flow reserve was performed in one left main coronary artery; 37 left descending coronary arteries; 12 circumflex arteries and 4 right coronary arteries. Fractional flow reserve < 0.8 was considered positive. The comparative analysis between the results of the tests was performed by two-tailed Fisher's test and a p-value 0.05 was considered significant.Fractional flow reserve < 0.8 was found in the left main coronary artery (100%); 13 in the left descending coronary artery (35.14%); 6 in circumflex artery (50%) and 2 in the right coronary artery (50%). Among the patients with positive fractional flow reserve, 83% had myocardial ischemia demonstrated by the myocardial perfusion scintigraphy (p = 0.058).When analyzing specifically the left descending coronary artery, 83% of the patients with negative fractional flow reserve showed no ischemia at the myocardial perfusion scintigraphy, but 69% of the patients with positive fractional flow reserve showed no ischemia at the myocardial perfusion scintigraphy (p = 0.413). Disagreements can occur between the results of the functional analysis of moderate coronary lesions by invasive and noninvasive tests

Comparison between accelerated and conventional dobutamine stress protocols for myocardial perfusion scintigraphy.

The conventional dobutamine (Dob) stress protocol for myocardial perfusion scintigraphy (MPS) is long, with frequent adverse effects, and generally requires atropine injection to reach target heart rate. Atropine is usually administered at the end of the protocol, when adverse effects are more frequent. Earlier atropine injection may be useful to shorten the stress protocol and reduce adverse effects. We sought to compare a Dob stress protocol with early atropine injection to a conventional Dob stress protocol in the same patients undergoing MPS. 30 patients underwent Dob-MPS with a conventional protocol (steps of 10, 20, 30 and 40 mcg/kg/min at 3 min intervals, adding atropine to the maximal Dob dose if necessary to achieve 85% of the age-corrected maximal predicted heart rate) and with an accelerated protocol with early atropine injection (at the end of the first stage). We compared stress duration, maximal heart rate (HR), percentage of maximal predicted HR, rate-pressure product, ST changes, MPS scores and the incidence of adverse effects between the 2 protocols. The accelerated protocol was shorter than the conventional protocol (7.1 ± 3.4 min vs. 11.8 ± 1.3 min; P < 0.0001), had the same efficacy to achieve hemodynamic parameters, without increasing adverse effects. The summed stress scores obtained by automatic analysis were similar in both protocols (6.3 ± 6.3 vs. 6.8 ± 6.3; P = NS) as well as the summed difference scores (2.5 ± 3.6 vs. 2.7 ± 3.4; P = NS). Early atropine injection during dobutamine stress protocol shortens stress duration. Our results suggest that patient safety and accuracy of MPS are unaltered, when compared to the conventional protocol, but further, larger studies are still necessary.

Autologous bone-marrow mononuclear cell transplantation after acute myocardial infarction: comparison of two delivery techniques.

The objective of this study was to investigate safety and feasibility of autologous bone marrow mononuclear cells (BMMNC) transplantation in ST elevation myocardial infarction (STEMI), comparing anterograde intracoronary artery (ICA) delivery with retrograde intracoronary vein (ICV) approach. An open labeled, randomized controlled trial of 30 patients admitted with STEMI was used. Patients were enrolled if they 1) were successfully reperfused within 24 h from symptoms onset and 2) had infarct size larger than 10% of the left ventricle (LV). One hundred million BMMNC were injected in the infarct-related artery (intra-arterial group) or vein (intravenous group), 1% of which was labeled with Tc(99m)-hexamethylpropylenamineoxime. Cell distribution was evaluated 4 and 24 h after injection. Baseline MRI was performed in order to evaluate microbstruction pattern. Baseline radionuclide ventriculography was performed before cell transfer and after 3 and 6 months. All the treated patients were submitted to repeat coronary angiography after 3 months. Thirty patients (57 +/- 11 years, 70% males) were randomly assigned to ICA (n = 14), ICV (n = 10), or control (n = 6) groups. No serious adverse events related to the procedure were observed. Early and late retention of radiolabeled cells was higher in the ICA than in the ICV group, independently of microcirculation obstruction. An increase of EF was observed in the ICA group (p = 0.02) compared to baseline. Injection procedures through anterograde and retrograde approaches seem to be feasible and safe. BMMNC retention by damaged heart tissue was apparently higher when the anterograde approach was used. Further studies are required to confirm these initial data.

Reduced adverse effects with an accelerated dobutamine stress protocol compared with the conventional protocol: a prospective, randomized myocardial perfusion scintigraphy study.

BACKGROUND: Dobutamine (Dob) stress myocardial perfusion scintigraphy (MPS) has been shown to have diagnostic and prognostic value. However, the protocol recommended for Dob-MPS is long and frequently associated with adverse effects. We sought to compare two stress protocols with Dob in patients undergoing MPS. METHODS AND RESULTS: 168 patients undergoing Dob-MPS were consecutively studied. Two protocols were randomly used: progressive doses of Dob (steps of 10 microg/kg/min at 3-min intervals) up to 40 microg/kg/min, aiming at reaching a minimum of 85% of the age-corrected maximal predicted heart rate (HR), possibly adding atropine to maximal Dob dose in case HR was not achieved (conventional protocol) or progressive doses of Dob aiming at the same HR, but adding atropine at the end of the first stage (accelerated protocol). We compared age, gender, coronary risk factors, history of MI or revascularization, Dob infusion and total stress times, maximal HR, percentage of maximal predicted HR, rate-pressure product, ST changes, MPS scores and incidence of adverse effects. In the 84 patients who underwent the accelerated protocol, the incidence of adverse effects was reduced (34.5%) compared to the conventional protocol (54.8%; P < 0.05), as well as Dob infusion duration (508 +/- 130 vs. 715 +/- 142 sec; P < 0.001). We did not observe significant differences between the groups as to age, gender, clinical aspects, maximal HR, percentage of achieved maximal HR, rate-pressure product, ST changes and perfusion scores. CONCLUSION: Early administration of atropine makes stress faster and reduces incidence of adverse effects, without reducing efficacy towards achieving the proposed goals.

Comparação da eficácia de um protocolo acelerado de estresse com dobutamina usando injeção precoce de atropina na cintiligrafia miocárdica de perfusão / Comparison of the efficacy of a new accelerated stress protocol with dobutamine using early injection of atropine in myocardial perfusion scintigraphy

Objetivo: Comparar a capacidade de induzir defeitos na cintilografia miocárdica de perfusão (CMP) em dois protocolos de estresse com dobutamina (Dob) em pacientes encaminhados para a realização de CMP. Métodos: Foram encaminhados 168 pacientes para a realização de CMP após estresse com Dob. Todos apresentavam contra indicação para a realização de estresse com vasodilatador. Os pacientes foram randomizados para um dos dois protocolos, constitutindo dois grupos: 1)Protocolo convencional: Doses progressivas de Dob (de 10mg/ kg/ min a intervalos de 3 minutos) até 40mg/ kg/ min, objetivando atingir, no mínuno, 85 por cento da frquência cardíaca (FC) máxima prevista para a idade, podendo-se acrescentar 0,5mg - 2,0mg de atropina à dose máxima de Dob quando esse objetivo não fosse alcançado 2) Protocolo acelerado: Doses progressivas de Dob visando a atingir o mesmo objetivo em termos de FC, porém administrado a atropina ao final do primeiro estágio (10mg/ kg/ min por 3 minutos). Foram comparados...

Objective: To compare two stress protocols with Dob in patients undergoing myocardial perfusion scintigraphy (MPS). Methods: 168 patients undergoing Dob-MPS wereconsecutively studied. Two protocols were used randomly: progressive doses of Dob (steps of 10mg/kg/min at 3minintervals) up to 40mg/kg/min, aiming a minimum of 85% of the age corrected maximal predicted heart rate (HR),possibly adding atropine to maximal Dob dose in case HR was not achieved (conventional protocol) or progressivedoses of Dob aiming at the same HR, but adding atropine at the end of the first stage (accelerated protocol). Wecompared age, gender, coronary risk factors, angina, history of myocardial infarction or revascularization, maximalHR, percentage of maximal predicted HR, rate-pressure product, ST changes and MPS scores. Results: Both groups presented similar demographic andclinical characteristics. We did not observe significant differences between the groups as maximal HR, percentageof achieved maximal HR, rate pressure product, ST changes, incidence of normal scans and perfusion scores.Conclusion: A new protocol with early atropine administration achieved the same perfusion scores in MPS as the conventional Dob protocol.

Valor prognóstico da cintigrafia de perfusão miocárdica em mulheres comparado com homens com suspeita clínica de doença coronariana / Prognostic value of myocardial scintigraphy in women compared to men with suspicious coronary artery disease

Fundamentos: A doença arterial coronariana (DAC) é causa freqüente de morbimortalidade. A cintigrafia de perfusão miocárdica (CPM) está estabelecida como instrumento para avalição diagnóstica e prognóstica na suspeita de DAC. Estudos prévios, originados populações predominantemente masculinas, podem ter subestimado diferenças relacionadas ao gênero, atualmente reconhecidas. Objetivo: Este estudo objetivou a avaliar a CPM na identificação de futuros eventos cardíacos em homens e mulheres com suspeita clínica de DAC. Métodos: Estudaram-se, retrospectivamente, 411 pacientes (175 mulheres e 236 homens) submetidos à CPM com Tc99m-sestamibi, acompanhados pelo período médio de 6,4 anos. As análises uni e multivariada foram utilizadas para identificar variáveis independentes clínicas e cintigráficas de valor prognóstico. O objetivo primário composto foi morte cardíaca ou infarto do miocárdio (eventos maiores) e como desfecho alternativo, considerou-se a revascularização miocárdica ou a angina instável (eventos menores). Resultados: A CPM evidenciou alto valor preditivo negativo para eventos futuros, tanto nos homens como nas mulheres. Valor preditivo positivo menor foi demonstrado na estatificação de risco das mulheres comparadas aos homens. A regressão logística múltipla identificou uma cintigrafia anormal, como variável isolada de maior valor prognóstico nos homens. Idade, hipertensão arterial e eletrocardiograma de esforço também foram variáveis independentes nos homens. Nas mulheres, idade, dislipidemia e tabagismo estavam independemente associados à evolução desfavorável...

Estudo comparativo entre o protocolo convencional de estresse com dobutamina e um novo protocolo mais rápido e com menos efeitos adversos / Comparative study between the conventional dobutamine stress protocol and new faster protocol with fewer adverse effects

Fundamentos: a cintilografia de perfusão miocárdica (CPM) após estresse com dobutamina (Dob) tem o seu valor diagnóstico comprovado, sendo principalmente utilizada em pacientes com contra-indicação para emprego de vasodilatadores, como dipiridamol ou adenosina.No entanto, o protocolo convencional recomendado para estresse com Dob é demorado e com efeitos adversos frequentes.Objetivos:comparar dois protocolos de estresse com Dob em pacientes encaminhados para a realização de CPM.Métodos: Foram estudados consecutivamente 110 pacientes encaminhados para a realização de CPM após estresse com Dob. Todos apresentavam contra-indicação para a realização de estresse com vasodilatador...

Dislipidemia associada à terapia anti-retroviral em pacientes com AIDS / Dyslipidemia associated with antiretroviral therapy in AIDS patients

A disponibilidade da terapia anti-retroviral tem resultado em um enorme declínio nas taxas de morbidade e mortalidade dos pacientes infectados pelo vírus da imunodeficiência humana. entretanto, tal terapia tem sido associada a efeitos metabólicos adversos, como a dislipidemia; sendo assim, indivíduos com doença arterial coronariana devem ser identificados e tratados. Este artigo faz uma revisão das anormalidades dos lipídios e das lipoproteínas associadas ao uso dos inibidores de proteases, sobre o possível mecanismo da dislipidemia associada a estes inibidores e usa o protocolo do programa de educação para tratamento do colesterol em adultos(National Cholesterol Education Program Adult Treatment Panel III Guidelines) para o acompanhamento do paciente com dislipidemia.

Parada cardíaca e ressuscitação cardiopulmonar em pacientes com infarto agudo do miocárdio após hospitalização em unidade de terapia intensiva cardiológica / Cardiac arrest and cardiopulmonary resuscitation in patients with acute myocardial infarction after admition to a cardiac intensive care unit

Fundamentos: a parada cardíaca é uma complicação relativamente frequente do infarto agudo do miocárdio. Nas primeiras horas de evolução, em geral, a parada cardíaca é consequência de arritmia primária por ritmo fibrilatório. Após a hospitalização, entretanto, a frequência de ritmos não fibrilatórios, secundários muitas vezes à deterioração hemodinâmica, passam a assumir maior relevância. Objetivos: Documentar a frequência de parada cardíaca em pacientes com infarto agudo do miocárdio após hospitalização em unidade de terapia intensiva cardiológica e comparar populações de pacientes que cursaram com e sem parada cardíaca; analisar as características dos episódios de parada cardíaca e suas respostas à ressuscitação cardiopulmonar. Métodos: Estudou-se de maneira retrospectiva 318 internações consecutivas por infarto agudo do miocárdio e foram computados 42 episódios de parada cardíaca em 38 pacientes. Resultados: Pouco mais de 10 por cento dos pacientes com infarto agudo do miocárdio apresentaram parada cardíaca e quase 10 por cento dos episódios de parada cardíaca foram de caráter recorrente. Os episódios de parada cardíaca foram mais frequentes por ritmos não fibrilatórios, em circunstâncias com prévio comprometimento hemodinâmico, após as primeiras 24 horas de evolução do infarto agudo do miocárdio e em faixa etária mais avançada. Conclusão: Foi documentado que nesse cenário o sucesso na ressuscitação cardiopulmonar não é satisfatório