Diuretics and Ultrafiltration in Heart Failure.

Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.

The use of peripherally inserted central catheter reduced the incidence of phlebitis in heart failure patients: A randomized trial.

BACKGROUND: During decompensated heart failure, the use of intravenous inotropes can be necessary. With peripheral venous access, prolonged inotrope infusion can cause phlebitis. However, traditional central venous catheters have possible complications. Peripherally inserted central catheters (PICCs) may be an alternative to traditional catheters. AIM: Our objective was to compare the incidence of phlebitis between patients with PICC and those with peripheral venous access catheter indwelling. METHODS: In a randomized clinical trial, the patients were randomized to PICC and control groups, with 40 patients in each group. The inclusion criteria were hospitalized patients with advanced heart failure, ejection fraction of <0.45, and platelet count of >50,000/mm3 and current use of continuous intravenous infusion of dobutamine. The patients were randomly assigned to receive a PICC or keep their peripheral venous access. The primary end point was the occurrence of phlebitis. RESULTS: The PICC and control groups included 40 patients each. The median age was 61.5 years; ejection fraction, 0.24; and dobutamine dose, 7.73 µg/(kg min). Phlebitis occurred in 1 patient (2.5%) in the PICC group and in 38 patients (95.0%) in the control group, with an odds ratio of 0.10% (95% confidence interval: 0.01%-1.60%, p < 0.001). CONCLUSION: In conclusion, in severe heart failure patients who received intravenous dobutamine, PICC use reduced the incidence of phlebitis when compared to patients with peripheral venous access. Therefore, the PICC use should considered over peripheral venous access for prolonged intravenous therapy in heart failure patients.

Insuficiência cardíaca em cão / Congestive heart failure in a dog / Insuficiencia cardíaca congestiva en un perro

A insuficiência cardíaca congestiva é considerada, atualmente, a principal causa de óbitos em cães, sendo resultante da degeneração mixomatosa da válvula mitral, processo que inviabiliza o fechamento total da mesma durante a sístole. Apesar de se tratar de uma doença progressiva, os efeitos patológicos podem ser reduzidos significativamente e concomitantemente prolongar a vida do animal, desde que haja protocolos de tratamentos específicos e descritos por profissionais capacitados na área médica animal. Esse estudo teve como objetivo relatar um caso de insuficiência congestiva em um animal da espécie canina, sem raça definida, sexo masculino resgatado pela prefeitura do município de Botucatu, São Paulo, Brasil. Durante a necropsia foi observado os seguintes achados macroscópicos: neoplasias cutâneas aderidas ao tecido, tártaro dentário, pneumonia intersticial hemorrágica, companhias de fibrose e enfisema pulmonar hemorrágico, metástase calcificada circular em lobo pulmonar direito, necrose pulmonar, cardiomiopatia hipertrófica concêntrica, insuficiência cardíaca congestiva, aderência de pericárdio na cavidade torácica, fígado em aspecto de noz moscada, metástase hepática, hepatite, esplenomegalia, dilatação entérica multifocal, intussuscepção, necrose intestinal, hipertrofia de pelve renal e aderência de cápsula renal. Esses achados demonstram o comprometimento de todos os órgãos do animal, demonstrando que a causa mortis foi em decorrência de uma insuficiência respiratória de origem infecciosa que ocasionou a insuficiência cardíaca congestiva.(AU)

Congestive heart failure is currently considered the main cause of death in dogs, resulting from myxomatous degeneration of the mitral valve, a process that prevents its total closure during systole. Despite being a progressive disease, the pathological effects can be significantly reduced and, at the same time, prolong the animal's life, as long as there are specific treatment protocols described by trained professionals in the field of animal medicine. This study aimed to report a case of congestive insufficiency in an animal of the canine species, mixed breed, male, rescued by the municipality of Botucatu, Sao Paulo, Brazil. During the necropsy, the following macroscopic findings were observed: skin neoplasms adhered to the tissue, dental tartar, hemorrhagic interstitial pneumonia, fibrosis and hemorrhagic pulmonary emphysema, circular calcified metastasis in the right pulmonary lobe, pulmonary necrosis, concentric hypertrophic cardiomyopathy, congestive heart failure, adherence of pericardium in the thoracic cavity, nutmeg liver, liver metastasis, hepatitis, splenomegaly, multifocal enteric dilation, intussusception, intestinal necrosis, renal pelvis hypertrophy and renal capsule adherence. These findings showed the involvement of all tissues, demonstrating that the cause of death was due to respiratory failure of infectious origin that caused congestive heart failure.(AU)

Actualmente se considera la insuficiencia cardíaca congestiva como la principal causa de muerte en perros, resultante de la degeneración mixomatosa de la válvula mitral, proceso que impide su cierre total durante la sístole. A pesar de ser una enfermedad progresiva, los efectos patológicos pueden reducirse significativamente y, al mismo tiempo, prolongar la vida del animal, siempre y cuando existan protocolos de tratamiento específicos descritos por profesionales capacitados en el campo de la medicina animal. Este estudio tuvo como objetivo reportar un caso de insuficiencia congestiva en un animal canino, mestizo, macho, rescatado por el municipio de Botucatu, São Paulo, Brasil. Durante la necropsia se observaron los siguientes hallazgos macroscópicos: neoplasias cutáneas adheridas al tejido, sarro dental, neumonía intersticial hemorrágica, compañías de fibrosis y enfisema pulmonar hemorrágico, metástasis circular calcificada en lóbulo pulmonar derecho, necrosis pulmonar, miocardiopatía hipertrófica concéntrica, insuficiencia cardíaca, adherencia del pericardio en la cavidad torácica, hígado de nuez moscada, metástasis hepática, hepatitis, esplenomegalia, dilatación entérica multifocal, intususcepción, necrosis intestinal, hipertrofia de la pelvis renal y adherencia de la cápsula renal. Estos hallazgos demuestran la afectación de todos los órganos del animal, demostrando que la causa de la muerte se debió a una insuficiencia respiratoria de origen infeccioso que provocó una insuficiencia cardíaca congestiva.(AU)

Quality of Life in Patients With Heart Failure Assisted By Telerehabilitation: A Systematic Review and Meta-Analysis.

Introduction: Heart failure (HF) is a syndrome that implies several physical and emotional changes that compromise quality of life. Telerehabilitation is a strategy developed with the aim of involving and motivating cardiac patients to participate in cardiac rehabilitation in their daily routine at home. Objective: To review the impact of telerehabilitation on the quality of life of patients with HF. Methods: This is a systematic review using the PICO strategy, with a search conducted in the electronic data sources PubMed, LILACS (Latin American and Caribbean Literature in Health Sciences) and SciELO (Scientific Electronic Library Online), with the following descriptors: heart failure, congestive heart failure, chronic heart failure, distance rehabilitation, virtual rehabilitation, telerehabilitation, telemedicine, quality of life and HRQoL, combined by the Boolean operators "AND" and "OR", including articles between 2011 and 2021. Results: Nine articles were found after reading the abstract and titles; five of these met the inclusion criteria. They showed that telerehabilitation contributes to a better quality of life due to the daily increase in mental, social, and sexual activities, exercise tolerance, improvement of symptoms such as edema, fatigue, and dyspnea and reduction of mortality and readmission rates. Telerehabilitation was effective in improving quality of life in patients with HF (mean difference (MD) = -0,22; CI 95% -0.40 to 0.04. Conclusion: Telerehabilitation was at least as effective as usual care and conventional cardiac rehabilitation in improving the quality of life in patients with HF.

The Effect in Renal Function and Vascular Decongestion in Type 1 Cardiorenal Syndrome Treated with Two Strategies of Diuretics, a Pilot Randomized Trial.

AIM: The main treatment strategy in type 1 cardiorenal syndrome (CRS1) is vascular decongestion. It is probable that sequential blockage of the renal tubule with combined diuretics (CD) will obtain similar benefits compared with stepped-dose furosemide (SF). METHODS: In a pilot double-blind randomized controlled trial of CRS1 patients were allocated in a 1:1 fashion to SF or CD. The SF group received a continuous infusion of furosemide 100 mg during the first day, with daily incremental doses to 200 mg, 300 mg and 400 mg. The CD group received a combination of diuretics, including 4 consecutive days of oral chlorthalidone 50 mg, spironolactone 50 mg and infusion of furosemide 100 mg. The objectives were to assess renal function recovery and variables associated with vascular decongestion. RESULTS: From July 2017 to February 2020, 80 patients were randomized, 40 to the SF and 40 to the CD group. Groups were similar at baseline and had several very high-risk features. Their mean age was 59 ± 14.5 years, there were 37 men (46.2%). The primary endpoint occurred in 20% of the SF group and 15.2% of the DC group (p = 0.49). All secondary and exploratory endpoints were similar between groups. Adverse events occurred frequently (85%) with no differences between groups (p = 0.53). CONCLUSION: In patients with CRS1 and a high risk of resistance to diuretics, the use of CD compared to SF offers the same results in renal recovery, diuresis, vascular decongestion and adverse events, and it can be considered an alternative treatment. ClinicalTrials.gov with number NCT04393493 on 19/05/2020 retrospectively registered.

Insuficiencia cardiaca congestiva en el embarazo, secundaria a miocardiopatía periparto. Reporte de caso / Congestive heart failure in pregnancy secondary to peripartum cardiomyopathy. Case report

Resumen INTRODUCCIÓN: En Estados Unidos, las cardiopatías periparto se registran en 1 de cada 4000 pacientes. Se consideran idiopáticas y se asocian con enfermedades genéticas, problemas inmunológicos y malformaciones cardiacas, sin que se tenga certeza del origen real de este tipo de enfermedades. La miocardiopatía periparto se asocia con el embarazo y el puerperio; los criterios diagnósticos incluyen: a) insuficiencia cardiaca en las últimas cuatro semanas del embarazo o en los cinco meses siguientes al parto, b) ausencia de causas identificables de insuficiencia cardiaca, c) ausencia de enfermedad cardiaca demostrable antes de las últimas cuatro semanas del embarazo y alteración de la función del ventrículo izquierdo (fracción de eyección del ventrículo izquierdo, menor del 45%). La presentación del caso ayudará a que se tenga conocimiento de este problema. CASO CLINICO: Paciente de 26 años, en curso de las 35.4 semanas de embarazo, con inicio abrupto de signos de cardiopatía congestiva: tos, edema, taquicardia e hipertensión arterial. El embarazo finalizó por cesárea, con traslado inmediato a la unidad de cuidados intensivos. La ecocardiografía reportó una valvulopatía no conocida, insuficiencia ventricular izquierda y disminución de la fracción de eyección del ventrículo izquierdo; con lo anterior se integró el diagnóstico de miocardiopatía periparto. CONCLUSIONES: Las cardiopatías periperiparto son alteraciones excepcionales, con cuadros clínicos debidamente definidos y diagnóstico complejo. Las valvulopatías son el último diagnóstico diferencial de cardiopatía congestiva peripuerperal y se han descrito pocos casos asociados con miocardiopatía periparto.

Abstract BACKGROUND: Peripartum heart disease occurs in 1 out of 4000 cases in the United States; currently, its exact origin is unknown, which is why they are called idiopathic. Genetic diseases, immunological problems and heart malformations have been associated, without being certain about the real origin of these pathologies. Peripartum cardiomyopathy is a rare pathology associated with pregnancy and the puerperium, the diagnosis criteria includes: a) Development of heart failure in the last month of pregnancy or in the 5 months after delivery, b) absence of identifiable causes of heart failure, c) absence of demonstrable heart disease prior to the last month of pregnancy and impaired left ventricular function (FEVI less than 45%). The presentation of the case will help to raise awareness about this problem. CLINICAL CASE: A 26-year-old female patient coursing second gestation in the 35.4 pregnancy week, who debuts abruptly with signs of congestive heart disease such as cough, edema, tachycardia and arterial hypertension. The pregnancy was solved by cesarean section with a subsequent stay in Intensive Care Unit, an unknown valvular disease was identified by echocardiography, as well as left ventricular failure and decreased FEVI. Finally, a definitive diagnosis of peripartum cardiomyopathy was integrated. CONCLUSIONS: Peripartum heart disease is a rare occurrence, with well-defined clinical pictures, but difficult to approach and diagnose. Where valvular heart disease is the last differential diagnosis for peripuerperal congestive heart disease, and few cases associated with peripartum cardiomyopathy have been described.

Fibrosis endomiocárdica: una cardiomiopatía restrictiva en países en vía de desarrollo / Endomyocardial fibrosis: a restrictive cardiomyopathy in developing countries

Resumen Objetivo: La fibrosis endomiocárdica (FE) es una cardiomiopatía restrictiva infrecuente. En América Latina son escasos los reportes. En el presente trabajo se realiza una descripción de una serie de pacientes diagnosticados de FE en Colombia. Método: Realizamos una búsqueda en los registros de imágenes de resonancia magnética (RM) cardiaca realizadas en nuestra institución entre 2016 y 2019 en busca de pacientes con diagnóstico de FE. Se describieron sus características sociodemográficas, clínicas y de imagen. Resultados: Nueve pacientes fueron diagnosticados de FE (el 66.7% mujeres), con una edad promedio de 69 años. Los pacientes presentaron un promedio de 2.6 años de evolución. El principal síntoma referido fue disnea, seguido de síncope, dolor torácico y palpitaciones. En ninguno de ellos se sospechó FE como diagnóstico inicial. En cuanto a los hallazgos ecocardiográficos, se identificó compromiso predominante del ventrículo izquierdo, seguido de compromiso biventricular. Todos los pacientes presentaron patrón de llenado restrictivo con dilatación auricular izquierda severa. En el análisis retrospectivo se cumplieron los criterios de Mocumbi para el diagnóstico de FE en el 100% de los pacientes con gravedad moderada (77.8%). Las imágenes de RM mostraron función sistólica biventricular y volúmenes preservados. Se observó depósito focal de gadolinio subendocárdico a nivel apical y se confirmó la presencia de trombo en el 66% de los casos Conclusión:: La FE es una cardiomiopatía restrictiva infrecuente circunscrita a países tropicales. La mayoría de los pacientes en nuestra serie presentaron compromiso aislado del ventrículo izquierdo, seguido de compromiso biventricular, con función ventricular usualmente preservada.

Abstract Objective: Endomyocardial fibrosis (EF) is an unusual restrictive cardiomyopathy. In Latin America there are few reports. Here, we made a description of patients diagnosed with EF in Colombia. Method: We conducted a search in the records of cardiac magnetic resonance imaging (MRI) performed in our institution between 2016-2019 looking for patients with a diagnosis of EF; sociodemographic, clinical and imaging characteristics were described. Results: Nine patients were diagnosed with EF (66.7% female), with an average age of 69 years. Patients presented an average evolution of 2.6 years. The main reported symptom was dyspnea, followed by syncope, chest pain, and palpitations. None of them was initially suspected for EF. Regarding echocardiographic findings, predominant left ventricular involvement was identified, followed by bi-ventricular involvement. All the patients presented a restrictive filling pattern with severe left atrial dilation. In a retrospective analysis, Mocumbi criteria for diagnosis of EF were met in 100% of the patients, majority with moderate severity (77.8%). Cardiac MRI showed biventricular systolic function and volumes preserved. Focal subendocardial late gadolinium enhancement was observed on the apex and apical thrombus was confirmed in 66% of the patients Conclusion: FE is an uncommon restrictive cardiomyopathy limited to tropical countries. Most of patients in our series presented isolated involvement of left ventricle, followed by bi-ventricular involvement, with ventricular function usually preserved.

Endomyocardial fibrosis: a restrictive cardiomyopathy in developing countries.

OBJECTIVE: Endomyocardial fibrosis (EF) is an unusual restrictive cardiomyopathy. In Latin America there are few reports. Here, we made a description of patients diagnosed with EF in Colombia. METHOD: We conducted a search in the records of cardiac magnetic resonance imaging (MRI) performed in our institution between 2016-2019 looking for patients with a diagnosis of EF; sociodemographic, clinical and imaging characteristics were described. RESULTS: Nine patients were diagnosed with EF (66.7% female), with an average age of 69 years. Patients presented an average evolution of 2.6 years. The main reported symptom was dyspnea, followed by syncope, chest pain, and palpitations. None of them was initially suspected for EF. Regarding echocardiographic findings, predominant left ventricular involvement was identified, followed by bi-ventricular involvement. All the patients presented a restrictive filling pattern with severe left atrial dilation. In a retrospective analysis, Mocumbi criteria for diagnosis of EF were met in 100% of the patients, majority with moderate severity (77.8%). Cardiac MRI showed biventricular systolic function and volumes preserved. Focal subendocardial late gadolinium enhancement was observed on the apex and apical thrombus was confirmed in 66% of the patients. CONCLUSION: FE is an uncommon restrictive cardiomyopathy limited to tropical countries. Most of patients in our series presented isolated involvement of left ventricle, followed by bi-ventricular involvement, with ventricular function usually preserved.

OBJETIVO: La fibrosis endomiocárdica (FE) es una cardiomiopatía restrictiva infrecuente. En América Latina son escasos los reportes. En el presente trabajo se realiza una descripción de una serie de pacientes diagnosticados de FE en Colombia. MÉTODO: Realizamos una búsqueda en los registros de imágenes de resonancia magnética (RM) cardiaca realizadas en nuestra institución entre 2016 y 2019 en busca de pacientes con diagnóstico de FE. Se describieron sus características sociodemográficas, clínicas y de imagen. RESULTADOS: Nueve pacientes fueron diagnosticados de FE (el 66.7% mujeres), con una edad promedio de 69 años. Los pacientes presentaron un promedio de 2.6 años de evolución. El principal síntoma referido fue disnea, seguido de síncope, dolor torácico y palpitaciones. En ninguno de ellos se sospechó FE como diagnóstico inicial. En cuanto a los hallazgos ecocardiográficos, se identificó compromiso predominante del ventrículo izquierdo, seguido de compromiso biventricular. Todos los pacientes presentaron patrón de llenado restrictivo con dilatación auricular izquierda severa. En el análisis retrospectivo se cumplieron los criterios de Mocumbi para el diagnóstico de FE en el 100% de los pacientes con gravedad moderada (77.8%). Las imágenes de RM mostraron función sistólica biventricular y volúmenes preservados. Se observó depósito focal de gadolinio subendocárdico a nivel apical y se confirmó la presencia de trombo en el 66% de los casos. CONCLUSIÓN: La FE es una cardiomiopatía restrictiva infrecuente circunscrita a países tropicales. La mayoría de los pacientes en nuestra serie presentaron compromiso aislado del ventrículo izquierdo, seguido de compromiso biventricular, con función ventricular usualmente preservada.

Evaluation of super-responders to cardiac resynchronization therapy in the presence of left bundle branch block and absence of scar in the posterolateral wall of the left ventricle.

Patients with heart failure (HF) undergoing cardiac resynchronization therapy (CRT) who exhibit above-expected improvement are known as super-responders. We assessed the rate of super-responders in a population with left bundle branch block (LBBB) > 150 ms in the absence of scar tissue in the left ventricular posterolateral wall as well as prognostic variables. In this prospective observational cohort study (n=20) an electrocardiogram (ECG) was performed pre- and post-CRT. The classic and Strauss LBBB criteria were adopted (> 150 ms). The percent (%) reduction of the QRS was calculated after implantation. All patients responded to the Minnesota Living with Heart Failure questionnaire and underwent an echocardiogram to measure left ventricular ejection function (LVEF), left atrium (LA) diameter, left ventricular end-systolic volume (LVEDV), left ventricular end-diastolic volume (LVESV), and left ventricular end-diastolic diameter (LVEDD) pre- and 6 months post-CRT. Cardiac magnetic resonance imaging (MRI) measured the presence of scar tissue in the posterolateral LV wall and the total scar burden (% LV mass). Fisher's exact test and the Mann-Whitney test were performed to evaluate possible prognostic variables. The mean age was 58.20±8.79 years old, 60% female, with a mean LVEF of 28.15±5.10%, ECG with LBBB mean QRS of 162.15±7.86 ms, LBBB > 150 ms with Strauss standard in 90% of cases, and 90% with non-ischemic cardiomyopathy. Twelve cases (60%) of super-responders (reduction > 30% LVESV after 6 months) were observed. Super-responders did not present a difference in response in sex (12 vs 8 P=0.67), age (58.67 vs 57.7 P=087), Minnesota quality of life (55.50 vs 67.70 P=0.2), % initial QRS reduction (21.16 vs 18.69 P=0.21), LVEF (29.25 vs 26.5 P=0.38), LVEDD (66.33 vs 67.67 P=0.83), LVEDV (211.16 vs 228.53 P=0.75), LVESV (145.83 vs 167.00 P=0.75), or LA diameter (41.58 vs 43.63 P=0.45). The presence of LBBB > 150 ms, using the Strauss standard (90%) and the absence of scar in the posterolateral wall may account for these positive results. Super-responders benefit the most from CRT, and the results of this study can contribute to a better selection of CRT candidates.

Relationship between air pollution and hospitalizations for congestive heart failure in elderly people in the city of São Paulo.

To evaluate the effects of air pollutants on hospitalizations of elderly people for congestive heart failure (CHF) in the city of São Paulo, stratified by sex, exploring lag structures, from 2000 to 2013. Ecological time series study using information on hospitalization of elderly patients for CHF (ICD-10th: I50) obtained from DATASUS for the city of São Paulo. Information on O3, PM10, NO2, SO2, CO, temperature and humidity was obtained from CETESB. Descriptive analyses, Pearson correlation, and generalized linear Poisson regression model were applied to estimate the effects of pollutants. The interquartile variations of O3 (52.45 µg/m3), PM10 (24.28 µg/m3), NO2 (7.63 µg/m3), SO2 (50.22 µg/m3), and CO (1.28 ppm) were associated with increased hospitalizations for CHF. Air pollutants continue to be a factor that contributes to the increase in the number of hospitalizations due to CHF.

Digitoxin Attenuates Heart Failure, Reduces Myocardial Hypertrophy, and Preserves the Calcium-Binding Proteins in Infarcted Rats.

We previously showed that digitoxin prolongs the survival of rats with heart failure due to myocardial infarction (MI). In this study, we evaluated the effect of digitoxin on myocardial structure, ventricular function, and proteins involved in calcium kinetics. Seventy-two rats with MI >35% of the left ventricle were randomly assigned to 4 treatment groups: sham (n = 15), digitoxin (n = 11), infarction (n = 20), and infarction + digitoxin (n = 26). The rats were assessed 120 days after surgery by echocardiogram, hemodynamics, papillary muscle mechanics, collagen content, cardiomyocyte nuclear volume, and Western blot analysis of proteins involved in calcium kinetics. Digitoxin was administered via the rat chow. Two-way analysis of variance was used for comparisons. Myocardial infarction caused inotropic impairment, pulmonary congestion, increase of nuclear volume, myocardial collagen, and Na+/Ca2+ exchanger levels, and decreased SERCA2 and phosphorylated phospholamban levels. Treatment with digitoxin showed improvements in cardiac remodeling, inotropism, ventricular performance, pulmonary congestion, collagen accumulation, nuclear volume, and proteins involved in calcium kinetics. In rats with heart failure due to MI, long-term treatment with digitoxin attenuates congestive heart failure, mitigates myocardial remodeling and contractile impairment, and preserves myocardial levels of proteins involved in calcium kinetics.

Adductor pollicis muscle and nutritional status in heart failure patients: Is there an association?

OBJECTIVES: Adductor pollicis muscle thickness (APMT) has been used as a simple index for muscle mass for the assessment of nutritional status among hospitalized patients to identify malnutrition. The aim of this study was to evaluate the association between APMT and nutritional status in clinical patients diagnosed with congestive heart failure (CHF). METHODS: APMT was measured in 500 patients with CHF on the dominant side. Nutritional status was assessed means of by the Subjective Global Assessment (SGA). Functional classification was performed according to guidelines provided by the New York Heart Association (NYHA), which establishes four categories of CHF severity. Poisson regression was used to verify the association of APMT, malnutrition, and severity of CHF. P ≤ 0.05 was considered statistically significant. RESULTS: The malnutrition prevalence varied from 1.5% in patients with functional class I CHF to 96.2% in patients classified as functional class IV (P ≤ 0.001). In both sexes, APMT values were significantly lower in patients who were malnourished (P< 0.001). The proportion of patients with CHF and malnutrition was higher among women than men (47.2 versus 37.4%, P = 0.027). Malnutrition was slightly more common among patients ≥60 y of age compared with other age groups (48.3%, P ≤ 0.001). APMT is a significant protective factor for malnutrition even after controlling for sex, age, body mass index, and CHF functional class. CONCLUSIONS: Malnutrition is highly prevalent among patients with CHF and is associated with functional class. APMT may be used as a simple index for muscle mass for the assessment of nutritional status in these patient populations, and is also associated with malnutrition in these patients, even after controlling for other risk factors.

Efeitos da pressão positiva contínua e de dois níveis na via aérea em edema agudo de pulmão cardiogênico: uma revisão sistemática / Effects of continuous positive pressure and of two levels on the airline in acute cardiogenic lung edema: a systematic review

INTRODUÇÃO: O edema agudo de pulmão cardiogênico (EAPC) representa uma importante causa de insuficiência respiratória aguda podendo ser atenuada com a instalação de ventilação mecânica não-invasiva (VNI). OBJETIVO: Comparar pressão positiva contínua (CPAP) e pressão positiva de dois níveis (BIPAP) na via aérea em pacientes adultos com EAPC, quanto à função pulmonar, ao tempo de permanência, suas complicações e a dispneia através de uma revisão sistemática. METODOLOGIA: Ensaios clínicos controlados e randomizados (ECR), revisados por dois revisores independentes, conforme recomendações PRISMA, nas bases de dados PubMed e Biblioteca Cochrane. Incluídos estudos originais que utilizaram a CPAP e a BIPAP em pacientes com EAPC publicados na língua inglesa. A Escala PEDro foi utilizada para analisar a qualidade metodológica dos estudos e a Cochrane Collaboration para análise de risco de viés. RESULTADOS: Foram incluídos 13 artigos, publicados entre os anos 1997 e 2014. Os níveis de CPAP variaram entre 5 e 20 cmH2O nos estudos, e BIPAP apresentou-se com pressão inspiratória positiva (IPAP) entre 8 e 20 cmH2O e pressão expiratória positiva (PEEP) entre 3 e 10 cmH2O. Os estudos apresentaram CPAP e BIPAP sem diferença estatisticamente significante para a melhora da função pulmonar (FR, PaO2 e PaCO2), tempo de internamento, taxas de mortalidade, entubação e infarto agudo do miocárdio (IAM); mostrando-se como modalidades igualmente eficazes. CONCLUSÃO: CPAP e a BIPAP garantem os mesmos efeitos para melhora da função pulmonar, não mantém relação com a permanência da internação e complicações, e melhoram o quadro de dispneia.

INTRODUCTION: Acute cardiogenic lung edema (EAPC) represents an important cause of acute respiratory failure and can be attenuated with the installation of non-invasive mechanical ventilation (NIV). OBJECTIVE: To compare the use of continuous positive pressure (CPAP) and two-way positive airway pressure (BIPAP) in adult patients with acute pulmonary edema of pulmonary function, length of stay and complications, and dyspnea through a systematic review METHODOLOGY: Systematic review of randomized controlled trials (RCTs) performed by two independent reviewers, as recommended by the PRISMA platform, in the PubMed and Cochrane Library databases. Original studies using CPAP and BIPAP were used in patients with acute cardiogenic lung edema published in English. The PEDro Scale was used to analyze the methodological quality of the studies and Cochrane Collaboration. RESULTS: We included 13 articles, published between 1997 and 2014. CPAP levels ranged from 5 to 20 cmH2O in the studies, and BIPAP presented positive inspiratory pressure (IPAP) between 8 and 20 cmH2O and positive expiratory pressure (EPAP) between 3 and 10 cmH2O. The studies presented CPAP and BIPAP without statistically significant difference for the improvement of the pulmonary function (FR, PaO2 and PaCO2), permanence of hospitalization, mortality rates, intubation and acute myocardial infarction (AMI); as equally effective modalities. CONCLUSION: CPAP and BIPAP guarantee the same effects to improve pulmonary function, does not maintain relation with the permanence of hospitalization and complications, namely: mortality, intubation and AMI, and improve dyspnea.

Multifractal Spectrum Curvature of RR Tachograms of Healthy People and Patients with Congestive Heart Failure, a New Tool to Assess Health Conditions.

We calculate the multifractal spectra of heartbeat RR-interval time series (tachograms) of healthy subjects and patients with congestive heart failure (CHF). From these time series, we obtained new subseries of 6 h durations when healthy persons and patients were asleep and awake respectively. For each time series and subseries, we worked out the multifractal spectra with the Chhabra and Jensen method and found that their graphs have different shapes for CHF patients and healthy persons. We suggest to measure two parameters: the curvature around the maximum and the symmetry for all these multifractal spectra graphs, because these parameters were different for healthy and CHF subjects. Multifractal spectra of healthy subjects tend to be right skewed especially when the subjects are asleep and the curvature around the maximum is small compared with the curvature around the maximum of the CHF multifractal spectra; that is, the spectra of patients tend to be more pointed around the maximum. In CHF patients, we also have encountered differences in the curvature of the multifractal spectra depending on their respective New York Heart Association (NYHA) index.

Major Predictors of Incidence of Congestive Heart Failure and the Responsive Character of Enteral Nutrition: Meta-Analysis.

BACKGROUND: Statistical data from the USA estimate that 5.7 million Americans over 20 years of age have congestive heart failure (CHF) and this number is expected to increase approximately 46.0% between 2012 and 2030. In Brazil, there are no epidemiological studies involving the incidence of heart failure; however, according to other countries, it can be estimated that up to 6.4 million Brazilians suffer from this syndrome. Randomized and controlled clinical studies on the efficacy of enteral nutrition (EN) in patients with CHF are lacking. The aim of the present study was to perform a systematic review of the main predictors of CHF that promote EN, as well as to find if the literary findings were conclusive in the efficacy of EN for treatment and prophylaxis of CHF. METHODS: A total of 105 papers were submitted to the eligibility analysis, after which 28 studies were selected, following the rules of the systematic review - PRISMA. The search strategy was followed in MEDLINE/Pubmed, Web of Science, ScienceDirect Journals (Elsevier), Scopus (Elsevier) and ONEFile (Gale), with the following steps: search for mesh terms and use of bouleanos "and" between terms and "or" between historical findings. RESULTS: The present study listed the major predictors of CHF with indication for EN. After testing the normality of each group of variables of causes of decompensation in CHF, it was analyzed that all the variables did not present normal distribution, with P < 0.10. Thus, a non-parametric Kruskal-Wallis analysis was performed, obtaining P > 0.05 in all analyses, that is, in all groups of causes of decompensation in CHF, there was no statistical difference in each group studied. CONCLUSION: There is still no known influence of the efficacy of EN on increasing survival and reducing the morbidity of patients with CHF because there are few clinical trials that have evaluated this question; however, EN is very indicated in the attempt to mitigate the weight loss in these patients.

Blood lactate increases with the progression of mitral valve disease in dogs / Aumento de lactato sanguíneo com progressão de valvopatia mitral em cães

In dogs with congestive heart failure, the upregulated sympathetic tone causes vasoconstriction that impairs peripheral blood supply, therefore causing the accumulation of lactate. In this prospective cross-sectional study with a longitudinal component, blood lactate was quantified in 10 healthy and 34 myxomatous mitral valve disease (MMVD) dogs to investigate its potential use as a diagnostic and prognostic biomarker. While there were no differences in lactate concentration between control animals and stages B1 (3.31±0.62mmol/L) and B2 (3.32±0.46mmol/L) dogs, significant differences were found between healthy (2.50±0.69mmol/L) and both C (3.99±0.47mmol/L) and D (6.97±1.23mmol/L) animals. When a cut-off of 3.35mmol/L was used, lactate was able to distinguish dogs with normal and remodeled hearts with a sensitivity of 78.2% and specificity of 63.6%. Also, significant correlations existed between lactate and indicators of cardiac remodeling. Finally, animals with blood lactate <3.5mmol/L carried a better prognosis when compared with dogs in which lactate was >5.0mmol/L. Our results suggest that the progression of MMVD results in accumulation of lactate within the bloodstream, which is likely attributable to the impaired peripheral tissue perfusion. In MMVD dogs, blood lactate may be used as a surrogate for cardiac remodeling, and an increased concentration is associated with a worse prognosis regarding the time to evolve into congestive heart failure.(AU)

Em cães com insuficiência cardíaca congestiva, o tônus simpático hiperregulado causa vasoconstrição e interfere com o suprimento sanguíneo periférico, resultando no acúmulo de lactato. Neste estudo prospectivo transversal com um componente longitudinal, o lactato sanguíneo foi quantificado em 10 cães saudáveis e 34 cães com doença mixomatosa da valva mitral (DMVM) para investigar seu potencial como biomarcador diagnóstico e prognóstico. Embora não tenham sido identificadas diferenças na concentração de lactato entre animais controle e cães com DMVM nos estágios B1 (3,31±0,62mmol/L) e B2 (3,32±0,46mmol/L), diferenças significativas foram constatadas entre os cães saudáveis (2,50±0,69mmol/L) e cães com DMVM estágio C (3,99±0,47mmol/L) ou D (6,97±1,23mmol/L). Quando utilizado o valor de corte de 3,35mmol/L, o lactato foi capaz de diferenciar cães com corações normais daqueles com corações remodelados com sensibilidade de 78,2% e especificidade de 63,6%. Além disso, correlações significativas foram encontradas entre o lactato e os indicadores de remodelamento cardíaco. Por fim, os animais com lactato sanguíneo <3,5mmol/L tiveram prognóstico melhor comparativamente aos cães com concentrações >5,0mmol/L. Nossos resultados sugerem que a progressão da DMVM resulta no acúmulo de lactato na corrente sanguínea, fato que é provavelmente atribuído à perfusão periférica prejudicada. Em cães com DMVM, o lactato sanguíneo pode ser utilizado como indicador de remodelamento cardíaco, cuja concentração elevada está associada com pior prognóstico relativo ao tempo para evoluir para insuficiência cardíaca congestiva.(AU)

Blood lactate increases with the progression of mitral valve disease in dogs / Aumento de lactato sanguíneo com progressão de valvopatia mitral em cães

In dogs with congestive heart failure, the upregulated sympathetic tone causes vasoconstriction that impairs peripheral blood supply, therefore causing the accumulation of lactate. In this prospective cross-sectional study with a longitudinal component, blood lactate was quantified in 10 healthy and 34 myxomatous mitral valve disease (MMVD) dogs to investigate its potential use as a diagnostic and prognostic biomarker. While there were no differences in lactate concentration between control animals and stages B1 (3.31±0.62mmol/L) and B2 (3.32±0.46mmol/L) dogs, significant differences were found between healthy (2.50±0.69mmol/L) and both C (3.99±0.47mmol/L) and D (6.97±1.23mmol/L) animals. When a cut-off of 3.35mmol/L was used, lactate was able to distinguish dogs with normal and remodeled hearts with a sensitivity of 78.2% and specificity of 63.6%. Also, significant correlations existed between lactate and indicators of cardiac remodeling. Finally, animals with blood lactate <3.5mmol/L carried a better prognosis when compared with dogs in which lactate was >5.0mmol/L. Our results suggest that the progression of MMVD results in accumulation of lactate within the bloodstream, which is likely attributable to the impaired peripheral tissue perfusion. In MMVD dogs, blood lactate may be used as a surrogate for cardiac remodeling, and an increased concentration is associated with a worse prognosis regarding the time to evolve into congestive heart failure.(AU)

Em cães com insuficiência cardíaca congestiva, o tônus simpático hiperregulado causa vasoconstrição e interfere com o suprimento sanguíneo periférico, resultando no acúmulo de lactato. Neste estudo prospectivo transversal com um componente longitudinal, o lactato sanguíneo foi quantificado em 10 cães saudáveis e 34 cães com doença mixomatosa da valva mitral (DMVM) para investigar seu potencial como biomarcador diagnóstico e prognóstico. Embora não tenham sido identificadas diferenças na concentração de lactato entre animais controle e cães com DMVM nos estágios B1 (3,31±0,62mmol/L) e B2 (3,32±0,46mmol/L), diferenças significativas foram constatadas entre os cães saudáveis (2,50±0,69mmol/L) e cães com DMVM estágio C (3,99±0,47mmol/L) ou D (6,97±1,23mmol/L). Quando utilizado o valor de corte de 3,35mmol/L, o lactato foi capaz de diferenciar cães com corações normais daqueles com corações remodelados com sensibilidade de 78,2% e especificidade de 63,6%. Além disso, correlações significativas foram encontradas entre o lactato e os indicadores de remodelamento cardíaco. Por fim, os animais com lactato sanguíneo <3,5mmol/L tiveram prognóstico melhor comparativamente aos cães com concentrações >5,0mmol/L. Nossos resultados sugerem que a progressão da DMVM resulta no acúmulo de lactato na corrente sanguínea, fato que é provavelmente atribuído à perfusão periférica prejudicada. Em cães com DMVM, o lactato sanguíneo pode ser utilizado como indicador de remodelamento cardíaco, cuja concentração elevada está associada com pior prognóstico relativo ao tempo para evoluir para insuficiência cardíaca congestiva.(AU)

Usefulness of Routine Transtelephonic Monitoring for Supraventricular Tachycardia in Infants.

OBJECTIVE: We hypothesize that routine daily transtelephonic monitoring (TTM) transmissions can accurately detect supraventricular tachycardia (SVT) in asymptomatic infants and/or assuage parental concerns rather than being used solely to diagnose arrhythmias. STUDY DESIGN: Single center, retrospective chart review of 60 patients with fetal or infant SVT prescribed TTM for at least 30 days, January 2010-September 2016. Patients were excluded if initial SVT was not documented, was perioperative, was atrial flutter/fibrillation, or chaotic atrial tachycardia. Categorical variables expressed as mean ± SD. Mann-Whitney, Spearman correlation, and Fisher exact tests were used for continuous and categorical variables respectively. RESULTS: Sixty patients were included. There were 2688 TTM transmissions received from 55 of 60 patients over 61.1 ± 66.7 days (0.73 ± 0.65 TTM/patient/days). Routine asymptomatic TTM transmissions revealed actionable findings in 5 of 2801 TTM transmissions sent by 5 patients (8.3%). No patient presented in shock or died. Forty-five of 2688 TTM transmissions were sent for parental concerns/symptoms in 16 patients (25.8%) with findings of normal sinus rhythm in 37 of 45 TTM transmissions and SVT in 8 of 45 TTM transmissions. Symptomatic actionable findings were more likely sent by patients discharged on class I or III antiarrhythmics (95% CI = 11.5%-68.3%, P = .004) and patients with prolonged initial hospitalizations (95% CI = 6.98%-59.7%, P = .01). Flecainide was discontinued in 1 patient after widened QRS was noted on routine TTM. CONCLUSIONS: TTM accurately diagnose asymptomatic recurrent SVT in neonates and infants before they develop signs of congestive heart failure or shock and is helpful for recurrent SVT management.

Quality of life in patients with implantable cardioverter-defibrillator: systematic review of randomized controlled trials.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) therapy significantly improves the survival of patients who are at high risk for sudden cardiac death. However, it is unclear whether this survival is accompanied by impairment on quality of life (QoL). OBJECTIVES: This systematic review sought to describe whether ICD therapy, as compared with standard treatment, can have an impact on QoL outcomes. METHODS: Extensive literature searches were carried out in PubMed, EMBASE, LILACS and Cochrane Library. Eligible studies were randomized controlled trials (RCTs) of ICD versus medical therapy that reported valid and reliable measures of QoL. Included studies were reviewed to determine baseline patient characteristics, mean duration of follow-up, questionnaires used to assess QoL and association between QoL scores and ICD shock therapy. RESULTS: Seven studies, enrolling a total of 5,701 patients, were included in this review. The analyzed trials showed conflicting results about the impact of ICD on QoL outcomes. Among the secondary prevention studies, CIDS reported a clear benefit from ICD and AVID showed no difference between ICD and amiodarone groups. Of the primary prevention trials, AMIOVIRT, MADIT II, DEFINITE, and SCD-HeFT found no evidence of impaired QoL in patients with an ICD. Evidence for an association between ICD shocks and QoL was mixed and seemed to depend on the interval between shocks and QoL assessment. CONCLUSION: There was no evidence of impaired QoL in patients with an ICD. However, ICD patients must be educated of all possible risks and benefits, including transitory declines in QoL after ICD shocks.

Estenose de valva mitral associada a um trombo na aurícula esquerda em cão / Mitral valve stenosis associated with a left auricle thrombus in a dog

Background: Mitral valve stenosis is a congenital or acquired condition characterized by the narrowing of the orifice of the mitral valve of the heart. It causes flow obstruction and inadequate left ventricular filling, leading to increased left atrial pressure, left atrial and auricle enlargement, pulmonary venous congestion, and left-sided congestive heart failure. Mitral valve stenosis is extremely rare in dogs, and mitral valve stenosis associated with thrombus is even less common in this species. The etiology of thrombus development in mitral valve stenosis in dogs is still not clear. In human beings, mitral valve stenosis associated with thrombus has been related to rheumatic fever. This paper aims to report a case of mitral valve stenosis associated with a left auricle thrombus in a dog.Case: A small mixed-breed, 9-year-old, spayed female dog was received by the emergency service of the veterinary hospital a few hours after a syncopal episode. The dog presented dyspnea, apathy, and appetite loss for a week. At physical examination, the dog had pale and cyanotic mucous membranes, 92 mmHg systolic blood pressure, 7% dehydration, and 36.9°C rectal temperature. Cardiac auscultation revealed tachyarrhythmia and diastolic murmur grade IV/VI on the left cardiac apex. During pulmonary auscultation, bilateral crackles were noted. Electrocardiography showed sinus tachycardia with supraventricular tachycardia episodes, increased P wave amplitude and duration, and increased QRS complex duration. Generalized cardiomegaly was noted in thoracic radiography with enlarged left atrium, left cardiac edge bulging, pulmonary hypertension and congestion signs, as well as areas of pulmonary opacification.[...](AU)