Thermal vasodilation using a portable infrared thermal blanket in decompensated heart failure.

Adjunctive and non-pharmacological therapies, such as heat, for the treatment of heart failure patients have been proposed. Positive results have been obtained in clinically stable patients, but no studies of the use of thermal therapy in patients with decompensated heart failure (DHF) have been reported. An open randomized clinical trial was designed in patients with DHF and controls. We studied 38 patients with a mean age of 56.9 years. A total of 86.8% were men, and 71% had nonischemic myocardiopathy. All participants were using dobutamine, and the median brain natriuretic peptide (BNP) level was 1396 pg/mL. An infrared thermal blanket heated the patients, who were divided into 2 groups: group T (thermal therapy) and group C (control). Group T underwent vasodilation using the thermal blanket at 50°C for 40 minutes in addition to drug treatment. The cardiac index increased by 24.1% (P = 0.009), and systemic vascular resistance decreased by 16.0% in group T (P < 0.024) after thermal therapy. Heat as a vasodilator increased the cardiac index and lowered systemic vascular resistance in DHF patients. These data suggest thermal therapy as a therapeutic approach for the adjuvant treatment of DHF patients.

Role of BNP levels on the prognosis of decompensated advanced heart failure.

BACKGROUND: Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES: To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS: 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS: BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION: In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

Papel dos níveis de BNP no prognóstico da insuficiência cardíaca avançada descompensada / Role of BNP levels on the prognosis of decompensated advanced heart failure

FUNDAMENTO: A insuficiência cardíaca (IC) é doença que cursa com má evolução, especialmente naqueles com IC avançada. A dosagem de peptídeo natriurético tipo B(BNP), ao lado da utilidade no diagnóstico da descompensação cardíaca, vem se mostrando útil na avaliação prognóstica. OBJETIVOS: Verificar se os níveis de BNP identificam quais pacientes evoluiriam pior e se o BNP seria fator independente de mortalidade considerando-se idade, sexo, funções cardíaca e renal e etiologia da cardiopatia. MÉTODOS: 189 pacientes com IC avançada em classe funcional III/IV foram estudados. Todos tinham disfunção sistólica e dosaram-se os níveis de BNP na hospitalização. Analisaram-se as variáveis relacionadas com a mortalidade através de análises univariada e multivariada. RESULTADOS: Os níveis de BNP foram mais elevados nos pacientes que morreram no primeiro ano de seguimento (1.861,9 versus 1.408,1 pg/dL; p = 0,044) e nos chagásicos (1.985 versus 1.452 pg/mL; p = 0,001), e esses pacientes chagásicos tiveram maior mortalidade no primeiro ano de seguimento (56% versus 35%; p = 0,010). Pela curva ROC, o valor de BNP de 1.400 pg/mL foi o melhor preditor de eventos, estando os valores elevados associados a FEVE mais baixa (0,23 versus 0,28; p = 0,002) e maior grau de disfunção renal (ureia média 92 versus 74,5 mg/dL; p = 0,002). CONCLUSÃO: Na IC avançada, os níveis elevados de BNP identificam pacientes com maior potencial de pior evolução. Os pacientes chagásicos apresentam níveis mais elevados de BNP do que as outras etiologias e têm pior evolução.

BACKGROUND: Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES: To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS: 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS: BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION: In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

É necessário suspender o betabloqueador na insuficiência cardíaca descompensada com baixo débito? / Is it necessary to suspend betablockers in decompensated heart failure with low output? / ¿Es necesario suspender el betabloqueante en la insuficiencia cardíaca descompensada con bajo débito?

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.

[Is it necessary to suspend betablockers in decompensated heart failure with low output?]. / É necessário suspender o betabloqueador na insuficiência cardíaca descompensada com baixo débito?

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.

Por que os portadores de cardiomiopatia chagásica têm pior evolução que os não-chagásicos? / Why do patients with chagasic cardiomyopathy have worse outcomes than those with non-chagasic cardiomyopathy?

FUNDAMENTO: A insuficiência cardíaca é uma doença de alta prevalência, com prognóstico dependente de diferentes fatores preditores. OBJETIVO: A doença de Chagas é um preditor de mau prognóstico em pacientes com insuficiência cardíaca (IC) crônica. O objetivo deste estudo é analisar se ela também prediz pior evolução para pacientes agudamente descompensados. MÉTODOS: Estudamos 417 pacientes hospitalizados por IC descompensada. A idade média foi de 51,8 anos, sendo 291 (69,8 por cento) homens. Os pacientes foram divididos em dois grupos: 133 (31,9 por cento) chagásicos (CH) e 284 com outras etiologias. Num subgrupo de 63 pacientes (15,1 por cento com doença de Chagas), dosaram-se citocinas e noradrenalina. RESULTADOS: Na internação, 24,6 por cento necessitaram de inotrópicos, e em um ano a mortalidade foi de 54,7 por cento. Os CH apresentaram maior mortalidade (69,2 por cento vs. 47,9 por cento, p < 0,001). Na comparação de dados, os CH eram mais jovens (47,6 vs. 53,8 anos, p < 0,001) e apresentavam, em média, PA sistólica (96,7 vs. 111,2 mmHg, p < 0,001), fração de ejeção (32,7 vs. 36,4 por cento, p < 0,001), Na sérico (134,6 vs. 136,0, p = 0,026) mais baixos e TNF-alfa mais elevado (33,3 vs. 14,8, p = 0,001). A presença de hipotensão necessitando de inotrópicos, o diâmetro diastólico do ventrículo esquerdo (VE), os dados de função renal, os níveis de interleucina-6 e os de noradrenalina não diferiram nos dois grupos. CONCLUSÃO: Os pacientes chagásicos hospitalizados com IC descompensada tiveram pior prognóstico quando comparados com aqueles de outras etiologias. Esse fato pode dever-se ao maior comprometimento cardíaco (fração de ejeção mais baixa), maior instabilidade hemodinâmica (pressão sistólica e freqüência cardíaca mais baixas) e maior ativação do sistema renina angiotensina (sódio mais baixo) e das citocinas (TNF-alfa).

BACKGROUND: Heart failure is a highly prevalent disease, the prognosis of which depends on different predictive factors. OBJECTIVE: Chagas disease is a predictor of poor prognosis in patients with chronic heart failure (HF). The purpose of this study is to investigate whether this condition also predicts poor outcome in acutely decompensated patients. METHODS: Four hundred and seventeen patients admitted for decompensated heart failure were studied. Mean age was 51.8 years, and 291 (69.8 percent) were male. They were divided into two groups: 133 (31.9 percent) patients with Chagas heart disease (CH) and 284 patients with heart failure of other etiologies. Cytokine and norepinephrine plasma levels were measured in a subgroup of 63 patients (15.1 percent with Chagas disease). RESULTS: At admission, 24.6 percent of the patients needed inotropic support, and one-year mortality was 54.7 percent. Mortality rates were higher in the CH group (69.2 percent vs. 47.9 percent, p < 0.001). When data were compared, patients with Chagas disease were younger (47.6 vs. 53.8 years, p < 0.001) and, on average, showed lower systolic blood pressure (96.7 vs. 111.2 mmHg, p < 0,001), ejection fraction (32.7 vs. 36.4 percent, p < 0.001), and serum Na (134.6 vs. 136.0, p = 0.026), in addition to higher TNF-α levels (33.3 vs. 14.8, p = 0.001). The presence of hypotension requiring inotropic support, left ventricular (LV) diastolic diameter, renal function findings, and interleukin-6 and norepinephrine plasma levels did not differ between both groups. CONCLUSION: Chagas disease patients admitted with decompensated heart failure had worse prognoses than patients with heart failure of other etiologies. This may be owing to a greater degree of cardiac impairment (lower ejection fraction) and hemodynamic instability (lower systolic blood pressure and heart rate), increased activation of the renin-angiotensin system (lower sodium), and increased cytokine levels (TNF-α).

Re-hospitalizações e morte por insuficiência cardíaca: índices ainda alarmantes / Hospital readmissions and death from heart failure: rates still alarming

FUNDAMENTO: Os pacientes com insuficiência cardíaca (IC) que necessitam ser hospitalizados para compensação constituem grupo de maior gravidade, que evoluem com alta mortalidade e alta taxa de re-hospitalizações. OBJETIVO: Procuramos avaliar a atual história natural da IC por meio da taxa de mortalidade e de re-hospitalizações, nessa nova era do bloqueio neuro-hormonal. MÉTODOS: Acompanhamos a evolução de 263 pacientes com FE média de 27,1 por cento, internados para compensação, entre janeiro de 2005 e outubro de 2006. Foram hospitalizados somente os pacientes que após avaliação e medicação no PS não estavam em condições de ter alta. Os pacientes encontravam-se em CF III/IV, a idade média foi de 59,9±15,2 anos, a maioria homens e 63,1 por cento necessitaram de inotrópicos para compensação na fase aguda. RESULTADOS: O tempo médio de internação foi de 25,1±16,7 dias. Durante a internação 23 (8,8 por cento) morreram. Após a alta, no período médio de seguimento de 370 dias, dos 240 que tiveram alta, 123 (51,2 por cento) procuraram o PS de 1 a 12 vezes (total de passagens: 350), sendo 76 re-internados, sendo a média de dias da re-hospitalização de 23,5±18,0. No primeiro ano de seguimento 62 (25,8 por cento) pacientes morreram. CONCLUSÃO: A IC continua evoluindo com alta mortalidade e alta taxa de re-hospitalização. Ao final do primeiro ano 44,5 por cento desses pacientes não necessitaram passar no PS ou morreram, números que indicam que devemos continuar dando grande atenção aos portadores de IC, na tentativa de mudar a história natural dos portadores dessa síndrome, cada vez mais freqüente.

BACKGROUND: Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES: We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS: We followed the progress of 263 patients with a mean EF of 27.1 percent, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9±15.2 years, most were men, and 63.1 percent required inotropic drugs for cardiac compensation in the acute phase. RESULTS: Average hospital stay was 25.1±16.7 days. During hospitalization, 23 (8.8 percent) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2 percent) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5±18.0 days. Over the first year of follow-up, 62 (25.8 percent) patients died. CONCLUSIONS: HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5 percent of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

Why do patients with chagasic cardiomyopathy have worse outcomes than those with non-chagasic cardiomyopathy?

BACKGROUND: Heart failure is a highly prevalent disease, the prognosis of which depends on different predictive factors. OBJECTIVE: Chagas disease is a predictor of poor prognosis in patients with chronic heart failure (HF). The purpose of this study is to investigate whether this condition also predicts poor outcome in acutely decompensated patients. METHODS: Four hundred and seventeen patients admitted for decompensated heart failure were studied. Mean age was 51.8 years, and 291 (69.8%) were male. They were divided into two groups: 133 (31.9%) patients with Chagas heart disease (CH) and 284 patients with heart failure of other etiologies. Cytokine and norepinephrine plasma levels were measured in a subgroup of 63 patients (15.1% with Chagas disease). RESULTS: At admission, 24.6% of the patients needed inotropic support, and one-year mortality was 54.7%. Mortality rates were higher in the CH group (69.2% vs. 47.9%, p < 0.001). When data were compared, patients with Chagas disease were younger (47.6 vs. 53.8 years, p < 0.001) and, on average, showed lower systolic blood pressure (96.7 vs. 111.2 mmHg, p < 0,001), ejection fraction (32.7 vs. 36.4%, p < 0.001), and serum Na (134.6 vs. 136.0, p = 0.026), in addition to higher TNF-alpha levels (33.3 vs. 14.8, p = 0.001). The presence of hypotension requiring inotropic support, left ventricular (LV) diastolic diameter, renal function findings, and interleukin-6 and norepinephrine plasma levels did not differ between both groups. CONCLUSION: Chagas disease patients admitted with decompensated heart failure had worse prognoses than patients with heart failure of other etiologies. This may be owing to a greater degree of cardiac impairment (lower ejection fraction) and hemodynamic instability (lower systolic blood pressure and heart rate), increased activation of the renin-angiotensin system (lower sodium), and increased cytokine levels (TNF-alpha).

Hospital readmissions and death from Heart Failure--rates still alarming.

BACKGROUND: Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES: We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS: We followed the progress of 263 patients with a mean EF of 27.1%, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9+/-15.2 years, most were men, and 63.1% required inotropic drugs for cardiac compensation in the acute phase. RESULTS: Average hospital stay was 25.1+/-16.7 days. During hospitalization, 23 (8.8%) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2%) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5+/-18.0 days. Over the first year of follow-up, 62 (25.8%) patients died. CONCLUSIONS: HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5% of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

[Serum NT-proBNP levels are a prognostic predictor in patients with advanced heart failure]. / O nível sérico de NT-proBNP é um preditor prognóstico em pacientes com insuficiência cardíaca avançada.

OBJECTIVE: To verify if the determination of NT-proBNP values would help predict the prognosis in advanced heart failure (HF) patients. METHODS: One hundred and five subjects with average age of 52.4 years were evaluated, 66.6% of them males. Thirty-three (32.0%) subjects were outpatients and 70 (67.9%) were inpatients (functional class III/IV) admitted to the hospital for cardiac compensation. All patients had left ventricular systolic dysfunction and a mean ejection fraction of 0.29. The NT-proBNP levels were measured in all patients and they were followed-up over a period from 2 to 90 days (average 77 days). A ROC curve was drawn to determine the best cut-off point, as well as the corresponding Kaplan-Meyer survival curves. RESULTS: During the follow-up period, 22 patients died. The average NT-proBNP value of the patients who remained alive was 6,443.67+/-6,071.62 pg/ml, whereas that of those who died was 14,609.66+/-12,165.15 pg/ml (p=0.001). The ROC curve identified a cut-off point at 6,000 pg/ml with 77.3% sensitivity (area under the curve: 0.74). The survival curve for values below and above 6,000 pg/ml was significantly different (p=0.002): patients with values below 6,000 pg/ml had a 90.2% 90-day survival, and those patients with values above, a 66% survival. CONCLUSION: Patients with advanced HF, especially those admitted to the hospital for cardiac compensation, had much higher NT-proBNP values, with a two-fold increase among those who died during the follow-up period. Values above 6,000 pg/ml identify the patients most likely to die within 90 days after hospital discharge.

O nível sérico de NT-proBNP é um preditor prognóstico em pacientes com insuficiência cardíaca avançada / Serum NT-proBNP levels are a prognostic predictor in patients with advanced heart failure

OBJETIVO: Verificar se a dosagem de NT-proBNP seria de auxílio na predição do prognóstico de pacientes com insuficiência cardíaca (IC) avançada. MÉTODOS: Foram estudados 105 pacientes: 33 (32,0 por cento) do ambulatório e 70 (67,9 por cento) em classe funcional III/IV, hospitalizados para compensação cardíaca, com média de idade de 52,4 anos, dos quais, 66,6 por cento homens. Todos tinham disfunção sistólica do ventrículo esquerdo sendo a fração de ejeção média de 0,29. Em todos dosou-se o NT-proBNP e foram acompanhados por um período de 2 a 91 dias (média 77 dias). Construiu-se a curva ROC para determinação do melhor nível de corte e curvas de sobrevida Kaplan-Meyer de acordo com esse nível. RESULTADOS: Durante o período de seguimento, 22 pacientes (20,9 por cento) morreram. O NT-proBNP médio dos pacientes vivos foi de 6.443,67±6.071,62 pg/ml e dos que morreram foi de 14.609,66±12.165,15 pg/ml (p=0,001). A curva ROC identificou nível de corte de 6.000 pg/ml com sensibilidade de 77,3 por cento (área da curva de 0,74). A curva de sobrevida para valores abaixo e acima de 6.000 pg/ml diferiu significantemente (p=0,002) com os pacientes com valores abaixo de 6.000 pg/ml apresentando sobrevida de 90,2 por cento em 90 dias e os pacientes com valores superiores, sobrevida de 66,6 por cento. CONCLUSÃO: Os pacientes. com IC avançada, especialmente os internados para compensação, apresentam valores muito aumentados de NT-proBNP, sendo estes duas vezes mais elevados entre os que morreram no seguimento. Valor acima de 6.000 pg/ml identifica grupo de pacientes com alta probabilidade de morrer em 90 dias após a alta hospitalar.

[Cost analysis of the treatment of acute decompensated heart failure. Levosimendan versus dobutamine]. / Análise de custos do tratamento de episódios de descompensação aguda de insuficiência cardíaca. Levosimendan versus dobutamina.

OBJECTIVE: To assess whether the treatment with levosimendan is more expensive than the usual one with dobutamine, since price of medications does not usually represent the greatest expense in the treatment of cardiac decompensation. METHODS: The cost of treatment of 18 inpatients with cardiac decompensation, 9 of which treated with dobutamine (dobuta group) and 9 with levosimendan (levo group), was compared. Groups were similar concerning age, sex, functional class and cardiac function. RESULTS: Treatment costs were similar for both groups. In the levo group, the costs with the drug were higher than in the dobuta group, but those related to the length of stay in intensive care unit and to the material used during admission were lower. Levo-drug: R$ 5,414.00; material: R$ 399.90; hospital daily rates: R$ 5,061.20; professional honorarium: R$ 3,241.80; total costs: R$ 14,117.00. Dobuta-drug: R$ 2,320.10; materials: R$ 1,665.70; hospital daily rates: R$ 6,261.90; professional honorarium: R$ 3,894.30; total costs: R$ 14,142.00. CONCLUSION: Despite the higher price of levosimendan, the global cost of the treatment was similar for patients who were treated either with dobutamine or levosimendan. Patients who were treated with levosimendan had a shorter length of stay in intensive care unit.

Análise de custos do tratamento de episódios de descompensacão aguda de insuficiência cardíaca: levosimendan versus dobutamina / Cost analysis of the treatment of acute decompensated heart failure: levosimendan versus dobutamine

OBJETIVO: Verificar se o tratamento com levosimendan seria mais dispendioso que o usual com dobutamina, uma vez que o preco dos medicamentos não representa a maior despesa no tratamento da descompensacão cardíaca. MÉTODOS: Comparou-se o custo do tratamento de 18 pacientes hospitalizados devido a descompensacão cardíaca, 9 tratados com dobutamina (grupo dobuta) e 9 com levosimendan (grupo levo). Os grupos foram semelhantes quanto à idade, sexo, classe funcional e funcão cardíaca. RESULTADOS: O custo do tratamento foi semelhante para os dois grupos. No grupo levo as despesas com medicamentos foram maiores, mas as relativas ao período de terapia intensiva e do material empregado foram menores. Levo - medicamentos: R$ 5.414,00; materiais: R$ 399,90; diárias hospitalares: R$ 5.061,20; servicos profissionais: R$ 3.241,80; final: R$ 14.117,00. Dobuta - medicamentos: R$ 2.320,10; materiais: R$ 1.665,70; diárias hospitalares: R$ 6.261,90; servicos profissionais: R$ 3.894,30; final: R$ 14.142,00. CONCLUSAO: Apesar do preco mais elevado da droga, o custo global do tratamento foi semelhante para os pacientes tratados com dobutamina ou levosimendan. O paciente tratado com levosimendan permaneceu menos tempo em terapia intensiva.

[Major clinical characteristics of patients surviving 24 months or more after hospitalization due to decompensated heart failure]. / Principais características clínicas de pacientes que sobrevivem 24 meses ou mais após uma hospitalização devido a descompensação cardíaca.

OBJECTIVE: To study the major clinical characteristics of patients with heart failure who survived more than 24 months after hospitalization for compensation. METHODS: The study comprised 126 patients with heart failure in functional class III or IV, with a mean age of 51.7 years. Most patients were men (73%), had a mean ejection fraction (EF) of 0.36 and left ventricular diastolic diameter (DD) of 7.13 cm. The major clinical and laboratory characteristics were assessed, and, on follow-up, 25 (19.8%) patients, who survived more than 24 months after hospital discharge, were identified. Data of survivors (G1) were compared with those of patients who died (G2) before 24 months. RESULTS: In G1, the following levels were greater: serum sodium (138.3+/-3.4 vs 134.5+/-5.8 mEq/L; P=0.001); blood pressure levels (120.0 vs 96.7 mm Hg; P=0.003); and LVEF levels (0.40+/-0.08 vs 0.34+/-0.09; P=0.004); and the following levels were lower: urea (59.8 vs 76.3 mg/dL; P=0.007); prothrombin time (12.9 vs 14.8 seconds; P=0.001); LVDD (6.78+/-0.55 vs 7.22+/-0.91; P=0.003); and LA diameter (4.77 vs 4.99 cm; P=0.0003). More survivors were found among patients with idiopathic cardiomyopathy and arterial hypertension than among patients with Chagas' disease and coronary artery disease. In multivariate analysis, the following variables remained as independent predictors of mortality: LVDD > 7.8 cm (HR 1.95); Na < 132 mEq/L (HR 2.30); and prothrombin time > 14 seconds (HR 1.69). CONCLUSION: The study allowed predicting which patients with heart failure will have a good survival after hospital discharge and those with a greater chance of a long survival after discharge.

Principais características clínicas de pacientes que sobrevivem 24 meses ou mais após uma hospitalização devido a descompensação cardíaca / Major clinical characteristics of patients surviving 24 months or more after hospitalization due to decompensated heart failure

OBJETIVO: Estudar as principais características clínicas dos pacientes com insuficiência cardíaca sobreviventes há mais de 24 meses após hospitalização para compensação. MÉTODOS: Estudados 126 pacientes com insuficiência cardíaca, em classe funcional III ou IV, com idade média de 51,7 anos, a maioria homens (73 por cento), com fração de ejeção (FE) média de 0,36 e diâmetro diastólico (DD) do VE de 7,13 cm. Avaliaram-se as principais características clínicas e laboratoriais e no seguimento identificaram-se 25 (19.8 por cento) pacientes que sobreviveram mais de 24 meses após a alta hospitalar. Compararam-se os dados dos sobreviventes (G1) aos dos que faleceram (G2) antes de 24 meses. RESULTADOS: No G1 encontraram-se níveis mais elevados do sódio sérico (138,3±3,4 vs 134,5±5,8 mEq/l; p=0,001), da pressão arterial (120,0 vs 96,7 mmHg; p=0,003) e da FE do VE (0,40±0,08 vs 0,34±0,09; p=0,004) e valores menores da uréia (59,8 vs 76,3 mg/dl; p=0,007), do tempo de protrombina (12,9 vs 14,8s; p=0,001), do DDVE (6,78±0,55 vs 7,22±0,91; p=0,003) e do diâmetro do AE (4,77 vs 4,99cm; p=0,0003). Houve mais sobreviventes entre os portadores de cardiomiopatia idiopática e hipertensiva do que entre os chagásicos e doença coronariana. Na análise multivariada permaneceram como variáveis preditoras independentes da mortalidade o DDVE > 7,8 cm (HR 1,95), o Na < 132 mEq/l (HR 2,30) e o tempo de protrombina > 14 seg (HR 1,69). CONCLUSÃO: O estudo permite predizer quais os pacientes com insuficiência cardíaca que poderão apresentar uma boa sobrevida após a alta e os com maior possibilidade de longa sobrevivência após a alta.

Cardiologistas de um hospital escola adotam as diretrizes para o tratamento da insuficiência cardíaca? / Do cardiologists at a university hospital adopt the guidelines for the treatment of heart failure?

OBJECTIVE: To verify whether the guidelines for the treatment of heart failure have been adopted at a university hospital. The guidelines recommend the following: use of angiotensin-converting enzyme inhibitors for all patients with systolic ventricular dysfunction, use of digitalis and diuretics for symptomatic patients, use of beta-blockers for patients in functional classes II or III, use of spironolactone for patients in functional classes III or IV. METHODS: We analyzed the prescriptions of 199 patients. All these patients had ejection fraction (EF) <=0.50, their ages ranged from 25 to 86 years, and 142 were males. Cardiomyopathy was the most frequent diagnosis: 67 (33.6 percent) patients had dilated cardiomyopathy, 65 (32.6 percent) had ischemic cardiomyopathy. RESULTS: Angiotensin-converting enzyme inhibitors were prescribed for 93 percent of the patients. 71.8 percent also had a prescription for digitalis, 86.9 percent for diuretics, 27.6 percent for spironolactone, 12 percent for beta-blockers, 37.2 percent for acetylsalicylic acid, 6.5 percent for calcium channel antagonists, and 12.5 percent for anticoagulants. In regard to vasodilators, 71 percent of the patients were using captopril (85.2mg/day), 20 percent enalapril (21.4mg/day), 3 percent hydralazine and nitrates. In 71.8 percent of the cases, the dosages prescribed were in accordance with those recommended in the large studies. CONCLUSION: Most patients were prescribed the same doses as those recommended in the large studies. Brazilian patients tolerate well the doses recommended in the studies, and that not using these doses may be a consequence of the physician's fear of prescribing them and not of the patient's intolerance