Evaluation of the relationship between end-tidal carbon dioxide level and heart failure classification.

OBJECTIVE: Heart failure is a disease with cardiac dysfunction, and its morbidity and mortality are associated with the degree of dysfunction. The New York Heart Association classifies the heart failure stages based on the severity of symptoms and physical activity. End-tidal carbon dioxide refers to the level of carbon dioxide that a person exhales with each breath. End-tidal carbon dioxide levels can be used in many clinical conditions such as heart failure, asthma, and chronic obstructive pulmonary disease. The aim of the study was to reveal the relationship between end-tidal carbon dioxide levels and the New York Heart Association classification of heart failure stages. METHODS: This study was conducted at Kahramanmaras Sütçü Imam University Faculty of Medicine Adult Emergency Department between 01/03/2019 and 01/09/2019. A total of 80 patients who presented to the emergency department with a history of heart failure or were diagnosed with heart failure during admission were grouped according to the New York Heart Association classification of heart failure stages. The laboratory parameters, ejection fraction values, and end-tidal carbon dioxide levels of the patients were measured and recorded in the study forms. RESULTS: End-tidal carbon dioxide levels and ejection fraction values were found to be significantly lower in the stage 4 group compared to the other groups. Furthermore, pro-B-type natriuretic peptide (BNP) values were found to be significantly higher in stage 4 group compared to the other groups. CONCLUSION: It was concluded that end-tidal carbon dioxide levels could be used together with pro-BNP and ejection fraction values in determining the severity of heart failure.

Prevalencia, caracterización y pronóstico de pacientes con sospecha de insuficiencia cardíaca en atención primaria de salud en Chile / Characterization and prognosis of patients with suspected heart failure at primary health care institutions in Chile

Introducción: La insuficiencia cardíaca (IC) tiene alta morbilidad y mortalidad. Su diagnóstico temprano en atención primaria de salud (APS) es un reto dada la baja especificidad de sus criterios clínicos y las limitaciones en acceso a técnicas diagnósticas. Objetivo: Analizar la prevalencia de IC, subtipos y pronóstico de pacientes con disnea y/o edema de extremidades inferiores que consultan en APS. Metodología: Se trata de un estudio prospectivo de 340 pacientes en APS, sin diagnóstico previo de IC. Se realizó una evaluación clínica, electrocardiograma, NT-proBNP "point-of-care", ecocardiografía con interpretación telemática por cardiólogos. Utilizando los algoritmos HFA-PEFF y H2FPEF se clasificaron los pacientes como :1) IC con fracción de eyección (FE) reducida (ICFER); 2) IC con FE preservada (ICFEP) y 3) pacientes sin diagnóstico de IC. Se efectuó un análisis de sobrevida de los diferentes grupos. Resultados: La prevalencia de ICFER fue 8%, ICFEP por HFA-PEFF 42% y por H2FPEF 8%. Los algoritmos sugieren efectuar un estudio complementario en el 47% con HFA-PEFF y 76% con H2FPEF (p<0.05). La sobrevida global a 36 meses fue 90±2% y cardiovascular 95±1%. Usando HFA-PEFF, los pacientes con IC tuvieron menor sobrevida que aquellos sin IC (HR 2.3, IC95% 1.14.9; p=0.029). No hubo diferencias de mortalidad con H2FPEF. Conclusiones: En pacientes de APS que consultan por disnea y/o edema de extremidades inferiores sometidos a evaluación con NT-proBNP y ecocardiografía, se observó una prevalencia de IC de hasta 50%, 8% de ICFER y 42% de ICFEP. La caracterización de IC utilizando HFA-PEFF está asociada al pronóstico vital.

Background: Heart failure (HF) is a condition associated with high morbidity and mortality. Its early diagnosis in primary health care (PHC) represents a substantial challenge, considering its non-specific clinical manifestations and the limitations on timely access to diagnostic techniques. Objective: To evaluate the prevalence of HF, characterize subtypes and determine the prognosis of patients consulting in PHC for dyspnea Edema of the lower extremities. Methods: Prospective study in 340 patients who consulted in PHC, without previous diagnosis of HF. Clinical evaluation, electrocardiogram, NT-proBNP point-ofcare and echocardiography with telematic interpretation by cardiologists were performed. Using the HFA-PEFF and H2FPEF algorithms patients were classified as: 1) HF with reduced ejection fraction (HFREF); 2) HF with preserved ejection fraction (HFPEF) and 3) No HF. Actuarial survival analyses were performed. Results: We observed a prevalence of HFREF of 8%, high probability of HFPEF by HFA-PEFF in 42% and by H2FPEF in 8%. Intermediate probability of HFPEF, requiring complementary study, was observed in 47% of patients with HFA-PEFF and 76% of patients with H2FPEF (p<0.05). Overall survival at 36 months was 90±2% and cardiovascular survival at 36 months was 95±1%. Using HFA-PEFF, patients with HF presented lower overall survival compared to patients with no HF (HR 2.3, 95%CI 1.1-4.9; p=0.029). We did not observe mortality differences with H2FPEF. Conclusions: In patients consulting for dyspnea and/or lower extremity edema at PHC and undergoing evaluation with NT-proBNP and echocardiography, we observed a HF prevalence of 50%. HF classification through HFA-PEFF was associated with lower survival rates.

Insuficiencia cardíaca secundaria a cardiopatías congénitas y adquiridas en edades pediátricas / Heart Failure Secondary to Congenital and Acquired Heart Disease in the Pediatric Age Group

Introducción: Las cardiopatías congénitas son causa frecuente de insuficiencia cardíaca mientras las cardiopatías adquiridas resultan menos frecuentes. La expresión clínica difiere en gran manera de la población adulta y representa la emergencia cardiovascular más frecuente en pediatría. El diagnóstico es completamente clínico, y el tratamiento está encaminado a corregir la causa que la origina. Objetivo: Actualizar conceptos, fisiopatología, manifestaciones clínicas, y tratamiento de la insuficiencia cardíaca en pediatría. Métodos: Se revisaron las bases de datos Medline, PubMed, SciELO y plataforma Springerlink, disponibles desde Infomed; desde el año 2000 hasta 2020, en idioma español e inglés. Análisis y síntesis de la información: La insuficiencia cardíaca es un síndrome clínico resultado de disfunción ventricular, sobrecarga de presión o volumen, independiente o en combinación, que conlleva a signos y síntomas característicos. La identificación de su causa, el diagnóstico precoz y el tratamiento oportuno mejoraran el pronóstico de los pacientes aquejados. Conclusiones: La insuficiencia cardíaca en edad pediátrica representa una compleja afección de causas multifactoriales. El diagnóstico puede hacerse con el método clínico, complementándose con los diferentes exámenes. El tratamiento médico farmacológico o no, se encamina a tratar la causa, además de nuevas terapias en desarrollo prometedoras en el futuro(AU)

Introduction: Congenital heart disease is a frequent cause of heart failure while acquired heart disease is less frequent. The clinical expression differs greatly from the adult population and represents the most frequent cardiovascular emergency in pediatrics. Diagnosis is completely clinical and treatment is aimed at correcting the cause. Objective: To update concepts, pathophysiology, clinical manifestations and treatment of heart failure in pediatrics. Methods: The databases Medline, PubMed, SciELO and Springerlink platform, available from Infomed, were reviewed from 2000 to 2020, in Spanish and English. Analysis and synthesis of the information: Heart failure is a clinical syndrome resulting from ventricular dysfunction, pressure or volume overload, independently or in combination, leading to characteristic signs and symptoms. Identification of its cause, early diagnosis and timely treatment improve the prognosis of afflicted patients. Conclusions: Heart failure in pediatric age represented a complex condition with multifactorial causes. The diagnosis can be made with the clinical method, complemented with different examinations. Pharmacological or non-pharmacological medical treatment is aimed at treating the cause, in addition to promising new therapies under development in the future(AU)

Revisiting heart failure assessment based on objective measures in NYHA functional classes I and II.

OBJECTIVE: New York Heart Association (NYHA) functional class plays a central role in heart failure (HF) assessment but might be unreliable in mild presentations. We compared objective measures of HF functional evaluation between patients classified as NYHA I and II in the Rede Brasileira de Estudos em Insuficiência Cardíaca (ReBIC)-1 Trial. METHODS: The ReBIC-1 Trial included outpatients with stable HF with reduced ejection fraction. All patients had simultaneous protocol-defined assessment of NYHA class, 6 min walk test (6MWT), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and patient's self-perception of dyspnoea using a Visual Analogue Scale (VAS, range 0-100). RESULTS: Of 188 included patients with HF, 122 (65%) were classified as NYHA I and 66 (35%) as NYHA II at baseline. Although NYHA class I patients had lower dyspnoea VAS Scores (median 16 (IQR, 4-30) for class I vs 27.5 (11-49) for class II, p=0.001), overlap between classes was substantial (density overlap=60%). A similar profile was observed for NT-proBNP levels (620 pg/mL (248-1333) vs 778 (421-1737), p=0.015; overlap=78%) and for 6MWT distance (400 m (330-466) vs 351 m (286-408), p=0.028; overlap=64%). Among NYHA class I patients, 19%-34% had one marker of HF severity (VAS Score >30 points, 6MWT <300 m or NT-proBNP levels >1000 pg/mL) and 6%-10% had two of them. Temporal change in functional class was not accompanied by variation on dyspnoea VAS (p=0.14). CONCLUSIONS: Most patients classified as NYHA classes I and II had similar self-perception of their limitation, objective physical capabilities and levels of natriuretic peptides. These results suggest the NYHA classification poorly discriminates patients with mild HF.

Comparação entre classificação funcional e fração de ejeção em pacientes com insuficiência cardíaca na Doença de Chagas / Functional classification versus ejection fraction in patients with heart failure and Chagas Disease

Introdução: A doença de Chagas é uma infecção causada pelo protozoário Trypanosoma cruzi. É considerada um importante problema de saúde do mundo, tendo como manifestações a dilatação cardíaca, arritmias e morte. A insuficiência cardíaca é uma síndrome complexa e de elevada morbimortalidade, que evolui com complicações semelhantes. Para categorizar a gravidade da insuficiência cardíaca, utilizamos a classificação funcional da New York Heart Association, para estratificar risco e terapias para cardiopatias. Além disso, a reduzida fração de ejeção do ventrículo esquerdo, medida pelo ecocardiograma, tem relação direta com mau prognóstico. Objetivo: Comparar a relação entre a classificação funcional pela New York Heart Association e a medida da fração de ejeção do ventrículo esquerdo em pacientes ambulatoriais chagásicos e não chagásicos. Metódos: Estudo de corte transversal na coorte, composto de pacientes acompanhados em ambulatório de insuficiência cardíaca. Foram realizadas avaliação de prontuários, entrevista clínica e verificação da classificação funcional e da fração de ejeção do ventrículo esquerdo pelo ecocardiograma. Os dados foram arquivados em banco de dados e analisados pelo Statistical Package for the Social Sciences. Resultados: No período de agosto de 2018 a julho de 2019, foram selecionados 127 indivíduos com insuficiência cardíaca. Destes, 34 (26,8%) eram portadores da doença de Chagas e 93 (73,3%) eram não Chagas. Observou-se predominância do sexo masculino (53,5%) e de idade >60 anos (61,4%). Houve predomínio da classe funcional II nos grupos. Em relação à fração de ejeção dos pacientes chagásicos e não chagas, observou-se que, respectivamente, 71% contra 93% dos pacientes tinham fração de ejeção reduzida, 21% versus 6% tinham fração de ejeção intermediária e 8% versus 1% fração de ejeção preservada. Conclusão: Houve associação entre classe funcional avançada e reduzida fração de ejeção do ventrículo esquerdo principalmente em chagásicos, podendo ser usada para acompanhamento evolutivo ambulatorial. (AU)

Introduction: Chagas disease, an infection caused by the protozoan Trypanosoma cruzi, is an important health problem worldwide that causes cardiac dilation, arrhythmias, and death. Heart failure is a complex syndrome with high morbidity and mortality rates that progresses with similar complications. The New York Heart Association functional classification is used to categorize heart failure severity and stratify heart disease risks and therapies. A reduced left ventricular ejection fraction measured by echocardiography is directly related to a poor prognosis. Objective: To compare the relationship between New York Heart Association functional classification and left ventricular ejection fraction in Chagas versus no Chagas disease outpatients. Methods: Cross-sectional study in a cohort of patients followed at a heart failure clinic. Medical records, clinical interviews, functional classification, and left ventricular ejection fraction by echocardiography were analyzed. The data were filed in a database and analyzed using SPSS software. Results: A total of 127 patients with heart failure were selected from August 2018 to July 2019. Of them, 34 (26.8%) had Chagas disease and 93 (73.3%) had no Chagas disease. There was a predominance of men (53.5%) and patients aged > 60 years (61.4%). There was also a predominance of functional class II. Of the Chagas and no Chagas disease patients, 71% versus 93% had a reduced ejection fraction, 21% versus 6% had a mid-range ejection fraction, and 8% versus 1% had a preserved ejection fraction, respectively. Conclusion: There was an association between advanced functional class and reduced left ventricular ejection fraction, especially in Chagas patients, information that can be used for outpatient follow-up. (AU)

Achados ao ecocardiograma transtorácico em pacientes hospitalizados com COVID- 19: resultados do registro brasileiro de ecocardiografia durante a pandemia de COVID-19 (ECOVID) / Transthoracic echocardiography findings of hospitalized patients with COVID-19: results from the brazilian echocardiography registry during the COVID-19 Pandemic (ECOVID)

Fundamento: A ecocardiografia transtorácica (ETT) pode desempenhar um papel crucial na avaliação das manifestações cardíacas da COVID-19. Objetivo: Nosso objetivo foi relatar a prevalência das principais anormalidades ecocardiográficas em pacientes hospitalizados com COVID-19. Métodos: Realizou-se estudo observacional multicêntrico prospectivo com pacientes com COVID-19 submetidos a ETT durante a internação. Pacientes com insuficiência cardíaca prévia, doença arterial coronariana ou fibrilação atrial foram classificados como portadores de doença cardiovascular (DCV) prévia. Foram coletados dados clínicos e ecocardiográficos da estrutura e da função cardíaca. Resultados: Avaliamos 310 pacientes com COVID-19, com 62±16 anos de idade, 61% homens, 53% com hipertensão arterial, 33% com diabetes e 23% com DCV prévia. No total, 65% dos pacientes necessitaram de suporte em unidade de terapia intensiva. As alterações ecocardiográficas mais prevalentes foram hipertrofia do ventrículo esquerdo (VE) (29%), hipertensão pulmonar (25%), disfunção sistólida do VE (16,5%), disfunção sistólica do ventrículo direito (VD) (15,9%), disfunção diastólica do VE grau II/III (11%) e alteração da contratilidade regional do VE (11%). Derrame pericárdico foi incomum (7%). Hipertrofia do VE (25 vs. 45%, p=0,001), disfunção sistólica do VE (11 vs. 36%, p<0,001), alterações da contratilidade regional (6 vs. 29%, p<0,001), disfunção diastólica do VE grau II/III (9 vs. 19%, p=0,03) e hipertensão pulmonar (22 vs. 36%, p=0,019) foram menos comuns nos pacientes sem do que com DCV prévia. A disfunção sistólica do VD mostrou-se semelhante em pacientes sem e com DCV prévia (13 vs. 25%, p=0,07). Conclusões: Entre os pacientes hospitalizados com COVID-19, os achados ecocardiográficos anormais foram comuns, porém menos encontrados naqueles sem DCV. A disfunção sistólica do VD pareceu afetar de forma semelhante pacientes com e sem DCV prévia. (AU)

Background: Transthoracic echocardiography (TTE) may play a crucial role in the evaluation of cardiac manifestations of coronavirus disease 2019 (COVID-19). Objective: We aimed to report the prevalence of the main echocardiographic abnormalities of hospitalized COVID-19 patients. Methods: We performed a prospective multicenter observational study in patients with COVID-19 who underwent TTE during hospitalization. Patients with pre-existing heart failure, coronary artery disease, or atrial fibrillation were categorized as having previous cardiovascular disease (CVD). Clinical and echocardiographic data about cardiac structure and function were collected. Results: We evaluated 310 patients with COVID-19 (mean age, 62±16 years; 61% men; 53% with arterial hypertension; 33% with diabetes; and 23% with previous CVD). Overall, 65% of the patients required intensive care unit support. The most prevalent echocardiographic abnormalities were LV hypertrophy (29%), pulmonary hypertension (25%), left ventricular (LV) systolic dysfunction (16.5%), right ventricular (RV) systolic dysfunction (15.9%), grade II/III LV diastolic dysfunction (11%), and LV regional wall motion abnormality (11%). Pericardial effusion was uncommon (7% of cases). LV hypertrophy (25% vs. 45%, p=0.001), LV systolic dysfunction (11% vs. 36%, p<0.001), regional wall motion abnormalities (6% vs. 29%, p<0.001), grade II/III LV diastolic dysfunction (9% vs. 19%, p=0.03), and pulmonary hypertension (22% vs. 36%, p=0.019) were less common in patients without previous CVD. RV systolic dysfunction occurred at similar frequencies in patients with versus without previous CVD (13% vs. 25%, p=0.07). Conclusions: Among patients hospitalized with COVID-19, abnormal echocardiographic findings were common, but less so among those without previous CVD. RV systolic dysfunction appeared to affect similar proportions of patients with versus without previous CVD. (AU)

Cost-utility analysis of an implantable cardioverterdefibrillator for the treatment of patients with ischemic or non-ischemic New York Heart Association class II or III heart failure in Colombia / Análisis de costo-utilidad del desfibrilador cardioversor implantable para el tratamiento de pacientes colombianos con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association

INTRODUCTION: The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. OBJECTIVE: To determine the cost-utility relationship of an implantable cardioverter-defibrillator compared to optimal pharmacological therapy for patients with ischemic or non-ischemic New York Heart Association class II or III (NYHA II-III) heart failure in Colombia. MATERIALS AND METHODS: We developed a Markov model including costs, effectiveness, and quality of life from the perspective of the Colombian health system. For the baseline case, we adopted a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. We calculated the costs by consulting with the manufacturers of the device offered in the Colombian market and using national-level pricing manuals. We conducted probabilistic and deterministic sensitivity analyses. RESULTS: In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was USD$ 13,187 per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (USD$ 19,139 in 2017), the device would be a cost-effective strategy for the Colombian health system. However, the result may change according to the time horizon, the probability of death, and the price of the device. CONCLUSIONS: The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure would be a cost-effective strategy for Colombia. The results should be examined considering the uncertainty.

Introducción. El uso del desfibrilador cardioversor implantable reduce la probabilidad de muerte súbita en pacientes con insuficiencia cardíaca. Objetivo. Determinar la relación de costo-utilidad de un desfibrilador cardioversor implantable comparado con la terapia farmacológica óptima para pacientes con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association (NYHA II-III) en Colombia. Materiales y métodos. Se desarrolló un modelo de Markov que incluyó los costos, la efectividad y la calidad de vida desde la perspectiva del sistema de salud colombiano. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y de una 3,5 % para los beneficios. Las probabilidades de transición se obtuvieron de una revisión sistemática de la literatura. Los años de vida ajustados por calidad se usaron como resultado de salud. Para estimar los costos unitarios se usaron manuales tarifarios nacionales y, para los costos del dispositivo, se consultó a los fabricantes que lo comercializan en el mercado colombiano. Se hicieron análisis de sensibilidad probabilísticos y determinísticos. Resultados. En el caso base el costo adicional por año de vida ajustado por calidad ganado con el desfibrilador cardioversor implantable fue de USD$ 13,187. Usando un umbral de tres veces el producto interno bruto per cápita como referencia (USD$ 19.139 en 2017), el dispositivo sería costo-efectivo para el sistema de salud colombiano. Sin embargo, este resultado depende del horizonte temporal, de la probabilidad de muerte y del precio del dispositivo. Conclusiones. El uso de un desfibrilador cardioversor implantable sería una estrategia costo-efectiva para Colombia, aunque los resultados deben examinarse teniendo en cuenta la incertidumbre.

Cost-utility analysis of an implantable cardioverterdefibrillator for the treatment of patients with ischemic or non-ischemic New York Heart Association class II or III heart failure in Colombia / Análisis de costo-utilidad del desfibrilador cardioversor implantable para el tratamiento de pacientes colombianos con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association

Abstract Introduction: The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. Objective: To determine the cost-utility relationship of an implantable cardioverterdefibrillator compared to optimal pharmacological therapy for patients with ischemic or nonischemic New York Heart Association class II or III (NYHA II-III) heart failure in Colombia. Materials and methods: We developed a Markov model including costs, effectiveness, and quality of life from the perspective of the Colombian health system. For the baseline case, we adopted a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. We calculated the costs by consulting with the manufacturers of the device offered in the Colombian market and using national-level pricing manuals. We conducted probabilistic and deterministic sensitivity analyses. Results: In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was USD$ 13,187 per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (USD$ 19,139 in 2017), the device would be a cost-effective strategy for the Colombian health system. However, the result may change according to the time horizon, the probability of death, and the price of the device. Conclusions: The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure would be a cost-effective strategy for Colombia. The results should be examined considering the uncertainty

Resumen Introducción. El uso del desfibrilador cardioversor implantable reduce la probabilidad de muerte súbita en pacientes con insuficiencia cardíaca. Objetivo. Determinar la relación de costo-utilidad de un desfibrilador cardioversor implantable comparado con la terapia farmacológica óptima para pacientes con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association (NYHA II-III) en Colombia. Materiales y métodos. Se desarrolló un modelo de Markov que incluyó los costos, la efectividad y la calidad de vida desde la perspectiva del sistema de salud colombiano. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y de una 3,5 % para los beneficios. Las probabilidades de transición se obtuvieron de una revisión sistemática de la literatura. Los años de vida ajustados por calidad se usaron como resultado de salud. Para estimar los costos unitarios se usaron manuales tarifarios nacionales y, para los costos del dispositivo, se consultó a los fabricantes que lo comercializan en el mercado colombiano. Se hicieron análisis de sensibilidad probabilísticos y determinísticos. Resultados. En el caso base el costo adicional por año de vida ajustado por calidad ganado con el desfibrilador cardioversor implantable fue de USD$ 13,187. Usando un umbral de tres veces el producto interno bruto per cápita como referencia (USD$ 19.139 en 2017), el dispositivo sería costo-efectivo para el sistema de salud colombiano. Sin embargo, este resultado depende del horizonte temporal, de la probabilidad de muerte y del precio del dispositivo. Conclusiones. El uso de un desfibrilador cardioversor implantable sería una estrategia costo-efectiva para Colombia, aunque los resultados deben examinarse teniendo en cuenta la incertidumbre.

Insuficiencia cardíaca aguda / Acute heart failure

La insuficiencia cardíaca aguda continúa siendo causa frecuente de hospitalización y su morbimortalidad no ha podido ser reducida más allá de los esfuerzos realizados, de ahí la importancia de analizar todo lo referente a su manejo clínico. En este capítulo se aborda la práctica clínica, con detallado análisis de los aspectos diagnósticos y terapéuticos. Para una mayor comprensión del tema se examinan diferentes definiciones y clasificaciones de insuficiencia cardíaca aguda. Se propone un abordaje conceptual similar al del síndrome coronario agudo en el sentido de mejorar los tiempos de intervención terapéutica y se recomienda la aplicación de un esquema sencillo de evaluación clínica del paciente en base a la presencia o no de signos y síntomas de bajo gasto y congestión. Al final del capítulo se resumen los principales conceptos que el médico debe considerar frente a este cuadro clínico.

Acute heart failure continues to be a frequent cause of hospitalization and its morbidity and mortality have not been reduced beyond the efforts made, hence the importance to analyze everything related to its clinical management. This chapter addresses the acute heart failure clinical practice, with detailed analysis of diagnostic and therapeutic aspects. For a better understanding of the topic, different definitions and classifications of acute heart failure are analyzed. A conceptual approach similar to that of acute coronary syndrome is proposed in the sense of improving the times of therapeutic intervention. Application of a simple scheme for clinical evaluation is recommended, based on the presence or absence of signs and symptoms of low output and congestion. At the end of the chapter, the most important concepts that should be taken into account by physicians are summarized.

Insuficiencia cardíaca aguda / Acute heart failure

La insuficiencia cardíaca aguda continúa siendo causa frecuente de hospitalización y su morbimortalidad no ha podido ser reducida más allá de los esfuerzos realizados, de ahí la importancia de analizar todo lo referente a su manejo clínico. En este capítulo se aborda la práctica clínica, con detallado análisis de los aspectos diagnósticos y terapéuticos. Para una mayor comprensión del tema se examinan diferentes definiciones y clasificaciones de insuficiencia cardíaca aguda. Se propone un abordaje conceptual similar al del síndrome coronario agudo en el sentido de mejorar los tiempos de intervención terapéutica y se recomienda la aplicación de un esquema sencillo de evaluación clínica del paciente en base a la presencia o no de signos y síntomas de bajo gasto y congestión. Al final del capítulo se resumen los principales conceptos que el médico debe considerar frente a este cuadro clínico.

[Not Available]. / Body composition changes assessed by bioelectrical impedance and their associations with functional class deterioration in stable heart failure patients.

BACKGROUND: Heart failure (HF) patients develop important changes in body composition, but only a small number of studies have evaluated the associations between these changes and functional class deterioration in a prospective manner. OBJECTIVE: The aim of this study was to evaluate whether changes in bioimpedance parameters were associated with NYHA functional class deterioration over six months. METHODS: A total of 275 chronic stable HF patients confirmed by echocardiography were recruited. Body composition measurements were obtained by whole body bioelectrical impedance with multiple frequency equipment (BodyStat QuadScan 4000). We evaluated functional class using the New York Heart Association (NYHA) classification at baseline and after six months. RESULTS: According to our results, 66 (24%) subjects exhibited functional class deterioration, while 209 improved or exhibited no change. A greater proportion of patients exhibited higher extracellular water (> 5%), and these patients developed hypervolemia, according to location on the resistance/reactance graph. A 5% decrease in resistance/height was associated with functional class deterioration with an OR of 1.42 (95% CI 1.01-2.0, p = 0.04). CONCLUSIONS: Body composition assessment through bioelectrical impedance exhibited a valuable performance as a marker of functional class deterioration in stable HF patients.

Applicability of nursing outcomes in patients with heart failure and fluid volume excessive. / Aplicabilidade dos resultados de enfermagem em pacientes com insuficiência cardíaca e volume de líquidos excessivo.

OBJECTIVE: The purpose of this study was to test the clinical applicability of the Nursing Outcomes Classification in patients with decompensated heart failure and the nursing diagnosis of fluid volume excess. METHODS: This is a longitudinal study conducted in two stages at a university hospital, in 2013. During the first stage the consensus of experts was used to select the nursing outcomes and the indicators related to diagnosing fluid volume excess. The longitudinal study was conducted in the second stage to clinically evaluate the patients using the instrument containing the results and indicators produced in the consensus. RESULTS: A total of 17 patients were assessed. The nursing outcomes were measured during the clinical evaluation by analysing their indicators. The scores increased in six of the results, in comparison with the average results of the first and last assessment. The Nursing Outcomes Classification during medical practice revealed a clinical improvement among the patient who were admitted following decompensated heart failure. CONCLUSION: The Nursing Outcomes Classification managed to detect changes in the clinical status of patients.

Aplicabilidade dos resultados de enfermagem em pacientes com insuficiência cardíaca e volume de líquidos excessivo / Aplicabilidad de los resultados de enfermería en pacientes con insuficiencia cardíaca y exceso de volumen de líquidos / Applicability of nursing outcomes in patients with heart failure and fluid volume excessive

RESUMO Objetivo Testar a aplicabilidade clínica da Nursing Outcomes Classification em pacientes com insuficiência cardíaca descompensada e Diagnóstico de Enfermagem Volume de Líquidos Excessivo. Métodos Estudo longitudinal conduzido em duas etapas em um hospital universitário no ano de 2013. Na primeira etapa, utilizou-se a validação por consenso de especialistas para selecionar os resultados de enfermagem e os indicadores relacionados ao diagnóstico de enfermagem; na segunda, foi realizado um estudo longitudinal para avaliação clínica dos pacientes, utilizando-se o instrumento contendo os resultados e indicadores produzidos no consenso. Resultados Foram realizadas avaliações em 17 pacientes. Na avaliação clínica, mensuraram-se os resultados de enfermagem através da avaliação de seus indicadores. Seis resultados apresentaram aumento nos escores, quando comparados às médias da primeira e da última avaliação. A utilização da Nursing Outcomes Classification na prática clínica demonstrou melhora dos pacientes internados por insuficiência cardíaca descompensada. Conclusão A Nursing Outcomes Classification foi sensível às alterações no quadro clínico dos pacientes.

RESUMEN Objetivo Testar la aplicabilidad clínica de la Nursing Outcomes Classification en pacientes con insuficiencia cardíaca descompensada y Diagnóstico de Enfermería Volumen de Líquidos Excesivo. Método Estudio longitudinal, realizado en dos etapas, en un hospital universitario, en 2013. En la primera etapa se utilizó la validación por consenso de especialistas para seleccionar los resultados de enfermería y los indicadores relaciones al diagnóstico de enfermería; en la segunda fue realizado un estudio longitudinal para evaluación clínica de los pacientes, utilizándose el instrumento que contiene los resultados y los indicadores producto del consenso. Resultados Fueron realizadas evaluaciones en 17 pacientes. Durante la evaluación clínica se midieron los resultados de enfermería a través de la evaluación de sus indicadores. Seis resultados mostraron un aumento en las puntuaciones, cuando se comparó las medias de los resultados de la primera y última evaluación. La utilización de la Nursing Outcomes Classification en la práctica clínica fue capaz de demostrar mejoría clínica de los pacientes internados por insuficiencia cardíaca descompensada. Conclusión La Clasificación de Resultados de Enfermería fue sensible a las alteraciones en el cuadro clínicos de los pacientes.

ABSTRACT Objective The purpose of this study was to test the clinical applicability of the Nursing Outcomes Classification in patients with decompensated heart failure and the nursing diagnosis of fluid volume excess. Methods This is a longitudinal study conducted in two stages at a university hospital, in 2013. During the first stage the consensus of experts was used to select the nursing outcomes and the indicators related to diagnosing fluid volume excess. The longitudinal study was conducted in the second stage to clinically evaluate the patients using the instrument containing the results and indicators produced in the consensus. Results A total of 17 patients were assessed. The nursing outcomes were measured during the clinical evaluation by analysing their indicators. The scores increased in six of the results, in comparison with the average results of the first and last assessment. The Nursing Outcomes Classification during medical practice revealed a clinical improvement among the patient who were admitted following decompensated heart failure. Conclusion The Nursing Outcomes Classification managed to detect changes in the clinical status of patients.

Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction.

Exercise capacity and quality of life (QOL) are important outcome predictors in patients with systolic heart failure (HF), independent of left ventricular (LV) ejection fraction (LVEF). LV diastolic function has been shown to be a better predictor of aerobic exercise capacity in patients with systolic dysfunction and a New York Heart Association (NYHA) classification ≥ II. We hypothesized that the currently used index of diastolic function E/e' is associated with exercise capacity and QOL, even in optimally treated HF patients with reduced LVEF. This prospective study included 44 consecutive patients aged 55 ± 11 years (27 men and 17 women), with LVEF<0.50 and NYHA functional class I-III, receiving optimal pharmacological treatment and in a stable clinical condition, as shown by the absence of dyspnea exacerbation for at least 3 months. All patients had conventional transthoracic echocardiography and answered the Minnesota Living with HF Questionnaire, followed by the 6-min walk test (6MWT). In a multivariable model with 6MWT as the dependent variable, age and E/e' explained 27% of the walked distance in 6MWT (P=0.002; multivariate regression analysis). No association was found between walk distance and LVEF or mitral annulus systolic velocity. Only normalized left atrium volume, a sensitive index of diastolic function, was associated with decreased QOL. Despite the small number of patients included, this study offers evidence that diastolic function is associated with physical capacity and QOL and should be considered along with ejection fraction in patients with compensated systolic HF.

Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction

Exercise capacity and quality of life (QOL) are important outcome predictors in patients with systolic heart failure (HF), independent of left ventricular (LV) ejection fraction (LVEF). LV diastolic function has been shown to be a better predictor of aerobic exercise capacity in patients with systolic dysfunction and a New York Heart Association (NYHA) classification ≥II. We hypothesized that the currently used index of diastolic function E/e' is associated with exercise capacity and QOL, even in optimally treated HF patients with reduced LVEF. This prospective study included 44 consecutive patients aged 55±11 years (27 men and 17 women), with LVEF<0.50 and NYHA functional class I-III, receiving optimal pharmacological treatment and in a stable clinical condition, as shown by the absence of dyspnea exacerbation for at least 3 months. All patients had conventional transthoracic echocardiography and answered the Minnesota Living with HF Questionnaire, followed by the 6-min walk test (6MWT). In a multivariable model with 6MWT as the dependent variable, age and E/e' explained 27% of the walked distance in 6MWT (P=0.002; multivariate regression analysis). No association was found between walk distance and LVEF or mitral annulus systolic velocity. Only normalized left atrium volume, a sensitive index of diastolic function, was associated with decreased QOL. Despite the small number of patients included, this study offers evidence that diastolic function is associated with physical capacity and QOL and should be considered along with ejection fraction in patients with compensated systolic HF.

Use of an indicator to evaluate physician adherence to prescription guidelines for the treatment of heart failure

The aim of this study was to use indicators to evaluate physician adherence to prescription guidelines for heart failure treatment in a university hospital. This was a prospective cohort study conducted in a university hospital. The information collected at the time of patient admission, including therapeutic indication, absolute contra indications and intolerance, was utilised for the formulation of a guideline adherence indicator (GAI). This indicator was calculated as follows: (the number of patients who used the medication/the number of eligible patients) x 100. The percentage of eligible patients was calculated using the following formula: (the number of eligible patients/the total number patients) x 100. The GAI was applied to a population of 53 patients. Inhibitors of angiotensin-converting enzyme/angiotensin receptor blocker (ACE-I/ARB) combination therapy were used in the greatest percentage of eligible patients (92.4%) and demonstrated the largest GAI value (73.5%). The percentages of patients who were eligible for beta-blockers, spironolactone and digitalis treatments were 81.1%, 52.8% and 60.4%, respectively. The GAI values for the use of beta-blockers, spironolactone and digitalis were 60.4%, 57.1% and 56.2%, respectively. For the studied patient population, the GAI was consistent with the proportion of patients who were eligible to receive digitalis and spironolactone.

O objetivo deste estudo foi utilizar indicadores para avaliar a adesão de médicos às diretrizes para tratamento da Insuficiência Cardíaca em um hospital universitário. Estudo de coorte prospectivo, conduzido em um hospital universitário. As variáveis coletadas na admissão do paciente foram: indicação terapêutica, contraindicações absolutas e intolerância, sendo utilizadas para elaboração de um indicador de adesão à diretriz (IAD). Este indicador foi calculado através da relação: (número de pacientes que utilizaram o medicamento/número de pacientes elegíveis) x 100. A % de pacientes elegíveis foi calculada da seguinte forma: (número de pacientes elegíveis/número total de pacientes) x 100. Os IAD foram aplicados para uma população de 53 pacientes. Os Inibidores da Enzima Conversora de Angiotensina/Bloqueadores dos Receptores de Angiotensina foram as classes farmacológicas que apresentaram maior % de pacientes elegíveis (92,4%) e apresentaram o melhor IAD (73,5%). A % de pacientes elegíveis para beta-bloqueadores, espironolactona e digitálicos foi de 81,1%, 52,8% e 60,4%, respectivamente. O IAD para beta-bloqueadores foi 60,4%, espironolactona 57,1% e digitálicos 56,2%. Na população estudada, o IAD foi compatível com a proporção de pacientes elegíveis para digitálicos e espironolactona.

Capacidade funcional de indivíduos com insuficiência cardíaca avaliada pelo teste de esforço cardiopulmonar e classificação da New York Heart Association / Functional capacity of heart failure patients evaluated by cardiopulmonary exercise test and New York Heart Association class

O objetivo deste estudo foi avaliar a capacidade discriminativa da classificação da New York Heart Association (NYHA) em indivíduos com insuficiência cardíaca (IC) classes II e III por meio de variáveis do teste de esforço cardiopulmonar (TECP). Participaram do estudo 17 pessoas com IC classe II (44,47±10,11 anos; fração de ejeção ventricular 32,11±10,37%) e 15 classe III (46,73±8,74 anos; fração de ejeção ventricular 30,46±10,23%) da NYHA que realizaram TECP máximo em esteira ergométrica. De acordo com a distribuição dos dados, houve correlação de Pearson ou Spearman e, para comparação entre classes, utilizou-se o teste t de Student. Foram encontradas correlações significativas (p<0,05) entre consumo de oxigênio (VO2) e pulso de oxigênio (r=0,76), idade (r=0,35) e índice de massa corpórea (r=0,45). Não houve correlação significativa entre fração de ejeção ventricular e as demais variáveis estudadas. Comparando as classes da NYHA, foram encontradas diferenças para VO2 e pulso de oxigênio (p<0,05). Nesta pesquisa, as correlações refletem a complexidade de se analisar e entender o processo de disfunção da IC, considerando que provavelmente há outros fatores influenciando cada uma das variáveis estudadas. A classificação da NYHA foi efetiva na diferenciação dos indivíduos nos diferentes grupos, reforçando sua utilidade na caracterização de grupos de indivíduos com IC para fins de pesquisas científicas, assim como para avaliação de terapêuticas.

The purpose of this study was to evaluate the capacity of the New York Heart Association (NYHA) classification to discriminate heart failure (HF) individuals classes II and III using cardiopulmonary exercise test (CPET) variables. Seventeen patients class II (age 44.47±10.11 years; ejection fraction 32.11±10.37%) and 15 class III (age 46.73±8.74 years; ejection fraction 30.46±10.23%) of NYHA participated in this study. They did a maximal CPET in a treadmill ergometer. According to the distribution of data, correlation of Pearson or Spearman was performed and, to compare the functional classes of NYHA, the Student's t-test was used. Significant correlations (p<0.05) between oxygen consumption (VO2) and oxygen pulse (r=0.76), age (r=0.35) and body mass index (r=0.45) were found. There was no significant correlation between ventricular ejection fraction and the others studied variables. Comparing the functional classes of NYHA, significantly differences were found to VO2 and oxygen pulse (p<0.05). In this study, the correlations reflect the complexity in analyzing and understanding the process of disfunction in HF, once probably other factors influence each of the variables studied. The classification of NYHA was effective to differentiate the patients with HF, reinforcing the indication of this stratification to identify different groups of HF patients to scientific researches and therapeutic interventions.

Cardiomiopatias: conceito e classificação / Definition and classification of cardiomyopathies

Cardiomiopatias compõem um grupo heterogêneo de doenças do músculo cardíaco vinculadas a múltiplas etiologias e uma variedade de expressões fenotípicas. Em 1995, a Organização Mundial de Saúde as definiu como sendo "doenças do miocárdio associadas com disfunção cardíacas", e classificadas em: dilatada, hipertrófica, restritiva e cardiomiopatia arritmogênica do ventrículo direito. Um comitê de especialistas da American Heart Association (AHA) em 2006 conceituou que as cardiomiopatias compreendem um "grupo heterogêneo de doenças do miocárdio associadas com disfunção mecânica e/ou elétrica, e que usualmente (mas não invariavelmente) exibem dilatação ou hipertrofia ventriculares inapropriadas", e são devido a uma variedade de causas, frequentemente genéticas. Foram divididas em 2 tipos: primárias e secundárias (Tabela 1). Foi incluída ainda uma importante subcaracterização das cardiomiopatias primárias, dividida em 3 grupos principais: genético, misto e adquirido (Tabela 2). Em 2007, um posicionamento do comitê europeu mudou a conceituação: uma afecção miocárdica na qual o músculo cardíaco é funcionalmente e estruturalmente anormal, em ausência de doença coronariana, hipertensão arterial, doença valvular, defeito cardíaco congênito, suficiente para causar a anormalidade miocárdica observada...

The cardiomyopathies are an important and complex group of heart muscle diseases with multiple tiologies and heterogeneous phenotypic expression. The WHO classification published in 1995 proposed “ Cardiomyopathies are defined as diseases of the myocardium associated with cardiac dysfunction”, and they are classified as dilated, hypertrophic, restrictive, and arrhythmogenic right ventricular cardiomyopathy. In 2006 AHA scientific statement, the original distinction into primary and secondary forms was reintroduced. A sub classification of cardiomyopathies into familial/genetic and non-familial/non-genetic was considered of help in orienting towards genetic mutational analysis and creening. All this was changed in 2007 by ESC, when they clearly stated that cardiomyopathy is ‘a myocardial disorder in which heart muscle is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease, and congenital heart diseases’. While accepting and reinforcing the idea advanced by the AHA statement to separated cardiomyopathies into familial/genetic and non-familial/non-genetic, the traditional separation of primary and secondary (specific) cardiomyopathies was abolished...