Portuguese Heart Failure Prevalence Observational Study (PORTHOS) rationale and design - A population-based study.

INTRODUCTION AND OBJECTIVES: Current epidemiological data on heart failure (HF) in Portugal derives from studies conducted two decades ago. The main aim of this study is to determine HF prevalence in the Portuguese population. Using current standards, this manuscript aims to describe the methodology and research protocol applied. METHODS: The Portuguese Heart Failure Prevalence Observational Study (PORTHOS) is a large, three-stage, population-based, nationwide, cross-sectional study. Community-dwelling citizens aged 50 years and older will be randomly selected via stratified multistage sampling. Eligible participants will be invited to attend a screening visit at a mobile clinic for HF symptom assessment, anthropomorphic assessment, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing, one-lead electrocardiogram (ECG) and a sociodemographic and health-related quality of life questionnaire (EQ-5D). All subjects with NT-proBNP ≥125 pg/mL or with a prior history of HF will undergo a diagnostic confirmatory assessment at the mobile clinic composed of a 12-lead ECG, comprehensive echocardiography, HF questionnaire (KCCQ) and blood sampling. To validate the screening procedure, a control group will undergo the same diagnostic assessment. Echocardiography results will be centrally validated, and HF diagnosis will be established according to the European Society of Cardiology HF guidelines. A random subsample of patients with an equivocal HF with preserved ejection fraction diagnosis based on the application of the Heart Failure Association preserved ejection fraction diagnostic algorithm will be invited to undergo an exercise echocardiography. CONCLUSIONS: Through the application of current standards, appropriate methodologies, and a strong research protocol, the PORTHOS study will determine the prevalence of HF in mainland Portugal and enable a comprehensive characterization of HF patients, leading to a better understanding of their clinical profile and health-related quality of life.

Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. / Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear, Ressonância Magnética e Tomografia Computorizada Cardíaca, de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca.

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

[Application of the 2015 Beers Criteria Operationalized for Portugal in Institutionalized Elderly: A Cross-Sectional Study]. / Aplicação dos Critérios de Beers de 2015 Operacionalizados para Portugal em Pessoas Idosas Institucionalizadas: Um Estudo Transversal.

INTRODUCTION: The consumption of potentially inappropriate medicines is high among institutionalized elderly, predisposing to potential drug interactions, adverse drug events, risk of iatrogenic cascade, increased morbidity and mortality and health costs. Medication review is a promising strategy for therapeutic optimization, although scarcely documented in Portugal. The aim of this study was to characterize, using explicit criteria, the existence of potentially inappropriate medicines, among institutionalized elderly, and to calculate the eventual cost savings, with their discontinuation. MATERIAL AND METHODS: Descriptive and cross-sectional study conducted in three residential homes for the elderly, from different geographic regions, based on a random sample of 33 health records. In order to characterize the existence of potentially inappropriate medicines, we used the 2015 Beers criteria, revised by the American Geriatrics Society and in the Portuguese version. RESULTS: On average, 11 drugs are prescribed to elderly residents of three residential structures for the elderly. All health records contain potentially inappropriate medicines (mean 4.8 ± 2.0 per resident), with anxiolytics (17.7%), antidepressants (17.7%) and antipsychotics (15.8%) being the most prevalent. Its reduction would result in an average monthly savings of €9.6 per resident. DISCUSSION: The consumption of potentially inappropriate medicines is higher than the literature describes, and the cost of medicines is high. The involvement of nurses in the process of drug management and reconciliation, in coordination with the physician, could be an effective strategy. This is the first study using the latest Portuguese version of the Beers criteria, which makes the comparability of the results difficult. CONCLUSION: The consumption of potentially inappropriate medicines is high, which suggest the need for adoption of improvement measures.

Introdução: O consumo de medicamentos potencialmente inapropriados é elevado entre idosos institucionalizados, predispondo à ocorrência de potenciais interações medicamentosas, eventos adversos a medicação, risco de cascata iatrogénica, aumento da morbimortalidade e dos custos em saúde. A revisão da medicação é uma estratégia promissora com vista à otimização terapêutica, ainda que pouco documentada em Portugal. Este estudo pretende caraterizar, utilizando critérios explícitos, a existência de medicamentos potencialmente inapropriados, entre idosos institucionalizados, e calcular a eventual poupança, em medicamentos, com a sua supressão.Material e Métodos: Estudo descritivo e transversal, realizado em três estruturas residenciais para pessoas idosas, de regiões geográficas distintas, a partir de uma amostra aleatória de 33 processos clínicos. Para a caracterização da existência de medicamentos potencialmente inapropriados, utilizaram-se os Critérios de Beers de 2015, revistos pela American Geriatrics Society e na versão operacionalizada para Portugal.Resultados: Em média, 11 fármacos são prescritos aos idosos residentes das estruturas residenciais para pessoas idosas. Todos os processos contêm medicamentos potencialmente inapropriados (média de 4,8 ± 2,0 por residente), sendo os ansiolíticos (17,7%), antidepressivos (17,7%) e antipsicóticos (15,8%) os mais prevalentes. A sua redução resultaria numa poupança média mensal de €9,6, por residente.Discussão: O consumo de medicamentos potencialmente inapropriados é superior ao que a bibliografia descreve e o custo com os medicamentos é elevado. O envolvimento dos enfermeiros no processo de gestão e reconciliação medicamentosa, em articulação com o médico, poderá ser uma estratégia eficaz. O estudo é pioneiro na utilização da última versão portuguesa dos critérios de Beers, o que dificulta a comparabilidade dos resultados.Conclusão: O consumo de medicamentos potencialmente inapropriados é elevado, o que sugere a necessidade de adoção de medidas de melhoria.

Myocardial deformation and volume of exercise: a new overlap between pathology and athlete's heart?

Regular physical exercise induces cardiac adaptations that can overlap pathological conditions. Controversy still persists about the variability of myocardial deformation in different types and intensity of exercise. The aim of this study was to assess myocardial longitudinal deformation in athletes with different level of exercise. Two groups of young athletes involved in endurance sports characterized by high intensity dynamic component were enrolled. According to the level and the number of exercise training hours/week, two groups were defined: Group 1-high level (national/international and ≥ 20 training-hours/week; N = 60); Group 2-low level (recreational/regional and < 10 training-hours/week; N = 48). A comprehensive transthoracic echocardiogram including evaluation of global longitudinal strain (GLS) assessed by 2D speckle-tracking was performed. Athletes in Group 1 showed more pronounced cardiac remodeling and enhanced diastolic function. No significant differences were evident in left ventricle ejection fraction (LVEF) between groups. Overall, GLS (absolute values) was 18.0 ± 2.5%, but significantly lower in Group 1 compared to Group 2 (17.3 ± 2.6% vs. 18.9 ± 2.1%; p = 0.001). Thirty-three (31%) athletes had GLS below 17%, more frequently in Group 1 (79% vs. 45%; p = 0.001), with higher LV and left atrium volumes, lower E wave and A wave peak velocities and E/e' ratio. In a multivariate analysis to belong to Group 1 was the only independent variable associated with GLS < 17% (OR 6.5; 95% CI 2.4-17.4; p < 0.001). The athletes with a GLS < 17% were all men, more frequently involved in high level exercise, with higher chamber volumes and lower E/e' ratio. Left ventricular global myocardial longitudinal deformation evaluated by GLS was significantly lower in athletes with higher level of exercise. Although GLS in athletes overlap several pathological conditions, these lower values are associated with an enhanced diastolic performance that allows discrimination between physiologic adaptations and pathology.

Variability in interpretation of the electrocardiogram in athletes: Another limitation in pre-competitive screening. / Variabilidade na interpretação do eletrocardiograma do atleta: mais uma limitação na avaliação pré­competitiva.

INTRODUCTION: Assessment of the electrocardiogram (ECG) in athletes remains controversial, with lack of standardization and difficulty in applying specific criteria in its interpretation. The purpose of this study was to assess variability in the interpretation of the ECG in athletes. METHODS: Twenty ECGs of competitive athletes were assessed by cardiologists and cardiology residents, 11 of them normal or with isolated physiological changes and nine pathological. Each ECG was classified as normal/physiological or pathological, with or without the use of specific interpretation criteria. RESULTS: The study presents responses from 58 physicians, 42 (72.4%) of them cardiologists. Sixteen (27.6%) physicians reported that they regularly assessed athletes and 32 (55.2%) did not use specific ECG interpretation criteria, of which the Seattle criteria were the most commonly used (n=13). Each physician interpreted 15±2 ECGs correctly, corresponding to 74% of the total number of ECGs (variation: 45%-100%). Interpretation of pathological ECGs was correct in 68% (variation: 22%-100%) and of normal/physiological in 79% (variation: 55%-100%). There was no significant difference in interpretation between cardiologists and residents (74±10% vs. 75±10%; p=0.724) or between those who regularly assessed athletes and those who did not (77±12% vs. 73±9%; p=0.286), but there was a trend for a higher rate of correct interpretation using specific criteria (77±10% vs. 72±10%; p=0.092). The reproducibility of the study was excellent (intraclass correlation coefficient=0.972; p<0.001). CONCLUSIONS: A quarter of the ECGs were not correctly assessed and variability in interpretation was high. The use of specific criteria can improve the accuracy of interpretation of athletes' ECGs, which is an important part of pre-competitive screening, but one that is underused.

Impact of HIV infection on cardiac deformation.

AIM: The aim of this study was to detect abnormalities in left ventricular myocardial function due to HIV (human immunodeficiency virus) infection without established cardiovascular disease. METHODS: An echocardiogram was performed in 50 asymptomatic HIV-infected patients (age 41 ± 6 years, 64% male) and in 20 healthy individuals. Conventional echocardiography and pulsed tissue Doppler imaging (TDI) were performed according to the guidelines. The strain rate of the basal segments was obtained with color tissue Doppler and used to evaluate systolic strain rate (SRS), early diastolic strain rate (SRE) and late diastolic strain rate (SRA). Longitudinal, radial and circumferential strain were assessed by 2D speckle tracking. RESULTS: The mean duration of HIV infection was 10 ± 5 years, CD4 count was 579 ± 286 cells/mm³, 32% had detectable viral load, and 86% were under treatment. Of the HIV-infected patients, one had grade 1 diastolic dysfunction. The groups were not different except for E wave (HIV 0.72 ± 0.17 m/s vs. control 0.84 ± 0.16 m/s, p=0.01), longitudinal strain (-19.5 ± 1.9% vs. -21 ± 2%, p=0.005), SRS (-1.1 ± 0.28 s⁻¹ vs. -1.3 ± 0.28 s⁻¹, p=0.02) and SRE (1.8 ± 0.4 s⁻¹ vs. 2.2 ± 0.4 s⁻¹, p<0.001), but only SRS (p=0.03, 95% CI 0.036; 0.67) and SRE (p=0.001, 95% CI -0.599; -0.168) had independent value. CONCLUSION: In an HIV-infected population without established cardiovascular disease, myocardial deformation abnormalities can be detected with strain and strain rate, revealing markers of myocardial injury.

Cardiac magnetic resonance in a patient with MRI-conditional pacemaker.

An implanted pacemaker is generally considered a contraindication for magnetic resonance imaging (MRI). The increasing number of indications for MRI and the rising prevalence of implanted cardiac pacemakers have prompted the recent development of MRI-conditional pacemaker systems. We present the case of a 68-year-old woman with left ventricular hypertrophy, hypertension, aortic valve stenosis and a family history of cardiac amyloidosis, who developed complete heart block. In view of the foreseeable need for cardiac MRI, an MRI-conditional dual chamber pacemaker was implanted. The MRI scan confirmed moderate left ventricular hypertrophy and aortic valve stenosis, and showed no delayed enhancement suggestive of amyloid heart disease. This case illustrates the feasibility of cardiac MRI in this setting and the usefulness of the recently introduced MRI-conditional pacemaker systems.

[Carcinoid tumors: echocardiographic contribution to the diagnosis]. / Tumor carcinóide: contributo da ecocardiografia para o diagnóstico.

INTRODUCTION: Carcinoid tumors are rare, most commonly originating from the neuroendocrine cells in the gastrointestinal tract. Carcinoid syndrome is characterized by flushing, diarrhea, and bronchospasm. Half of these patients have carcinoid heart disease, affecting the right side of the heart, causing tricuspid and pulmonary regurgitation and stenosis and subsequently right heart failure. CASE REPORT: 73-year-old female was admitted with heart failure associated with episodes of diarrhea and flushing. The echocardiogram showed typical characteristics of carcinoid heart diasease. The CT scan of abdomen showed a small bowel mass. The 24-hour urine 5-hydroxyindoleacetic acid (5HIAA) and indium-111-pentetreotide scintigraphy confirmed the diagnosis. The patient was treated with furosemide, warfarine, digoxin and octreotide and there was clinical improvement. CONCLUSION: The echocardiogram was very useful, establishing the provisory diagnosis of a rare disease based on pathognomonic echocardiographic features.

Chronic medical comorbidities in patients with acute coronary syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) frequently present chronic noncardiovascular medical comorbidities that can influence treatment and prognosis. Compliance with therapeutic guidelines in ACS is crucial to event reduction and the presence of these comorbidities may be a determining factor in guideline adherence. OBJECTIVE: To assess the prevalence of chronic noncardiovascular medical comorbidities in patients with ACS and their impact on guideline adherence. METHODS: We studied consecutive patients admitted to the coronary care unit of our institution with a diagnosis of ACS. We identified patients with noncardiovascular comorbidities, divided into five groups: chronic renal failure, pulmonary disease, gastrointestinal disease, blood disease or cancer). We assessed complete adherence to pharmacological therapy plus reperfusion (mechanical or pharmacological) in ST-segment elevation myocardial infarction, and use of coronary angiography in non-ST segment elevation myocardial infarction. We compared guideline adherence according to the presence or absence of comorbidities and their impact on in-hospital mortality. RESULTS: The study sample consisted of 146 patients, mean age 64 +/- 13 years and 71% male. In 53% of the patients at least one comorbidity was identified: chronic renal failure in 23%, pulmonary disease in 14%, gastrointestinal disease in 20%, blood disease in 7% and cancer in 9%. Patients with comorbidities were older, and more frequently had a history of ACS, heart failure and peripheral arterial disease. Complete adherence to guidelines was worse in the group with comorbidities (56% vs. 74%; p = 0.025). The presence of noncardiovascular comorbidities was associated with higher in-hospital mortality (9% vs. 0%, p = 0.011). CONCLUSION: Noncardiovascular medical comorbidities are frequently found in patients with ACS. Adherence to therapeutic guidelines for ACS is suboptimal, particularly in patients with chronic noncardiovascular comorbidities. Moreover, the presence of such comorbidities influences short-term prognosis in ACS patients.

Miocardiopatia diabética em diabéticos sem comorbidades / Diabetes cardiomyopathy in diabetic patients without comorbidities

A miocardiopatia diabética tem-se afirmado como diagnóstico etiológico de insuficiência cardíaca. No entanto, a elevada frequência de comorbidades, no doente diabético, torna difícil a distinção da contribuição da alteração do metabolismo da glicose na fisiopatologia da insuficiência cardíaca. Objectivo: Estudar a função ventricular esquerda sistólica e diatólica em diabéticos sem comorbidades, com ecocardiografia convencional e Doppler tissular. Métodos: Foram estudados 23 doentes, com idade média de 53 + - 15 anos, sendo 10 mulheres, todos diabéticos, com pelo menos 5 anos de evolução e sem história prévia de insuficiência cardíaca, doença coronária ou hipertensão arterial grave. O grupo controle foi constituído por 18 doentes pareados para sexo e idade. A função sistólica foi avaliada através da fração de ejeção e da V máx da onda A, determinada por Doppler tissular, com amostras nos segmentos septal, lateral, inferior e anterior do anel mitral. A função diastólica foi avaliada pela razão E/A, tempo de desaceleração do fluxo transmitral (Doppler espectral pulsado), pela V máx d onda 'E, razão 'E/A' e 'E/'E obtida por meio do Doppler tissular, nos quatros segmentos anteriormente referidos. Foram avaliaddas as diferenças...

Load-independent parameters of diastolic and systolic function by speckle tracking and tissue doppler in hemodialysis patients.

BACKGROUND: Assessment of diastolic function using conventional Doppler techniques is limited by their significant dependence on volume load status. Whether new echocardiographic methods are load-independent in evaluating left ventricular systolic and diastolic function remains controversial. OBJECTIVE: The aim of this study was to identify load-independent echocardiographic parameters for systolic and diastolic function in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) and to evaluate agreement between the new methods. METHODS: We studied 20 clinically stable patients with ESRD on HD for >4 months (mean age 51+/-12 years, 14 men, four with coronary disease). All had a transthoracic echocardiogram immediately before and after HD. Cardiac chamber volumes, left ventricular ejection fraction, and transmitral Doppler flow (E/A ratio) were determined according to American Society of Echocardiography guidelines. Pulsed tissue Doppler imaging (TDI) was used to record septal and lateral mitral annular velocities. Longitudinal systolic (Sm), early diastolic (Em) and late diastolic (Am) myocardial velocities and strain were determined by color TDI and also by speckle tracking imaging (STI), using apical views. The ratio between the rapid filling wave E and mitral early diastolic filling velocity (E/Em) and the Am/Em ratio were calculated, using spectral Doppler, pulsed TDI, color TDI, and STI. RESULTS: Mean ultrafiltration volume was 2800+/-820 ml (range 1200-4200 ml). Left atrial (LA) and left ventricular (LV) end-diastolic volumes and transmitral pulsed Doppler flow decreased significantly after HD. Early diastolic myocardial velocities also decreased significantly, regardless of the evaluation method. Filling pressure ratios were high and remained unchanged after HD. LV ejection fraction was >44% in all patients and did not change after HD. Systolic myocardial velocities, by any method, and global and longitudinal strain were also similar before and after HD. CONCLUSION: Large acute changes in volume load were associated with significant variations in early diastolic myocardial longitudinal velocities, thus demonstrating the dependence of Em on volume load. By contrast, E/Em ratios appeared to be load-independent, as were systolic function parameters. Pulsed TDI, color TDI, and STI yielded similar results for the assessment of diastolic and systolic myocardial parameters.

Acute heart failure--intra-aortic balloon: a forgotten treatment.

Acute heart failure (AHF) is a serious clinical condition associated with high morbidity and mortality. The authors present the case of a 61-year-old man, with a past history of idiopathic dilated cardiomyopathy with heart failure, who came to the emergency room due to acute decompensation. During hospital stay he developed cardiogenic shock and inotropic support was initiated, followed by mechanical circulatory assistance with intra-aortic balloon counterpulsation, as a bridge to heart transplantation. The authors discuss theoretical considerations concerning subtypes and etiology of AHF, and indications for the use of mechanical support and heart transplantation.