Heart failure management with ß-blockers: can we do better?

Heart failure (HF) is associated with disabling symptoms, poor quality of life, and a poor prognosis with substantial excess mortality in the years following diagnosis. Overactivation of the sympathetic nervous system is a key feature of the pathophysiology of HF and is an important driver of the process of adverse remodelling of the left ventricular wall that contributes to cardiac failure. Drugs which suppress the activity of the renin-angiotensin-aldosterone system, including ß-blockers, are foundation therapies for the management of heart failure with reduced ejection fraction (HFrEF) and despite a lack of specific outcomes trials, are also widely used by cardiologist in patients with HF with preserved ejection fraction (HFpEF). Today, expert opinion has moved away from recommending that treatment for HF should be guided solely by the LVEF and interventions should rather address signs and symptoms of HF (e.g. oedema and tachycardia), the severity of HF, and concomitant conditions. ß-blockers improve HF symptoms and functional status in HF and these agents have demonstrated improved survival, as well as a reduced risk of other important clinical outcomes such as hospitalisation for heart failure, in randomised, placebo-controlled outcomes trials. In HFpEF, ß-blockers are anti-ischemic and lower blood pressure and heart rate. Moreover, ß-blockers also reduce mortality in the setting of HF occurring alongside common comorbid conditions, such as diabetes, CKD (of any severity), and COPD. Higher doses of ß-blockers are associated with better clinical outcomes in populations with HF, so that ensuring adequate titration of therapy to their maximal (or maximally tolerated) doses is important for ensuring optimal outcomes for people with HF. In principle, a patient with HF could have combined treatment with a ß-blocker, renin-angiotensin-aldosterone system inhibitor/neprilysin inhibitor, mineralocorticoid receptor antagonist, and a SGLT2 inhibitor, according to tolerability.

Reply to the letter "Understanding lactate and its clearance during extracorporeal membrane oxygenation for supporting refractory cardiogenic shock patients".

This is a reply to the letter titled "Understanding lactate and its clearance during extracorporeal membrane oxygenation for supporting refractory cardiogenic shock patients" by Eva Rully Kurniawati et al. In response to the concerns raised about our paper published in BMC Cardiovascular Disorders, titled "Association between serum lactate levels and mortality in patients with cardiogenic shock receiving mechanical circulatory support: a multicenter retrospective cohort study," we have addressed the confounding bias on the population included and the use of VA-ECMO and Impella CP. Furthermore, we have provided new data on the correlation of oxygen supply and lactate levels at admission of cardiogenic shock.

Association between serum lactate levels and mortality in patients with cardiogenic shock receiving mechanical circulatory support: a multicenter retrospective cohort study.

BACKGROUND: To evaluate the prognostic value of peak serum lactate and lactate clearance at several time points in cardiogenic shock treated with temporary mechanical circulatory support (MCS) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP®. METHODS: Serum lactate and clearance were measured before MCS and at 1 h, 6 h, 12 h, and 24 h post-MCS in 43 patients at four tertiary-care centers in Southern Brazil. Prognostic value was assessed by univariable and multivariable analysis and receiver operating characteristic (ROC) curves for 30-day mortality. RESULTS: VA-ECMO was the most common MCS modality (58%). Serum lactate levels at all time points and lactate clearance after 6 h were associated with mortality on unadjusted and adjusted analyses. Lactate levels were higher in non-survivors at 6 h, 12 h, and 24 h after MCS. Serum lactate > 1.55 mmol/L at 24 h was the best single prognostic marker of 30-day mortality [area under the ROC curve = 0.81 (0.67-0.94); positive predictive value = 86%). Failure to improve serum lactate after 24 h was associated with 100% mortality. CONCLUSIONS: Serum lactate was an important prognostic biomarker in cardiogenic shock treated with temporary MCS. Serum lactate and lactate clearance at 24 h were the strongest independent predictors of short-term survival.

Use of sacubitril/valsartan in non-compaction cardiomyopathy: a case report.

The use of sacubitril/valsartan significantly reduces death or hospitalization in patients with ejection fraction < 40%. There is no study evaluating this drug effects in non-compaction cardiomyopathy (NCCM) individuals. The aim of this article is to report a case of a patient with NCCM initially refractory to gold standard treatment and afterwards treated with sacubitril/valsartan and its improvements. This is a case report of a 48-year-old woman, presenting with NCCM heart failure, who had received standard guideline-directed medical therapy for 18 months without any improvement in clinical and echocardiographic parameters. After that period, sacubitril/valsartan was initiated. After 18 months of refractory usage of guideline-directed medical therapy, sacubitril/valsartan was started, and significant change in functional class (III to I) and important ventricular remodelling were achieved with an improvement of 29% in the ejection fraction, reduction of 7 mm in ventricular diastolic diameter, and mild to none mitral valve functional regurgitation. In this case report, sacubitril/valsartan use was associated with improvement of echocardiographic and clinical parameters in a patient with NCCM.

Avaliação de uma coorte de transplante cardíaco por escore relacionado ao doador / Assessment of a heart transplantation cohort using a donor-related scoring system

Existem poucos sistemas de avaliação de mortalidade após transplante cardíaco (TC) que se baseiem em fatores relacionados com o doador e que sejam capazes de predizer o prognóstico. Identificar características dos doadores que têm impacto na sobrevida depois do TC pode contribuir para melhorar os resultados e a alocação de órgãos. Aplicamos um sistema de avaliação americano para predizer a mortalidade pós-TC em uma coorte brasileira. Objetivo: Avaliar um escore americano como preditor de mortalidade depois de TC em uma coorte brasileira. Métodos: Análise de uma base de dados de um centro de TC brasileiro de 2013 a 2015. Foram avaliadas quatro características dos doadores: tempo de isquemia, idade do doador, discordância racial doador/receptor e a função renal do doador. A sobrevida foi estimada pelo teste de log-rank em faixas de pontuação pré-determinadas. Resultados: Foram 110 doadores, 89% homens e 62% brancos. A principal causa de morte foi trauma (66,6%). Os doadores tinham em média 29,8 anos, 18,6 de relação Nitrogênio da ureia sanguínea / Creatinina, 175 minutos de tempo de isquemia e 42% de discordância racial com o receptor. Não houve diferença de sobrevida entre as faixas de pontuação. Conclusão: Apesar de preditor de mortalidade após transplante cardíaco em uma população americana, esse escore não foi útil para uma coorte de transplante brasileira. As diferenças, inclusive a alta taxa de miscigenação pode ser uma explicação para esses achados

here are few systems to assess mortality after heart transplantation (CT) that are based on donor-related factors and can predict prognosis. Identifying donor characteristics that impact post-CT survival can contribute to improved outcomes and organ allocation. We applied a US evaluation system to predict mortality after CT in a Brazilian cohort. Objective: To evaluate an American score as a predictor of mortality following CT in a Brazilian cohort. Method: Database analysis of a Brazilian CT center from 2013 to 2015. Four donor characteristics were evaluated: ischemia time, donor age, donor-recipient race mismatch, and donor renal function. Survival was estimated by the log-rank test in predetermined score ranges. Results: There were 110 donors, 89% male and 62% white. The main cause of death was trauma (66.6%). Donors had a mean age of 29.8 years, a mean blood urea nitrogen / creatinine ratio of 18.6, a mean ischemia time of 175 minutes, and race mismatch with the recipient of 42%. There was no difference in survival between the score ranges. Conclusion: Although it was a predictor of mortality after cardiac transplantation in an American population, this score was not useful for a Brazilian transplant cohort. Differences, including the high rate of miscegenation, may explain these findings

Implementation of Heart Transplantation Program to Advanced Heart Failure Patients in Brazil.

PURPOSE: Heart transplantation is the gold standard treatment for advanced heart failure. Left ventricular assist devices (LVADs), despite being a good option for these patients, are not quite available in developing countries. Time spent in heart transplant waiting list has increased lately even in regions where the number of transplants has also risen showing that a new strategy should be sought. RECENT FINDINGS: Transplant process organization combined with multidisciplinary work are linked to better outcomes while improvement in donor's care and in pre-transplant evaluation might be opportunities to change the long waiting list scenario. For the first time in Brazil, a survey with the most expressive heart transplant centers has been made, which allows an overview of treatment of advanced heart failure in a developing country. We also described a model of heart transplant team, which has proved to be a success when compared to the largest heart transplant centers in Latin America.

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

INTRODUÇÃO: A organização de uma diretriz clínica é tarefa complexa, que necessariamente deve envolver planejamento prévio, coordenação apropriada, revisão aprofundada da literatura científica, com envolvimento de múltiplos profissionais da área da saúde com notório reconhecimento. A elaboração de uma diretriz clínica de insuficiência cardíaca é ainda mais difícil, por conta da complexidade da síndrome, da amplitude das evidências científicas que permeiam o tópico e do grande impacto que as recomendações propostas têm sobre os pacientes, a comunidade médica e a sociedade como um todo. No presente documento, o Departamento de Insuficiência Cardíaca (DEIC) da Sociedade Brasileira de Cardiologia (SBC) apresenta uma revisão e uma atualização detalhadas de sua Diretriz de Insuficiência Cardíaca Crônica. Os trabalhos se iniciaram em setembro de 2017, com a definição da Comissão Coordenadora, que estabeleceu prioridades, dividiu grupos de trabalho e definiu o cronograma das atividades. Os grupos de trabalho, compostos por três a cinco participantes, deram início a intensas discussões virtuais, que culminaram com a redação de tabelas preliminares, sendo posteriormente amplamente divulgadas e revisadas pelos 34 participantes da diretriz. As discussões finais foram realizadas em reunião presencial em março de 2018, com a participação de todos os colaboradores, nas quais as principais recomendações foram votadas individualmente. As decisões quanto à classe das recomendações foram definidas por maioria plena (concordância de mais de 75% dos participantes). As recomendações terapêuticas propostas no presente documento se embasam nas evidências científicas mais atuais, considerando não apenas aspectos de eficácia clínica demonstrados em grandes ensaios clínicos, mas também contextualizando seus achados para o cenário de saúde brasileiro e incorporando aspectos econômicos definidos em estudos de custo-efetividade. Buscamos sumarizar as principais recomendações em fluxogramas e algoritmos de fácil entendimento e grande aplicabilidade clínica, propondo abordagens para o diagnóstico e o tratamento da síndrome em formato moderno, atualizado e didático. Na última seção da diretriz, o que não podemos deixar de fazer e o que não devemos fazer no diagnóstico, prevenção e tratamento da síndrome foram sumarizados em apenas três tabelas. Em especial, destacamos seis intervenções que foram consideradas de alta prioridade, por apresentarem relações de custo-efetividade altamente favoráveis. Sobretudo, esperamos que a publicação deste documento possa auxiliar na redução das elevadas taxas de mortalidade que ainda estão associadas com a insuficiência cardíaca no Brasil, além de minimizar o cruel impacto que a síndrome causa na qualidade de vida de nossos pacientes. Acreditamos que esta diretriz apresenta, de forma hierarquizada, a linha mestra que deve nortear a prática clínica em diferentes níveis de atenção à saúde, permitindo reconhecimento precoce de pacientes em risco, diagnóstico apropriado e implementação de tratamento de forma escalonada, eficaz e coerente com nossa realidade.

Evaluation of the prevalence and nutritional and social determinants of overweight in a population of schoolchildren: a cross-sectional analysis of 5,037 children.

OBJECTIVE: To evaluate the prevalence and nutritional and social determinants of overweight in a population of schoolchildren in Southern Brazil. METHODS: Cross-sectional descriptive study of 5,037 children of both genders, between 6 and 10.9 years of age, from public and private schools of Maringá, Paraná, Brazil. Evaluation of factors associated with excess weight (overweight and obesity) included gender, age, school type, socioeconomic level, education of the head of the family, eating habits, and means of commuting to school. After univariate analysis (Fisher's exact test), we adjusted a logistic regression model and used Wald's test for decision-making (p < 0.05). RESULTS: The mean age was 8.7 ± 1.3 years, with 52.8% females; 79.1% of the students attended public school and 54.6% had families of socioeconomic class A or B. Regarding nutritional status, 24% of children were overweight (7% obesity, 17% overweight). Being male, attending a private school, and having a head of the family with over four years of education were significantly associated with excess weight. In relation to food, inadequate intake of carbohydrates was associated with a 48% greater chance of overweight/obesity (p < 0.001; OR: 1.48; 95% CI: 1.25-1.76). CONCLUSION: The prevalence of overweight found in this study is approximate to that reported in national studies. Its association with gender and inadequate food intake indicates that these factors should be considered in initiatives aimed at preventive measures in childhood.

Avaliação da prevalência e de determinantes nutricionais e sociais do excesso de peso em uma população de escolares: análise transversal em 5.037 crianças / Evaluation of the prevalence and nutritional and social determinants of overweight in a population of schoolchildren: a cross-sectional analysis of 5,037 children

OBJETIVO: Avaliar a prevalência e os determinantes nutricionais e sociais do excesso de peso em uma população de escolares no sul do Brasil. MÉTODOS: Estudo descritivo transversal com 5.037 crianças de ambos os sexos, entre seis e 10,9 anos, de escolas públicas e privadas de Maringá, Paraná. A avaliação de fatores associados ao excesso de peso (sobrepeso e obesidade) incluiu gênero, idade, tipo de escola, nível socioeconômico, instrução do chefe da família, hábitos alimentares e meio de deslocamento à escola. Após análise univariada (teste exato de Fisher), foi ajustado um modelo de Regressão Logística e considerado o teste de Wald para a tomada de decisão (p < 0,05). RESULTADOS: A média de idade foi de 8,7 ± 1,3 ano, sendo 52,8% do gênero feminino, 79,1% estudantes de escola pública e 54,6% pertencentes a famílias com classe socioeconômica A ou B. Com relação ao estado nutricional, 24% das crianças apresentavam excesso de peso (obesidade 7%; sobrepeso 17%). Ser do gênero masculino, estudar em escola privada e ter chefe de família com mais de quatro anos de escolaridade estiveram significativamente associados ao excesso de peso. Com relação à alimentação, o consumo inadequado de carboidratos esteve associado a uma chance 48% maior de sobrepeso/obesidade (p < 0,001; OR: 1,48; IC 95%: 1,25-1,76). CONCLUSÃO: A prevalência de excesso de peso encontrada nesse estudo é aproximada ao reportado em estudos nacionais. Sua associação a gênero e consumo inadequado de alimentos indica que esses fatores devem ser considerados em iniciativas que visem medidas preventivas na infância.

OBJECTIVE: To evaluate the prevalence and nutritional and social determinants of overweight in a population of schoolchildren in Southern Brazil. METHODS: Cross-sectional descriptive study of 5,037 children of both genders, between 6 and 10.9 years of age, from public and private schools of Maringá, Paraná, Brazil. Evaluation of factors associated with excess weight (overweight and obesity) included gender, age, school type, socioeconomic level, education of the head of the family, eating habits, and means of commuting to school. After univariate analysis (Fisher's exact test), we adjusted a logistic regression model and used Wald's test for decision-making (p < 0.05). RESULTS: The mean age was 8.7 ± 1.3 years, with 52.8% females; 79.1% of the students attended public school and 54.6% had families of socioeconomic class A or B. Regarding nutritional status, 24% of children were overweight (7% obesity, 17% overweight). Being male, attending a private school, and having a head of the family with over four years of education were significantly associated with excess weight. In relation to food, inadequate intake of carbohydrates was associated with a 48% greater chance of overweight/obesity (p < 0.001; OR: 1.48; 95% CI: 1.25-1.76). CONCLUSION: The prevalence of overweight found in this study is approximate to that reported in national studies. Its association with gender and inadequate food intake indicates that these factors should be considered in initiatives aimed at preventive measures in childhood.