Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Correlação entre as lesões coronarianas diagnosticadas pela angiotomografia e as diagnosticadas pelo método visual da cineangiocoronariografia / Correlation between coronary injuries diagnosed by multislice CT coronary angiography and diagnosed by visible coronary cineangiography method

Avaliar a eficácia diagnóstica da angiotomografia coronariana (AC) comparada com a cineangiocoronariografia (CAT). Material e Métodos: Foram avaliados retrospectivamente 146 pacientes submetidos a AC e CAT com angiografia coronariana quantitativa (ACQ), com intervalo médio de um mês entre os exames. O estudo foi realizado no Hospital Cardiológico Costantini. Foram avaliados os fatores de risco da amostra, a localização das lesões e o grau de severidade da obstrução coronariana nos grandes vasos (TCE, DA, CX e CD). Os resultados dos métodos diagnósticos foram comparados pelo coeficiente de correlação de Pearson. A partir dos achados positivos foi realizada a avaliação de correlação entre os métodos perante a severidade das lesões. Resultados: A amostra foi composta predominantemente por homens (73,97%), sendo a hipertensão arterial (HAS) (71,91%) o fator de risco mais frequente. A artéria mais acometida foi a DA. Quanto ao grau de severidade das lesões, os resultados foram os seguintes na comparação entre AC e CAT: lesões discretas com correlação r = 0,23; moderadas com r = 0,53 e severas com r = 0,70. Na comparação entre AC e ACQ: lesões discretas com correlação r = 0,45; moderadas com r = 0,70 e severas com r = 0,67. Conclusão: A AC apresentou moderada com ACQ e CAT em lesões moderadas e severas, e forte correlação na ausência de lesões quando comparada com ACQ

To evaluate the diagnostic efficacy of multislice CT coronary angiotomography compared with coronary cineangiography. Material and Methods: We retrospectively evaluated 146 patients submitted to MSCT and CA with quantitative coronary angiography (QCA), with a mean interval of one month between the exams. The study was carried out at the Costantini Cardiology Hospital. The risk factors for the sample, the location of the lesions and the degree of severity of the coronary obstruction in the large vessels (LCT, AD, CX and RC).The results of the diagnostic methods were compared using Pearson correlation coefficient. From the positive findings, a correlation evaluation was performed between the methods for the severity of the lesions. Results: The sample consisted predominantly of men (73.97%), and hypertension (SAH) (71.91%) was the most frequent risk factor. The most affected artery was AD. Regarding the degree of severity of the lesions, the results were as follows in the comparison between MSCT and CA: mild lesions with correlation r = 0.23, moderate with r = 0.53 and severe with r = 0.70. In the comparison between MSCT and QCA: mild lesions with correlation r = 0.45, moderate with r = 0.70 and severe with r = 0.67. Conclusion: MSCT showed moderate correlation with QCA and CA in moderate and severe lesions, and a strong correlation in the absence of lesions when compared with QCA

Comparative Study between Perfusion Changes and Positive Findings on Coronary Flow Reserve / Estudo Comparativo entre Alterações de Perfusão e Achados Positivos da Reserva de Fluxo Coronariano

Abstract Background: Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used. Objective: To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction. Methods: Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies. Results: All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed. Conclusion: Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS.

Resumo Fundamento: A avaliação funcional da obstrução arterial coronariana é empregada na prática cardiológica para correlacionar a obstrução anatômica e a queda de fluxo. Dentre as formas de avaliação, o estudo da reserva fracionada de fluxo (RFF) coronariano se tornou a mais utilizada. Objetivo: Avaliar a correlação entre a RFF com achados de isquemia, obtidos por métodos não invasivos como a ecocardiografia de estresse ou medicina nuclear, e a presença de obstrução crítica da artéria coronária. Métodos: Estudo retrospectivo de casos tratados com procedimentos sistematizados e padronizados para doença coronariana entre março de 2011 e agosto de 2014. Foram incluídos 96 pacientes com 107 obstruções coronarianas críticas (> 50% no tronco da coronária e/ou ≥ 70% nos demais segmentos) estimadas por angiografia coronariana quantitativa (ACQ) e ultrassonografia intracoronariana (USIC). Todos os casos apresentaram isquemia em um dos estudos não invasivos. Resultados: Ao estudo da RFF com adenosina na dose de 140 µg/kg/min, valores ≤ 0,80 foram encontrados em 52% dos casos. Na análise de correlação para RFF ≤ 0,80, avaliando-se sensibilidade/especificidade, valor preditivo positivo/negativo, acurácia e curva ROC em relação ao grau de estenose, extensão da estenose e presença de isquemia, não foram observados valores de significância ou de forte correlação. Conclusão: A RFF coronariana a um valor de corte de 0,80 não apresentou correlação com testes não invasivos de isquemia em pacientes com obstruções coronarianas graves à ACQ e USIC.

Comparative Study between Perfusion Changes and Positive Findings on Coronary Flow Reserve.

BACKGROUND: Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used. OBJECTIVE: To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction. METHODS: Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies. RESULTS: All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed. CONCLUSION: Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS.

Short-term effects of moderate intensity physical activity in patients with metabolic syndrome.

OBJECTIVES: To evaluate whether a short-term moderate intensity exercise program could change inflammatory parameters, and improve different components of metabolic syndrome in sedentary patients. METHODS: Sixteen patients completed the 12-week program of supervised exercise, which consisted of a 40 to 50 minutes of walking, 3 times a week, reaching 50 to 60% of the heart rate reserve. The parameters evaluated before and after intervention were waist circumference, systolic and diastolic blood pressure, triglycerides, LDL cholesterol, HDL cholesterol, total cholesterol, C-reactive protein and interleukin 8. RESULTS: There was a significant reduction in waist circumference (102.1±7.5cm to 100.8±7.4cm; p=0.03) and in body mass index (29.7±3.2kg/m² versus 29.3±3.5kg/m²; p=0.03). Systolic blood pressure dropped from 141±18 to 129±13mmHg and diastolic from 79±12 to 71±10mmHg (with p<0.05 for both). No changes were observed on total cholesterol, LDL cholesterol and triglycerides, although HDL cholesterol levels improved, from 45.5±6.0 to 49.5±9.8mg/dL (p=0.02). There was a trend toward reduction of C-reactive protein (8.3%; p=0.07) and interleukin 8 levels (17.4%; p=0.058). The improvement in cardiovascular capacity was demonstrated by an increase of 13% in estimated volume of oxygen (p<0.001). CONCLUSION: Benefits of aerobic exercise of moderate intensity were seen within only 12 weeks of training in sedentary patients with metabolic syndrome. Considering the easy self-applicability and proven metabolic effects, an exercise program could be a first approach to sedentary patients with metabolic syndrome.

Relação E/e' na predição da remodelação do ventrículo esquerdo após infarto agudo do miocárdio / E/e’ Ratio for the Prediction of Left Ventricular Remodeling After Acute Myocardial Infarction

Fundamentos: A dilatação do ventrículo esquerdo (VE), após infarto agudo do miocárdio, (IAM) é um importante determinante do prognóstico. A razão entre a velocidade diastólica E do fluxo mitral e a velocidade diastólica e’ do anel mitral (relação E/e’) é o melhor índice não invasivo para detectar elevação aguda da pressão de enchimento do VE. A hipótese deste estudo é E/e’ seja capaz de predizer remodelação do VE, após IAM tratado. Objetivo: Avaliar se E/e’ prediz remodelação ventricular após IAM, em comparação aos dados clínicos, laboratoriais e ecocardiográficos tradicionais. Método: Ecocardiogramas foram realizados em pacientes consecutivos com primeiro IAM, após angioplastia transluminal coronariana (ATC), seguida de recanalização efetiva, 48 horas e 60 dias após o evento. E/e’ foi calculada pela média de quatro sítios do anel mitral. Remodelação do VE foi definida como aumento ≥ 15%do volume sistólico final ao método de Simpson. Análises estatísticas incluíram teste t de Student, curvas receptor-operador (ROC) e regressão logística multivariada, com p significante < 0,05. Resultados: Estudados 55 pacientes, com idade 58±11 anos, 43 homens, observou-se E/e’ maior (13±4 versus8,5±2; p< 0,001) no grupo com remodelação (n= 13) em relação ao grupo sem remodelação (n= 42). A curva ROC indicou E/e’ como preditor de remodelação (área sob a curva= 0,81, p= 0,001). Análises de regressão contendo variáveis clínicas, laboratoriais e dopplerecocardiográficas confirmaram E/e’ como preditor independente da remodelação (odds ratio 1,42; p= 0,01). Conclusão: A relação E/e’ é um preditor útil de remodelação do VE após IAM, indicando pacientes com maior risco cardiovascular.

Background: Left ventricular (LV) dilation after acute myocardial infarction (AMI) is an important determinant of prognosis.The ratio of early mitral inflow velocity (E) and peak early diastolic annular velocity (e’) provides the best single index for noninvasive detection of acute elevation of LV filling pressure. Objective: To assess whether E/e’ ratio predicts LV remodeling after properly treated AMI compared with traditional clinical, laboratory and echocardiographic data.Methods: Comprehensive echocardiograms were performed in a series of consecutive patients with first AMI successfully treated with primary percutaneous transluminal angioplasty (PTCA), both 48 hours after intervention and 60 days later.Average E/e’ was determined from four sites of mitral annulus. LV remodeling was defined as more than 15% increase in end-systolic volume estimated by Simpson method.Statistical analysis included Student t test, receiver-operator curves (ROC) and multivariate logistic regression (all significant with “p” less than 0.05). Results: Fifty-five patients were included, with mean age 58 ± 11 years, 43 men. The group of patients who underwent LV remodeling (n=13) had higher baseline E/e’ than those without (13 ± 4 versus 8.5 ± 2, p <0.001). The ROC curve showed E/e’ > 15 as a predictor of remodeling (AUC=0.81, p=0.001). In addition, regression analysis (comprising clinical, laboratory and echocardiographic variables along with AMI site) confirmed the independent value of E/e’ in the prediction of LV remodeling (odds ratio 1.42, p=0.01). Conclusion: The E/e’ ratio is an useful predictor for LV remodeling after AMI, indicating patients with increased cardiovascular risk.

Efeitos de curto prazo de um programa de atividade física moderada em pacientes com síndrome metabólica / Short-term effects of moderate intensity physical activity in patients with metabolic syndrome

OBJETIVO: Avaliar se um programa de exercícios de intensidade moderada por um pequeno período pode alterar os parâmetros inflamatórios e melhorar os diferentes componentes da síndrome metabólica em pacientes sedentários. MÉTODOS: Dezesseis pacientes completaram 12 semanas de exercício supervisionado, que consistiu em caminhar 40 a 50 minutos 3 vezes por semana, atingindo 50 a 60% da frequência cardíaca de reserva. Os parâmetros avaliados pré e pós-intervenção foram circunferência de cintura, pressão arterial sistólica e diastólica, triglicérides, LDL-colesterol, HDL-colesterol, colesterol total, proteína C-reativa e interleucina 8. RESULTADOS: Houve redução significativa na circunferência da cintura (102,1±7,5cm versus 100,8±7,4cm; p=0,03) e índice de massa corporal (29,7±3,2kg/m² versus 29,3±3,5kg/m²; p=0,03). A pressão arterial sistólica diminuiu de 141±18 para 129±13mmHg e a diastólica de 79±12 para 71±10mmHg (p<0,05 para ambos). Não foram observadas alterações no colesterol total, LDL-colesterol e triglicérides, mas houve melhora significativa nos níveis de HDL-colesterol, - 45,5±6,0 versus 49,5±9,8mg/dL (p=0,02). Houve uma tendência na redução de proteína C-reativa (8,3%; p=0,07) e interleucina 8 (17,4%; p=0,058). A melhora na capacidade cardiovascular foi demonstrada por um aumento de 13% no volume de oxigênio estimado (p<0,001). CONCLUSÃO: Os benefícios do exercício aeróbico com intensidade moderada puderam ser observados em apenas 12 semanas de treinamento em pacientes sedentários com síndrome metabólica. Considerando a facilidade de autoaplicabilidade e os efeitos metabólicos comprovados, tal programa pode ser uma primeira abordagem para pacientes sedentários com síndrome metabólica.

OBJECTIVES: To evaluate whether a short-term moderate intensity exercise program could change inflammatory parameters, and improve different components of metabolic syndrome in sedentary patients. METHODS: Sixteen patients completed the 12-week program of supervised exercise, which consisted of a 40 to 50 minutes of walking, 3 times a week, reaching 50 to 60% of the heart rate reserve. The parameters evaluated before and after intervention were waist circumference, systolic and diastolic blood pressure, triglycerides, LDL cholesterol, HDL cholesterol, total cholesterol, C-reactive protein and interleukin 8. RESULTS: There was a significant reduction in waist circumference (102.1±7.5cm to 100.8±7.4cm; p=0.03) and in body mass index (29.7±3.2kg/m² versus 29.3±3.5kg/m²; p=0.03). Systolic blood pressure dropped from 141±18 to 129±13mmHg and diastolic from 79±12 to 71±10mmHg (with p<0.05 for both). No changes were observed on total cholesterol, LDL cholesterol and triglycerides, although HDL cholesterol levels improved, from 45.5±6.0 to 49.5±9.8mg/dL (p=0.02). There was a trend toward reduction of C-reactive protein (8.3%; p=0.07) and interleukin 8 levels (17.4%; p=0.058). The improvement in cardiovascular capacity was demonstrated by an increase of 13% in estimated volume of oxygen (p<0.001). CONCLUSION: Benefits of aerobic exercise of moderate intensity were seen within only 12 weeks of training in sedentary patients with metabolic syndrome. Considering the easy self-applicability and proven metabolic effects, an exercise program could be a first approach to sedentary patients with metabolic syndrome.

Avaliação não invasiva das pressões de enchimento e remodelação do ventrículo esquerdo após infarto do miocárdio / Non invasive assessment of left ventricular filling pressure and remodeling after acute myocardial infarction

FUNDAMENTO: A dilatação do ventrículo esquerdo (VE) após infarto agudo do miocárdio (IAM) é um importante determinante do prognóstico. A razão entre a velocidade diastólica E do fluxo mitral e a velocidade diastólica e' do anel mitral (relação E/e') é o melhor índice não invasivo para detectar elevação aguda da pressão de enchimento do VE. A hipótese deste estudo é que a E/e' possa predizer remodelação do VE após IAM tratado. OBJETIVO: Avaliar se a E/e' prediz remodelação ventricular após IAM, em comparação aos dados clínicos, laboratoriais e ecocardiográficos tradicionais. MÉTODO: Ecocardiogramas foram realizados em pacientes consecutivos com primeiro IAM, após angioplastia transluminal coronariana (ATC) seguida de recanalização efetiva, 48 horas e 60 dias após o evento. A E/e' foi calculada pela média de quatro sítios do anel mitral. Remodelação do VE foi definida como aumento ≥ 15% do volume sistólico final ao método de Simpson. Análises estatísticas incluíram teste t de Student, curvas receptor-operador (ROC) e regressão logística multivariada, com p significante < 0,05. RESULTADOS: Estudados 55 pacientes, com idade 58 ± 11 anos, 43 homens, observou-se E/e' maior (13 ± 4 versus 8,5 ± 2; p < 0,001) no grupo com remodelação (n = 13) em relação ao grupo sem remodelação (n = 42). A curva ROC indicou E/e' como preditor de remodelação (área sob a curva = 0,81, p = 0,001). Análises de regressão contendo variáveis clínicas, laboratoriais e Doppler-ecocardiográficas confirmaram E/e' como preditor independente da remodelação (odds ratio 1,42; p = 0,01). CONCLUSÃO: A relação E/e' é um preditor útil de remodelação do VE após IAM, indicando pacientes com maior risco cardiovascular.

BACKGROUND: Left ventricular (LV) dilation after acute myocardial infarction (AMI) is an important determinant of prognosis. The ratio of early mitral inflow velocity (E) and peak early diastolic annular velocity (e') provides the best single index for noninvasive detection of acute elevation of LV filling pressure. OBJECTIVE: To assess whether E/e' ratio predicts LV remodeling after properly treated AMI compared with traditional clinical, laboratory and echocardiographic data. METHODS: Comprehensive echocardiograms were performed in a series of consecutive patients with first AMI successfully treated with primary percutaneous transluminal angioplasty (PTCA), both 48 hours after intervention and 60 days later. Mean E/e' was determined from four sites of the mitral annulus. LV remodeling was defined as more than 15% increase in end-systolic volume estimated by Simpson method. Statistical analysis included Student's t test, receiver-operator curves (ROC) and multivariate logistic regression (all significant with p < 0.05). RESULTS: Fifty-five patients were included, with mean age 58 ± 11 years, 43 men. The group of patients who underwent LV remodeling (n = 13) had higher baseline E/e' than those without (13 ± 4 versus 8.5 ± 2, p < 0.001). The ROC curve showed E/e' > 15 as a predictor of remodeling (AUC = 0.81, p = 0.001). In addition, regression analysis (comprising clinical, laboratory and echocardiographic variables along with AMI site) confirmed the independent value of E/e' in the prediction of LV remodeling (odds ratio 1.42, p = 0.01). CONCLUSION: The E/e' ratio is a useful predictor of LV remodeling after AMI, indicating patients with increased cardiovascular risk.

Non invasive assessment of left ventricular filling pressure and remodeling after acute myocardial infarction.

BACKGROUND: Left ventricular (LV) dilation after acute myocardial infarction (AMI) is an important determinant of prognosis. The ratio of early mitral inflow velocity (E) and peak early diastolic annular velocity (e') provides the best single index for noninvasive detection of acute elevation of LV filling pressure. OBJECTIVE: To assess whether E/e' ratio predicts LV remodeling after properly treated AMI compared with traditional clinical, laboratory and echocardiographic data. METHODS: Comprehensive echocardiograms were performed in a series of consecutive patients with first AMI successfully treated with primary percutaneous transluminal angioplasty (PTCA), both 48 hours after intervention and 60 days later. Mean E/e' was determined from four sites of the mitral annulus. LV remodeling was defined as more than 15% increase in end-systolic volume estimated by Simpson method. Statistical analysis included Student's t test, receiver-operator curves (ROC) and multivariate logistic regression (all significant with p < 0.05). RESULTS: Fifty-five patients were included, with mean age 58 ± 11 years, 43 men. The group of patients who underwent LV remodeling (n = 13) had higher baseline E/e' than those without (13 ± 4 versus 8.5 ± 2, p < 0.001). The ROC curve showed E/e' > 15 as a predictor of remodeling (AUC = 0.81, p = 0.001). In addition, regression analysis (comprising clinical, laboratory and echocardiographic variables along with AMI site) confirmed the independent value of E/e' in the prediction of LV remodeling (odds ratio 1.42, p = 0.01). CONCLUSION: The E/e' ratio is a useful predictor of LV remodeling after AMI, indicating patients with increased cardiovascular risk.

Association between inflammatory markers and left atrial enlargement in patients on hemodialysis.

BACKGROUND: In individuals with concurrent chronic kidney disease (CKD) and cardiovascular disease (CVD), the association between left atrial volume (LAV) and serum levels of C-reactive protein (CRP) is shown. OBJECTIVE: Verify the presence of associations between systemic inflammation and LA dilation in patients on hemodialysis (HD) without clinically evident CVD. METHODS: This was an observational cross-sectional study of a population on HD (> 3 months), which excluded patients with acute or chronic inflammatory diseases (infections, malignancies, autoimmune diseases) hemodynamic instability, use of anti-inflammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior cardiovascular (CV) events. CRP and interleukin-6 (IL-6) measurements as well as Doppler echocardiography were obtained. Correlation coefficients were determined to evaluate the associations between variables. RESULTS: A total of 58 patients were included (28 men, aged 55 ± 15 years), on HD for 24 ± 16 months, 45% were hypertensive, 26% diabetic, with median CRP of 5.1 mg/dL and IL-6 of 6.1 pg/dL. CRP significantly correlated with LAV (p = 0.040), LAV index (LAVi, p = 0.02) and mitral inflow E wave (p = 0.014). IL-6, despite the strong association with CRP levels (r = 0.75, p < 0.001), did not correlate with echocardiographic indices. Individuals in the top quartile of CRP had significantly higher LAVi than the others (42 ± 17 versus 32 ± 11 mL/m², p = 0.015). CONCLUSIONS: In subjects on HD with no prior CV event, there was an association between elevated CRP levels and LA enlargement. The findings suggest an association between physiopathological processes related to left atrial dilation and systemic inflammatory state of patients on HD.

Associação entre marcadores de inflamação e aumento do átrio esquerdo em pacientes de hemodiálise / Association between inflammatory markers and left atrial enlargement in patients on hemodialysis

FUNDAMENTO: Em indivíduos com doença renal crônica e doença cardiovascular (DCV) concomitante, apontou-se relação entre o volume do átrio esquerdo (AE) e os níveis séricos de proteína C reativa (PCR). OBJETIVO: Verificar a presença de associações entre inflamação sistêmica e dilatação do AE em pacientes de hemodiálise (HD) sem DCV clinicamente manifesta. MÉTODOS: Estudo observacional transversal em população sob HD (> 3 meses), excluindo-se pacientes com afecções inflamatórias crônicas ou agudas (infecções, neoplasias, doenças autoimunes) instabilidade hemodinâmica, uso de drogas anti-inflamatórias, hiperparatireoidismo, arritmias, valvopatia mitral e evento cardiovascular (CV) prévio. Dosagens de PCR e interleucina 6 (IL-6), e ecodopplercardiograma foram obtidos. Coeficientes de correlação foram determinados para avaliar as associações entre as variáveis. RESULTADOS: Incluídos 58 pacientes (28 homens, idade 55 ± 15 anos), sob HD há 24 ± 16 meses, 45% hipertensos, 26% diabéticos, com medianas de PCR 5,1 mg/dl e IL-6 6,1 pg/dl. A PCR correlacionou-se significativamente com dimensão do AE (p = 0,040), volume indexado do AE (VIAE, p = 0,02) e onda E do fluxo mitral (p = 0,014). A IL-6, apesar da forte associação com a PCR (r = 0,75, p < 0,001), não se correlacionou com índices ecocardiográficos. Indivíduos no quartil superior da PCR tiveram VIAE significativamente maior do que os demais (42 ± 17 versus 32 ± 11 ml/m², p = 0,015). CONCLUSÕES: Em indivíduos sob HD sem evento CV prévio, houve associação entre elevação da PCR e aumento do AE. Os achados sugerem uma ligação entre processos fisiopatológicos relacionados à dilatação atrial esquerda e o estado inflamatório sistêmico de pacientes sob HD.

BACKGROUND: In individuals with concurrent chronic kidney disease (CKD) and cardiovascular disease (CVD), the association between left atrial volume (LAV) and serum levels of C-reactive protein (CRP) is shown. OBJECTIVE: Verify the presence of associations between systemic inflammation and LA dilation in patients on hemodialysis (HD) without clinically evident CVD. METHODS: This was an observational cross-sectional study of a population on HD (> 3 months), which excluded patients with acute or chronic inflammatory diseases (infections, malignancies, autoimmune diseases) hemodynamic instability, use of anti-inflammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior cardiovascular (CV) events. CRP and interleukin-6 (IL-6) measurements as well as Doppler echocardiography were obtained. Correlation coefficients were determined to evaluate the associations between variables. RESULTS: A total of 58 patients were included (28 men, aged 55 ± 15 years), on HD for 24 ± 16 months, 45% were hypertensive, 26% diabetic, with median CRP of 5.1 mg/dL and IL-6 of 6.1 pg/dL. CRP significantly correlated with LAV (p = 0.040), LAV index (LAVi, p = 0.02) and mitral inflow E wave (p = 0.014). IL-6, despite the strong association with CRP levels (r = 0.75, p < 0.001), did not correlate with echocardiographic indices. Individuals in the top quartile of CRP had significantly higher LAVi than the others (42 ± 17 versus 32 ± 11 mL/m², p = 0.015). CONCLUSIONS: In subjects on HD with no prior CV event, there was an association between elevated CRP levels and LA enlargement. The findings suggest an association between physiopathological processes related to left atrial dilation and systemic inflammatory state of patients on HD.

Efeitos agudos do exercício físico prolongado: avaliação após ultramaratona de 24 horas / Acute effects of prolonged physical exercise: evaluation after a twenty-four-hour ultramarathon

FUNDAMENTO: As consequências e os riscos do exercício físico contínuo por períodos prolongados não estão esclarecidos. OBJETIVO: Avaliar os efeitos do exercício prolongado em participantes de uma ultramaratona de 24 horas. MÉTODOS: Vinte corredores foram selecionados para avaliação, um dia antes e imediatamente após a prova em que os corredores devem percorrer a maior distância em 24 horas. Foram obtidos dados clínicos, laboratoriais e ecocardiográficos. RESULTADOS: A distância média percorrida foi de 140,3 ± 18,7 km. Os corredores apresentaram redução do peso corpóreo (p < 0,001) e da pressão arterial sistólica (p < 0,001) e diastólica (p = 0,004). As alterações hematológicas foram compatíveis com o estresse fisiológico. A concentração plasmática de creatinofosfoquinase (CPK) aumentou significativamente (163,4 ± 56,8 versus 2978,4 ± 1921,9 U/L; p < 0,001) e esteve inversamente correlacionada com a distância percorrida: os que correram maiores distâncias apresentaram níveis mais baixos de CPK (Pearson r = 0,69; p = 0,02). Após a corrida, dois corredores apresentaram discreta elevação de troponina T. Em um deles, houve queda concomitante na fração de ejeção (coronariopatia foi excluída subsequentemente). O ecocardiograma na avaliação basal mostrou hipertrofia de ventrículo esquerdo em um e aumento do volume atrial esquerdo em cinco corredores. Após a prova, houve redução na relação E/A (p < 0,01). CONCLUSÃO: O exercício físico prolongado está associado a alterações cardiovasculares e metabólicas. As alterações cardiológicas encontradas sugerem que o fenômeno de fadiga cardíaca pode ocorrer nessa modalidade de corrida. O efeito a longo prazo dessas alterações, com a manutenção da prática desse tipo de atividade, ainda é desconhecido.

BACKGROUND: The consequences and risks of prolonged physical exercise are not well established. OBJECTIVE: To evaluate the effects of prolonged physical exercise on the participants of a 24-hour ultramarathon race. METHODS: Twenty male runners were selected for evaluation a day before and immediately after the race, where the athletes had to cover the most distance in 24 hours. Clinical, laboratory and echocardiographic data were obtained at both evaluations. RESULTS: Mean distance covered was 140.3 ± 18.7 km. Runners showed weight loss (p < 0.001) and decrease in systolic (p < 0.001) and diastolic (p = 0.004) blood pressure. Hematological changes were compatible with the physiological stress. Plasma levels of creatine phosphokinase strikingly increased post-race (163.4 ± 56.8 vs. 2978.4 ± 1921.9 U/L; p < 0.001) and was inversely correlated with distance covered: those who covered the longest distances showed the lowest CPK levels (Pearson r = 0.69, p = 0.02). After the race, 2 runners showed a slight increase in Troponin levels. One of them also had simultaneous decrease in left ventricular ejection fraction (coronary artery disease was subsequently ruled out). Basal echocardiography assessment had shown LV hypertrophy in one and increased left atrial volume in five runners. After the race, there was a decrease in E/A ratio (p < 0.01). CONCLUSION: Prolonged physical exercise is associated with metabolic and cardiovascular alterations. Cardiac abnormalities found in our study suggest that cardiac fatigue may occur in this specific race modality. The long-term effect of these alterations, while maintaining the routine practice of prolonged strenuous physical activity, is still unknown.

Acute effects of prolonged physical exercise: evaluation after a twenty-four-hour ultramarathon.

BACKGROUND: The consequences and risks of prolonged physical exercise are not well established. OBJECTIVE: To evaluate the effects of prolonged physical exercise on the participants of a 24-hour ultramarathon race. METHODS: Twenty male runners were selected for evaluation a day before and immediately after the race, where the athletes had to cover the most distance in 24 hours. Clinical, laboratory and echocardiographic data were obtained at both evaluations. RESULTS: Mean distance covered was 140.3 ± 18.7 km. Runners showed weight loss (p < 0.001) and decrease in systolic (p < 0.001) and diastolic (p = 0.004) blood pressure. Hematological changes were compatible with the physiological stress. Plasma levels of creatine phosphokinase strikingly increased post-race (163.4 ± 56.8 vs. 2978.4 ± 1921.9 U/L; p < 0.001) and was inversely correlated with distance covered: those who covered the longest distances showed the lowest CPK levels (Pearson r = 0.69, p = 0.02). After the race, 2 runners showed a slight increase in Troponin levels. One of them also had simultaneous decrease in left ventricular ejection fraction (coronary artery disease was subsequently ruled out). Basal echocardiography assessment had shown LV hypertrophy in one and increased left atrial volume in five runners. After the race, there was a decrease in E/A ratio (p < 0.01). CONCLUSION: Prolonged physical exercise is associated with metabolic and cardiovascular alterations. Cardiac abnormalities found in our study suggest that cardiac fatigue may occur in this specific race modality. The long-term effect of these alterations, while maintaining the routine practice of prolonged strenuous physical activity, is still unknown.

Phase†I†of cardiac rehabilitation: A new challenge for evidence based physiotherapy.

Cardiac rehabilitation protocols applied during the in-hospital phase (phase I) are subjective and their results are contested when evaluated considering what should be the three basic principles of exercise prescription: specificity, overload and reversibility. In this review, we focus on the problems associated with the models of exercise prescription applied at this early stage in-hospital and adopted today, especially the lack of clinical studies demonstrating its effectiveness. Moreover, we present the concept of "periodization" as a useful tool in the search for better results.

Pharmacological stent deployment in the left anterior descending artery: late event indicators.

BACKGROUND: The efficacy of pharmacological stents in decreasing the incidence of cardiac events is not homogeneous for all lesions or patient subgroups. OBJECTIVE: 1) To evaluate the late clinical evolution of patients submitted to pharmacological stent implantation in atherosclerotic lesions of the left anterior descending artery; 2) to identify, among the clinical, angiographic and intravascular ultrasonographic characteristics, the ones predictive of cardiac event risk. METHODS: From May 2002 to August 2005, 205 patients were treated with 236 pharmacological stent implants, guided by the intravascular US (IVUS). RESULTS: After a mean follow-up period of 711 days, the rate of stent thrombosis was 0.48%, the same observed for acute myocardial infarction or revascularization surgery. The revascularization rate of the treated lesion was 7.31% and the general event rate was 10.24%. The event indicators, according to the multivariate analysis were the implant of more than one stent in the same artery, concentric lesions and the minimal intra-stent area measured by IVUS < 3.88 mm(2). CONCLUSION: Based on the data obtained, we conclude that the revascularization of the left anterior descending artery with pharmacological stent implant, chosen and optimized by IVUS, presents a low incidence of late events. The implant of two pharmacological stents for the treatment of long lesions was the main independent factor for the occurrence of late events. The final luminal area > 3.88 mm(2) obtained in the small reference-diameter segments is an independent indicator of event-free evolution.