Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial.

AIMS: Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC-1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals. METHODS: The ReBIC-1 trial is currently enrolling HF patients in NYHA functional class I-II, left ventricular ejection fraction ≤45%, without a HF-related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double-blinded protocol. The trial has two co-primary outcomes: (1) dyspnea assessment using a visual-analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow-up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre-defined sub-group analysis based on NT-proBNP levels at baseline is planned. PERSPECTIVE: Evidence-based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC-1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.

Prevalence of oral anticoagulation in atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores.

Prevalence of oral anticoagulation in atrial fibrillation

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores. .

Estudo das diferenças antropométricas e de comorbidades entre pacientes com insuficiência cardíaca com fração de ejeção preservada e reduzida / Study of anthropometric differences and co-morbidities among patients with heart failure with preserved and reduced ejection fraction

Introdução: As doenças cardiovasculares têm ampla prevalência e no Brasil são responsáveis pela terceira maior causa de internações do SUS sendo a a insuficiência cardíaca (IC) a principal razão. O presente estudo visa comparar as características antropométricas e presença de diferentes comorbidades em pacientes ambulatoriais com IC crônica, analisando as diferenças entre dois grupos, dicotomizados pela preservação ou comprometimento da fração de ejeção (FE). Métodos: Estudo observacional de pacientes com IC crônica atendidos na região metropolitana de Porto Alegre (RS). Os pacientes foram divididos em dois grupos de FE, preservada (FER ≥ 50 %) ou reduzida (FER ≤ 50%), de um total de 155 pacientes atendidos entre julho de 2010 e junho de 2011. Análise estatística: As variáveis contínuas foram apresentadas por média e desvio padrão e as categóricas por frequência. As diferenças entre as variáveis continuas foram aferidas pelo teste T de Student, e, entre as categóricas, pelo teste do qui-quadrado, e consideradas estatisticamente significativas quando p≤0,05. Resultados: Na amostra, 48 pacientes apresentavam FEP, sendo 60,4% do sexo feminino, com índice de massa corporal médio de 32,8 Kg/m2SC e circunferência abdominal e quadril com médias de 105,7 cm e 107,9 cm, respectivamente, que foram significativamente maiores do que no grupo com FER, além de níveis pressóricos sistólicos mais elevados. Conclusão: Os pacientes com FEP, na amostra estudada, foram significativamente mais obesos e com maior distribuição de gordura centrípeta, sem outras diferenças antropométricas, e com média de PA sistólica mais elevada, quando comparados aos pacientes com FER.

Introduction: Cardiovascular diseases are widely prevalent and in Brazil they are the third leading cause of SUS hospitalizations where heart failure (HF) is the main reason. This study aims to compare the anthropometric characteristics and presence of various co-morbidities in outpatients with chronic HF, analyzing the differences between two groups, dichotomized by preservation or impairment of the ejection fraction (EF). Methods: An observational study of patients with chronic heart failure treated in the metropolitan region of Porto Alegre (RS). The patients were divided into two groups of EF, preserved (PEF ≥ 50%) or reduced (REF ≤ 50%), from a total of 155 patients treated between July 2010 and June 2011. Statistical analysis: Continuous variables were presented as mean and standard deviation and categorical variables by frequency. Differences between continuous variables were assessed by the Student’s t test, and between categorical variables by the chi-square test, and considered statistically significant at p ≤ 0.05. Results: In the sample, 48 patients had PEF, 60.4% being females, with a mean body mass index of 32.8 Kg/m2SC and mean waist circumference and hip of 105.7 cm and 107.9 cm, respectively, which were significantly higher than in the REF group, and higher systolic blood pressure. Conclusion: In our sample, patients with PEF were significantly more obese and had more centripetal fat distribution, with no other anthropometric differences, and higher mean systolic BP than patients with REF.

1st Guidelines of the Brazilian Society of Cardiology on processes and skills for education in cardiology in Brazil--executive summary.

This article summarizes the "1st Guidelines of the Brazilian Society of Cardiology on Processes and Skills for Education in Cardiology in Brazil," which can be found in full at: . The guideline establishes the education time required in Internal Medicine and Cardiology with Specialization through theoretical and practical training. These requirements must be available at the center forming Specialists in Cardiology and the Cardiology contents.

Síndrome metabólica: complacência arterial e a velocidade de onda de pulso / Metabolic syndrome: arterial compliance and the pulse wave velocity

A Síndrome Metabólica (SM) caracteriza-se como um distúrbio complexo representado por um conjunto de fatores de risco cardiovascular, tendo sua frequência estimada entre 20% a 25% da população adulta mundial. Os diversos componentes da SM são responsáveis por alterações estruturais e funcionais de grandes artérias, dentre as quais destaca-se a diminuição da complacência arterial como um importante marcador de risco cardiovascular. A medida da Velocidade de Onda de Pulso (VOP) configura-se como um método relevante na avaliação da rigidez arterial. Discute-se, nesta revisão, os principais mecanismos pelos quais os componentes da SM atuam provocando estas alterações vasculares, a relevância destas modificações e o reflexo da influência terapêutica nestes casos. A revisão bibliográfica foi realizada através de consulta às bases de dados eletrônicos Medline, Lilacs e Pubmed, entre os anos de 2008 e 2009. Foram utilizados os descritores “metabolic syndrome”, “pulse wave velocity” e “arterial stiffness”, nos idiomas português e inglês, sendo selecionados estudos datados entre 1962 e 2009. Observou-se através dos estudos revisados que os componentes da SM atuam através de diferentes mecanismos para promover o aumento da VOP. A principal alteração vascular relacionada a estes componentes foi a diminuição da complacência das grandes artérias. A avaliação da complacência arterial através da medida da VOP permite o acompanhamento dos resultados obtidos através das intervenções terapêuticas e a identificação precoce destas alterações vasculares. Desta forma, torna-se possível a adoção de uma medida terapêutica precoce, possibilitando diminuir significativamente a progressão destas alterações vasculares e, portanto, reduzir a mortalidade cardiovascular destes pacientes.

The metabolic syndrome (MS) is characterized as a complex disorder represented by a set of cardiovascular risk factors, its frequency estimated between 20% to 25% of the adult population worldwide. The various components of MS are responsible for structural and functional alterations of large arteries, among which a decrease in arterial compliance stands out as an important cardiovascular risk marker. Measurement of Pulse Wave Velocity (PWV) figures as a relevant method in the evaluation of arterial stiffness. This review discusses the main mechanisms by which components of MS act causing these vascular changes, the relevance of these changes and the reflex of treatment influence in these cases. A literature review was conducted by consulting electronic databases Medline, Pubmed and Lilacs between years 2008 and 2009. Metabolic syndrome, pulse wave velocity and arterial stiffness, and their Portuguese equivalents, were the search words used, selecting studies dating from 1962 to 2009. The reviewed studies showed that the components of MS act through different mechanisms to promote the increase of PWV. The main change related to these vascular components was decreased compliance of large arteries. Assessment of arterial compliance by measuring PWV allows tracking the results obtained through therapeutic interventions and early identification of these vascular changes. It thus becomes possible to adopt an early treatment measure, which allows to slow down the progression of these vascular changes significantly and therefore reduce cardiovascular mortality in these patients.

I Diretriz da Sociedade Brasileira de Cardiologia sobre processos e competências para a formação em cardiologia no Brasil: resumo executivo / 1st Guidelines of the Brazilian Society of Cardiology on processes and skills for education in cardiology in Brazil: executive summary / I Directriz de la Sociedade Brasileira de Cardiologia sobre procesos y competencias para la formación en cardiología en el Brasil: resumen ejecutivo

Este artigo resume a "I Diretriz da Sociedade Brasileira de Cardiologia sobre Processos e Competências para a Formação em Cardiologia no Brasil", que pode ser encontrada na íntegra no seguinte endereço:

This article summarizes the "1st Guidelines of the Brazilian Society of Cardiology on Processes and Skills for Education in Cardiology in Brazil," which can be found in full at:

Este artículo resume la "I Directriz de la Sociedade Brasileira de Cardiologia sobre Procesos y Competencias para la Formación en Cardiología en el Brasil", que puede ser encontrada completa en la siguiente dirección:

Fatores de risco cardiovasculares e comorbidades em ambulatórios de cardiologia da região metropolitana de Porto Alegre, RS / Cardiovascular risk factors and comorbidities in cardiology outpatientin the metropolitan region of Porto Alegre, RS

As doenças cardiovasculares desempenham um importante papel na saúde pública atual, visto que representam a principal causa de morbimortalidade mundial e os mais altos custos em assistência médica. O objetivo do presente estudo foi descrever os fatores de riscos cardiovasculares e as comorbidades dos pacientes atendidos em ambulatórios de cardiologia na região metropolitana de Porto Alegre, RS. Métodos: Estudo transversal de pacientes adultos do ambulatório de cardiologia geral de atenção secundária à saúde, mantido pela Faculdade de Medicina da Universidade Luterana do Brasil (ULBRA). Entre setembro de 2009 e outubro de 2010, o estudo foi primeiramente realizado no posto de saúde da vila do IAPI, em Porto Alegre, e, posteriormente, no Hospital Universitário (HU), em Canoas. Foi utilizado um formulário padrão para a coleta de dados do prontuário médico. A análise estatística possibilitou descrever uma amostra única. Resultados: Foram analisados 204 pacientes no total. A maioria da população em estudo era composta de idosos (66%), mulheres (70,1%), brancos (83,3%), hipertensos (83,8%), sedentários (67%), com excesso de peso (85,6%) e obesidade visceral (92,1%). Quanto ao tabagismo, 12% eram ativos e 42% ex-tabagistas. A combinação de fatores de risco foi importante e identificada através da síndrome metabólica (85,0%). O cálculo do escore de risco de Framingham para um evento coronariano em 10 anos foi > 10% em 36,5% dos indivíduos. Conclusões: Foi identificada uma alta prevalência de fatores de risco cardiovasculares, suas combinações e comorbidades na população em estudo.

Cardiovascular diseases play an important role in public health today as the major cause of morbidity and mortality worldwide and the highest costs in medical care. The aim of this study was to describe the cardiovascular risk factors and comorbidities of patients seen in cardiology clinics in the metropolitan region of Porto Alegre RS. Methods: Cross-sectional study of adult patients from the general cardiology outpatient clinic of secondary care, run by the Medical School of Lutheran University of Brazil (ULBRA). Between Sep 2009 and Oct 2010, the study was first conducted at the Health Center of IAPI, a district in Porto Alegre, and afterwards at the School Hospital in Canoas. We used a standard form to collect data from medical records. The statistical analysis allowed to describe a unique sample. Results: We analyzed 204 patients in total. Most of the study population consisted of elderly (66%), females (70.1%), whites (83.3%), hypertensive (83.8%), sedentary (67%), overweight (85, 6%) and with visceral obesity (92.1%). As for smoking, 12% were active and 42% former smokers. The combination of risk factors was important and identified through the metabolic syndrome (85.0%). The calculation of Framingham risk score for a coronary event in 10 years was > 10% in 36.5% of individuals. Conclusions: We identified a high prevalence of cardiovascular risk factors, their combinations and comorbidities in the studied population.

Anemias na insuficiência cardíaca e sua interação com a função renal / Anemia in heart faillure and its interaction with renal function

Anemia é uma comorbidade frequente nos pacientes com insuficiência cardíaca (IC), havendo associação de ambas com a insuficiência renal. Avaliar correlações entre níveis de hemoglobina (Hb) e variáveis cardiorrenais em paciente com IC. Estudo transversal, incluindo 110 pacientes com IC selecionados em prontuários de hospitais da Universidade Luterana do Brasil (ULBRA). Analisaram-se dados clínicos, classificação funcional New York Heart Association (NYHA), exames laboratoriais e de ecocardiografia transtorácica...

Left atrioventricular remodeling in the assessment of the left ventricle diastolic function in patients with heart failure: a review of the currently studied echocardiographic variables.

Multiparametric echocardiographic imaging of the failing heart is now increasingly used and useful in decision making in heart failure. The reasons for this, relies on the need of different strategies of handling these patients, as differentiation of systolic or diastolic dysfunction, as well as on the gamma of approaches available, such as percutaneous and surgical revascularization, devices implantations, and valvular regurgitations and stenosis corrections. Congestive heart failure in patients with normal left ventricular diameters or preserved left ventricular ejection fraction had been pointed out recently as present in a proportion so high as 40 to 50 percent of cases of heart failure, mainly due to the epidemics in well developed countries, as is the problem of not well controlled metabolic states (such as obesity and diabetes), but also due to the real word in developing countries, as is the case of hypertension epidemics and its lack of adequate control. As a matter of public utility, the guidelines in the diagnosis and treatment of such patients will have to be cheap, available, easily reproducible, and ideally will furnish answers for the clinician questions not in a binary "black or white" manner, but with graduations, so if possible it has to be quantitative. The present paper aim to focus on the current clinical applications of tissue Doppler and of left atrial function and remodeling, and its pathophysiologic relationship with the left ventricle, as will be cleared in the documented review of echocardiography that follows, considering that the need of universal data on the syndrome of the failing heart does not mean, unfortunately, that all patients and clinicians in developing countries have at their own health facilities the same imaging tools, since they are, as a general rule, expensive.

Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome.

OBJECTIVE: To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. METHODS: This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration, extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. RESULTS: Of all patients, 12 (12.5%) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. CONCLUSION: The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation.

Comportamento dos marcadores inflamatórios e de injúria miocárdica na cirurgia cardíaca: correlaçäo laboratorial com quadro clínico de síndrome pós-pericardiotomia / Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome

OBJECTIVE: To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. METHODS: This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration , extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. RESULTS: Of all patients, 12 (12.5 percent) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. CONCLUSION: The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation

Estudo dos fatores de risco para o desenvolvimento da síndrome pós-pericardiotomia / Study of high risk factors for the occurrence of post-pericardiotomy syndrome

A síndrome pós-pericardiotomia ocorre entre a primeira e a segunda semanas de pós-operatório de cirurgia cardíaca, aparentemente como resposta imunoinflamatória ao trauma transoperatório. Permanece ainda sem definição o padrão-ouro para aferir sua ocorrência. OBJETIVO: Descrever a ocorrência de SPP em amostra de pacientes adultos, avaliando o papel de potenciais fatores de risco, assim como o desempenho diagnóstico da troponina I cardíaca (cTnI) e do fator necrose tumoral alfa...

Insuficiência cardíaca de alto débito causada por fístula renal arteriovenosa: relato de um caso / High-output cardiac failure caused by arteriovenous fistula: a case report

Os autores relatam um caso de insuficiência cardíaca de alto débito, causada por fístula arteriovenosa de origem renal, apresentando sua demonstraçäo angiográfica. Salientam o diagnóstico diferencial entre as patologias que se apresentam sob o quadro sindrômico de insuficiência cardíaca, e destacam o tratamento definitivo da fístula arteriovenosa

Estudo da evoluçäo intra-hospitalar da angina instável / Study of intra-hospitalar evolution of unstable angina

Os autores analisaram a evoluçäo intra-hospitalar de 94 pacientes portadores de angina instável, admitidos na Unidade de Terapia Coronária (UTC) do Hospital Clínicas Dr. Lazzarotto, durante um período de quatro anos. Os pacientes foram divididos em quatro grupos de angina: 1. angina de recente começo; 2. angina progressiva; 3. angina pós-infarto e 4. síndrome intermediária. Os autores relatam os resultados do tratamento clínico inicial a que foram submetidos os pacientes, concluindo que a maioria tornou-se assintomática. A melhor resposta clínica foi observada no grupo 2 (86%), e os pacientes do grupo 3 foram os mais refratários (41%). A incidência de infarto do miocárdio foi maior no grupo 1 (21%) e o maior percentual de óbitos foi observado no grupo 4 (13%). O tratamento clínico foi empregado como terapêutica definitiva em 70% dos casos, enquanto o tratamento cirúrgico foi adotado nos restantes 30%