Thermal vasodilation using a portable infrared thermal blanket in decompensated heart failure.

Adjunctive and non-pharmacological therapies, such as heat, for the treatment of heart failure patients have been proposed. Positive results have been obtained in clinically stable patients, but no studies of the use of thermal therapy in patients with decompensated heart failure (DHF) have been reported. An open randomized clinical trial was designed in patients with DHF and controls. We studied 38 patients with a mean age of 56.9 years. A total of 86.8% were men, and 71% had nonischemic myocardiopathy. All participants were using dobutamine, and the median brain natriuretic peptide (BNP) level was 1396 pg/mL. An infrared thermal blanket heated the patients, who were divided into 2 groups: group T (thermal therapy) and group C (control). Group T underwent vasodilation using the thermal blanket at 50°C for 40 minutes in addition to drug treatment. The cardiac index increased by 24.1% (P = 0.009), and systemic vascular resistance decreased by 16.0% in group T (P < 0.024) after thermal therapy. Heat as a vasodilator increased the cardiac index and lowered systemic vascular resistance in DHF patients. These data suggest thermal therapy as a therapeutic approach for the adjuvant treatment of DHF patients.

Short-term add-on therapy with angiotensin receptor blocker for end-stage inotrope-dependent heart failure patients: B-type natriuretic peptide reduction in a randomized clinical trial.

OBJECTIVE: We aimed to evaluate angiotensin receptor blocker add-on therapy in patients with low cardiac output during decompensated heart failure. METHODS: We selected patients with decompensated heart failure, low cardiac output, dobutamine dependence, and an ejection fraction <0.45 who were receiving an angiotensin-converting enzyme inhibitor. The patients were randomized to losartan or placebo and underwent invasive hemodynamic and B-type natriuretic peptide measurements at baseline and on the seventh day after intervention. ClinicalTrials.gov: NCT01857999. RESULTS: We studied 10 patients in the losartan group and 11 patients in the placebo group. The patient characteristics were as follows: age 52.7 years, ejection fraction 21.3%, dobutamine infusion 8.5 mcg/kg.min, indexed systemic vascular resistance 1918.0 dynes.sec/cm(5).m(2), cardiac index 2.8 L/min.m(2), and B-type natriuretic peptide 1,403 pg/mL. After 7 days of intervention, there was a 37.4% reduction in the B-type natriuretic peptide levels in the losartan group compared with an 11.9% increase in the placebo group (mean difference, -49.1%; 95% confidence interval: -88.1 to -9.8%, p = 0.018). No significant difference was observed in the hemodynamic measurements. CONCLUSION: Short-term add-on therapy with losartan reduced B-type natriuretic peptide levels in patients hospitalized for decompensated severe heart failure and low cardiac output with inotrope dependence.

Short-term add-on therapy with angiotensin receptor blocker for end-stage inotrope-dependent heart failure patients: B-type natriuretic peptide reduction in a randomized clinical trial

OBJECTIVE: We aimed to evaluate angiotensin receptor blocker add-on therapy in patients with low cardiac output during decompensated heart failure. METHODS: We selected patients with decompensated heart failure, low cardiac output, dobutamine dependence, and an ejection fraction <0.45 who were receiving an angiotensin-converting enzyme inhibitor. The patients were randomized to losartan or placebo and underwent invasive hemodynamic and B-type natriuretic peptide measurements at baseline and on the seventh day after intervention. ClinicalTrials.gov: NCT01857999. RESULTS: We studied 10 patients in the losartan group and 11 patients in the placebo group. The patient characteristics were as follows: age 52.7 years, ejection fraction 21.3%, dobutamine infusion 8.5 mcg/kg.min, indexed systemic vascular resistance 1918.0 dynes.sec/cm5.m2, cardiac index 2.8 L/min.m2, and B-type natriuretic peptide 1,403 pg/mL. After 7 days of intervention, there was a 37.4% reduction in the B-type natriuretic peptide levels in the losartan group compared with an 11.9% increase in the placebo group (mean difference, -49.1%; 95% confidence interval: -88.1 to -9.8%, p = 0.018). No significant difference was observed in the hemodynamic measurements. CONCLUSION: Short-term add-on therapy with losartan reduced B-type natriuretic peptide levels in patients hospitalized for decompensated severe heart failure and low cardiac output with inotrope dependence. .

Haemodynamic effects of aliskiren in decompensated severe heart failure.

AIM: The renin-angiotensin-aldosterone system (RAAS) has dual pathways to angiotensin II production; therefore, multiple blockages may be useful in heart failure. In this study, we evaluated the short-term haemodynamic effects of aliskiren, a direct renin inhibitor, in patients with decompensated severe heart failure who were also taking angiotensin-converting enzyme (ACE) inhibitors. MATERIALS AND METHODS: A total of 16 patients (14 men, two women, mean age: 60.3 years) were enrolled in the study. The inclusion criteria included hospitalisation due to decompensated heart failure, ACE inhibitor use, and an ejection fraction < 40% (mean: 21.9 ± 6.7%). The exclusion criteria were: creatinine > 2.0 mg/dl, cardiac pacemaker, serum K(+) > 5.5 mEq/l, and systolic blood pressure < 70 mmHg. Patients either received 150 mg/d aliskiren for 7 days (aliskiren group, n = 10) or did not receive aliskiren (control group, n = 6). Primary end points were systemic vascular resistance and cardiac index values. Repeated-measures analysis of variance (ANOVA) was used to assess variables before and after intervention. A two-sided p-value < 0.05 was considered statistically significant. RESULTS: Compared to pre-intervention levels, systemic vascular resistance was reduced by 20.4% in aliskiren patients, but it increased by 2.9% in control patients (p = 0.038). The cardiac index was not significantly increased by 19.0% in aliskiren patients, but decreased by 8.4% in control patients (p = 0.127). No differences in the pulmonary capillary or systolic blood pressure values were observed between the groups. CONCLUSION: Aliskiren use reduced systemic vascular resistance in patients with decompensated heart failure taking ACE inhibitors.

[Angiotensin II receptor blocker add-on therapy for low cardiac output in decompensated heart failure].

BACKGROUND: During heart failure (HF) decompensation, an intense activation of the renin-angiotensin-aldosterone system occurs; however, the use of angiotensin-converting enzyme inhibitor (ACEI) cannot block it completely. Otherwise, the addition of angiotensin II receptor blocker (ARB) can be useful when the inotropic dependence occurs. We evaluated the efficacy of the ARB-ACEI association on dobutamine withdrawal in advanced decompensated HF. OBJECTIVE: To assess the efficacy of association angiotensin receptor blocker--angiotensin converting enzyme inhibitor to withdraw the intravenous inotropic support in decompensated severe heart failure. METHODS: In a case-control study (N = 24), we selected patients admitted at the hospital due to HF that had been using dobutamine for more than 15 days, with one or more unsuccessful drug withdrawal attempts; optimized dose of ACEI and ejection fraction (EF) < 0.45. Then, the patients additionally received ARB (n=12) or not (control, n=12). The outcome was the successful dobutamine withdrawal, evaluated by logistic regression, with a p < 0.05. RESULTS: The EF was 0.25 and the age was 53 years, with a dobutamine dose of 10.7 microg/kg x min. The successful drug withdrawal was observed in 8 patients from the ARB group (67.7%) and in 2 patients from the control group (16.7%). The odds ratio (OR) was 10.0 (95%CI: 1.4 to 69.3; p = 0.02). The worsening in renal function was similar (ARB group: 42% vs. control group: 67%; p=0.129). CONCLUSION: In this pilot study, the ARB-ACEI association was associated with successful dobutamine withdrawal in advanced decompensated heart failure. The worsening in renal function was similar in both groups. Further studies are necessary to clarify the issue.

Adição de Bloqueador do receptor de angiotensina II na insuficiência cardíaca descompensada / Adición de bloqueante del receptor de angiotensina II en la insuficiencia cardiaca descompensada / Angiotensin II receptor blocker add-on therapy for low cardiac output in decompensated heart failure

FUNDAMENTO: Durante a descompensação da insuficiência cardíaca, ocorre uma intensa ativação do sistema renina-angiotensina-aldosterona, entretanto, o uso de inibidor da enzima de conversão de angiotensina (IECA) não pode bloqueá-lo completamente. De outro modo, a adição de bloqueador do receptor de angiotensina II (BRA) pode ser útil quando ocorre a dependência de inotrópico. Avaliamos a eficiência da associação BRA-IECA para retirada da dobutamina na insuficiência cardíaca avançada e descompensada. OBJETIVO: Avaliar a eficácia da associação de bloqueador do receptor AT1 de angiotensina II ao inibidor de enzima de conversão, para a retirada da dobutamina em pacientes com dependência de suporte inotrópico decorrente da descompensação aguda da insuficiência cardíaca crônica. MÉTODOS: Em um estudo caso-controle (N = 24), selecionamos pacientes internados por descompensação da insuficiência cardíaca e com uso por mais de 15 dias de dobutamina, ou uma ou mais tentativas sem sucesso de retirada; dose otimizada de IECA; e FEVE < 0,45. Os pacientes então receberam adicionalmente BRA (n = 12) ou não (controle, n = 12). O desfecho foi o sucesso na retirada da dobutamina, avaliado pela regressão logística, com p < 0,05. RESULTADOS: A fração de ejeção foi de 0,25, e a idade de 53 anos, com dose de dobutamina de 10,7 μg/kg.min. O sucesso na retirada de dobutamina ocorreu em oito pacientes do grupo BRA (67,7 por cento), e em dois no grupo controle (16,7 por cento). A "odds ratio" foi de 10,0 (intervalo de confiança de 95 por cento:1,4 a 69,3; p = 0,02). A piora da função renal foi semelhante (grupo BRA: 42 por cento vs. grupo controle: 67 por cento, p = 0,129). CONCLUSÃO: Neste estudo piloto, a associação BRA-IECA foi relacionada ao sucesso na retirada da dobutamina, na insuficiência cardíaca avançada descompesada. A piora da função renal foi semelhante em ambos os grupos. Estudos adicionais são necessários para esclarecer o assunto.

BACKGROUND: During heart failure (HF) decompensation, an intense activation of the renin-angiotensin-aldosterone system occurs; however, the use of angiotensin-converting enzyme inhibitor (ACEI) cannot block it completely. Otherwise, the addition of angiotensin II receptor blocker (ARB) can be useful when the inotropic dependence occurs. We evaluated the efficacy of the ARB-ACEI association on dobutamine withdrawal in advanced decompensated HF. OBJECTIVE: To assess the efficacy of association angiotensin receptor blocker - angiotensin converting enzyme inhibitor to withdraw the intravenous inotropic support in decompensated severe heart failure. METHODS: In a case-control study (N = 24), we selected patients admitted at the hospital due to HF that had been using dobutamine for more than 15 days, with one or more unsuccessful drug withdrawal attempts; optimized dose of ACEI and ejection fraction (EF) < 0.45. Then, the patients additionally received ARB (n=12) or not (control, n=12). The outcome was the successful dobutamine withdrawal, evaluated by logistic regression, with a p < 0.05. RESULTS: The EF was 0.25 and the age was 53 years, with a dobutamine dose of 10.7 μg/kg.min. The successful drug withdrawal was observed in 8 patients from the ARB group (67.7 percent) and in 2 patients from the control group (16.7 percent). The odds ratio (OR) was 10.0 (95 percentCI: 1.4 to 69.3; p = 0.02). The worsening in renal function was similar (ARB group: 42 percent vs. control group: 67 percent; p=0.129). CONCLUSION: In this pilot study, the ARB-ACEI association was associated with successful dobutamine withdrawal in advanced decompensated heart failure. The worsening in renal function was similar in both groups. Further studies are necessary to clarify the issue.

FUNDAMENTO: Durante la descompensación de la insuficiencia cardiaca, ocurre una intensa activación del sistema renina-angiotensina-aldosterona, sin embargo, el empleo de inhibidor de la enzima de conversión de angiotensina (IECA) no puede bloquearlo completamente. De otro modo, la adición de bloqueante del receptor de angiotensina II (BRA) puede ser útil cuando ocurre la dependencia de inotrópico. Evaluamos la eficiencia de la asociación BRA-IECA para retirada de la dobutamina en la insuficiencia cardiaca avanzada y descompensada. OBJETIVO: Evaluar la eficacia de la asociación de bloqueante del receptor AT1 de angiotensina II al inhibidor de enzima de conversión, para la retirada de la dobutamina en pacientes con dependencia de soporte inotrópico que trascurre de la descompensación aguda de la insuficiencia cardiaca crónica. MÉTODOS: En un estudio caso-control (N = 24), seleccionamos a pacientes internados por descompensación de la insuficiencia cardiaca y con empleo por más de 15 días de dobutamina, o una o más intentos sin éxito de retirada; dosis optimizada de IECA; y FEVI < 0,45. Así que los pacientes recibieron adicionalmente BRA (n = 12) o no (control, n = 12). El desenlace fue el éxito en la retirada de la dobutamina, evaluado por la regresión logística, con p < 0,05. RESULTADOS: La fracción de eyección fue de 0,25, y la edad de 53 años, con dosis de dobutamina de 10,7 μg/kg.min. El éxito en la retirada de dobutamina ocurrió en ocho pacientes del grupo BRA (67,7 por ciento), y en dos en el grupo control (16,7 por ciento). La "odds ratio" fue de 10,0 (intervalo de confianza de 95 por ciento:1,4 a 69,3; p = 0,02). El empeoramiento de la función renal se halló similar (grupo BRA: 42 por ciento vs grupo control: 67 por ciento, p = 0,129). CONCLUSIÓN: En este estudio piloto, la asociación BRA-IECA se relacionó al éxito en la retirada de la dobutamina, en la insuficiencia cardiaca avanzada descompensada. El empeoramiento de la función ...

Uric acid renal excretion and renal insufficiency in decompensated severe heart failure.

OBJECTIVE: To evaluate uric acid renal excretion, hyperuricemia, renal dysfunction, and prognosis in patients with decompensated severe heart failure, as there are few data available. METHODS: One hundred and twenty-two patients, hospitalized for heart failure decompensation, in NYHA class IV, were classified into 3 groups as follows. Pilot group [ejection fraction (EF)0.45 and valvular dysfunction, n=16). The patients in groups 1 and 2 underwent assessment of creatinine and uric acid clearance before and after pyrazinamide, to estimate uric acid tubular secretion. Uric acid clearance <6.8 mL/min and secretion <170 microg/min were considered reduced. In groups 1 and pilot (n=106), mortality was analyzed by Cox regression model, and the prognostic value of hyperuricemia was assessed by ROC curve. RESULTS: In groups 1 and 2, respectively, serum uric acid was 511.7 and 422.5 micromol/L, and creatinine clearance was 46.7 and 61.4 mL/min. Uric acid clearance (3.2 vs. 3.9 mL/min) and tubular secretion (116 vs. 128 microg/min) were not different, but lower than normal values. In groups 1 and pilot, the 12-month mortality was 46.4% (CI 95%: 36.7%-56.0%). At end of follow-up, mortality was associated with impaired creatinine clearance (p<0.001), but not with hyperuricemia (p=0.236). CONCLUSIONS: In patients with decompensated severe heart failure, the tubular secretion and the clearance of uric acid were reduced. Renal dysfunction was associated with mortality, but hyperuricemia was not.

[Correlation between evolution of the cognitive function and mortality after hospital discharge in elderly patients with advanced heart failure]. / Associação entre evolução da função cognitiva e mortalidade após a alta hospitalar em pacientes idosos com insuficiência cardíaca avançada.

OBJECTIVE: To assess the relation between the evolution of cognitive performance and the prognosis of elderly patients after compensation of advanced heart failure. METHODS: Thirty-one patients older than 64 (68 +/- 7) years and admitted with New York Heart Association class IV heart failure and ejection fraction = 0.45 (0.38 +/- 0.06) were consecutively selected. They underwent cognitive tests (digit span, digit symbol, letter cancellation, trail making A and B) and the 6-minute walking test 4 days before (T1) and 6 weeks after (T2) hospital discharge, and their performances were compared using the t test. The prognostic value of the scores of the cognitive tests was analyzed with logistic regression, and the value of greatest accuracy of the tests was associated with the prognosis determined by the ROC curve. RESULTS: After 24.7 months, 17 (55%) patients had died. The performances in the 6-minute walking test and most cognitive tests improved between T1 and T2. The digit span score of the survivors ranged from 3.9 to 5.2 (P=0.003) and remained unaltered among those who died (4.1 to 3.9; P=0.496). An improvement < 0.75 points in the score was associated with mortality (relative risk of 8.1; P=0.011). CONCLUSION: In the elderly, after compensation of advanced heart failure, the lack of evolutionary improvement in cognitive performance was associated with a worse prognosis.

Associação entre evolução da função cognitiva e mortalidade após a alta hospitalar em pacientes idosos com insuficiência cardíaca avançada / Correlation between evolution of the cognitive function and mortality after hospital discharge in elderly patients with advanced heart failure

OBJETIVO: Avaliar a associação entre a evolução do desempenho cognitivo e o prognóstico de idosos após compensação de insuficiência cardíaca avançada. MÉTODOS: Selecionados, consecutivamente, 31 pacientes internados com insuficiência cardíaca classe IV da New York Heart Association, com idade > 64 anos (68 ±7) e fração de ejeção < 0,45 (0,38 ± 0,06). Submetidos a testes cognitivos (digit span, digit symbol, letter cancellation, trail making A e B) e teste de caminhada de 6min, 4 dias antes da alta (T1) e 6 semanas após (T2), cujos desempenhos foram comparados pelo teste T. O valor prognóstico dos escores dos testes cognitivos foram analisados pela regressão logística e o valor de maior acurácia dos testes associado com o prognóstico determinado pela ROC curve. RESULTADOS: Após 24,7 meses, 17 (55 por cento) pacientes faleceram. Os desempenhos ao teste de caminhada e maioria dos testes cognitivos melhoraram entre T1 e T2. O escore do digit span entre os sobreviventes variou de 3,9 para 5,2 (p=0,003), permanecendo inalterado entre os que faleceram (4,1para 3,9; p=0,496). Melhora < 0,75 pontos no escore foi associada à mortalidade (risco relativo de 8,1; p=0,011). CONCLUSAO: Em idosos, após a compensação de insuficiência cardíaca avançada, a ausência de melhora evolutiva do desempenho cognitivo foi associada a pior prognóstico.