Are the recommendation of sodium and fluid restriction in heart failure patients changing over the past years? A systematic review and meta-analysis.

BACKGROUND: Heart failure (HF) is a growing problem for healthcare systems worldwide. Sodium and fluid restriction are non-pharmacological treatments recommended for patients with HF by several guidelines over the years, even without consensus. OBJECTIVE: To evaluate the effects of sodium and fluid restriction in patients with HF. METHODS: We searched MEDLINE, Embase, and Cochrane CENTRAL databases up to June 2020 and screened the reference lists of relevant articles. We included randomized controlled trials evaluating sodium and/or fluid restriction in patients with HF. We assessed three independent comparisons: (a) sodium restriction versus control; (b) fluid restriction versus control; and (c) sodium and fluid restriction versus control. Main outcomes of interest were all-cause mortality and hospitalization. Two independent reviewers selected studies and extracted data. We pooled the results using random-effects meta-analysis. We used the RoB 2.0 and the GRADE framework to assess risk of bias and quality of evidence. RESULTS: We included 16 studies totaling 3545 patients in our meta-analysis. Daily sodium intake was 1.5-2.4 g for the intervention group and >2.7 g for the control group, and daily fluid intake was 0.8-1.5 L for the intervention group and free oral fluid intake for the control group. Sodium restriction increased mortality (relative risk 1.92, 95% confidence interval 1.51 to 2.45, moderate quality of evidence) and hospitalization (relative risk 1.63, 1.11 to 2.40, low quality of evidence). Fluid restriction reduced mortality (relative risk 0.32, 0.13 to 0.82, low quality of evidence) and hospitalization (relative risk 0.46, 0.27 to 0.77, n = 331, low quality of evidence). The combination of sodium and fluid restriction did not significantly affect the risk of mortality (relative risk 0.92, 0.49 to 1.73, low quality of evidence) or the risk of hospitalization (relative risk 0.94, 0.75 to 1.19, low quality of evidence). CONCLUSION: The combination of sodium and fluid restriction in clinical trials resulted in a null effect although results in the opposite direction were observed for each intervention independently. Combined sodium and fluid restriction are usually recommended for patients with HF. Our findings of sodium restriction harm, risk of mortality and hospitalization are consistent with publications from several clinical trial and physiologic explanations. A well-designed clinical trial nested by an implementation study is urgent for definitive sodium range recommendation, specially considering the change of currently guidelines, pushing up the cut-off of sodium restriction range.

Telemedicine as support for primary care referrals to neurologists: decision-making between different specialists when guiding the case over the phone.

BACKGROUND: Brazil's public health system, the largest in the world, faces great challenges in establishing access to specialized care for all Brazilians. "Regula Mais Brasil" is a structuring project from the Ministry of Health that aims to optimize the referral process for specialized care throughout Brazil and uses telemedicine to support primary care physicians. The high demand for support and referrals in the neurology specialty raises questions about what the difficulties and doubts in managing these patients are and whether the training of the coordinating physician influences the orientation and outcome of referral. METHODS: In a retrospective analysis on a database, all teleconsultations in the neurology specialty were evaluated. The diagnoses were categorized using the ICD-10 and according to the specialty of the coordinating teleconsultant for multiple comparisons. RESULTS: In total, 1687 teleconsultations were conducted between January 10 and December 2, 2019, in the cities of Belo Horizonte and Porto Alegre and in the Federal District. The most frequent area of doubt for doctors was about epilepsy. After discussion via telemedicine, 25% of the referrals were avoided and the specialty of the teleconsultant physician did not impact the decision made: 72.3, 72.6 and 66.5%, in relation to approval by neurologists, family doctors and other experts, respectively. CONCLUSION: Increasing access to specialists, not only for patients but also for doctors, helps in achieving early resolution of issues of greater difficulty for primary healthcare doctors, thus resulting in lower numbers of referrals.

Telemedicine as support for primary care referrals to neurologists: decision-making between different specialists when guiding the case over the phone / Telemedicina como apoio à atenção primária para encaminhamento ao neurologista: tomada de decisão entre diferentes especialistas ao guiar o caso pelo telefone

ABSTRACT Background: Brazil's public health system, the largest in the world, faces great challenges in establishing access to specialized care for all Brazilians. "Regula Mais Brasil" is a structuring project from the Ministry of Health that aims to optimize the referral process for specialized care throughout Brazil and uses telemedicine to support primary care physicians. The high demand for support and referrals in the neurology specialty raises questions about what the difficulties and doubts in managing these patients are and whether the training of the coordinating physician influences the orientation and outcome of referral. Methods: In a retrospective analysis on a database, all teleconsultations in the neurology specialty were evaluated. The diagnoses were categorized using the ICD-10 and according to the specialty of the coordinating teleconsultant for multiple comparisons. Results: In total, 1687 teleconsultations were conducted between January 10 and December 2, 2019, in the cities of Belo Horizonte and Porto Alegre and in the Federal District. The most frequent area of doubt for doctors was about epilepsy. After discussion via telemedicine, 25% of the referrals were avoided and the specialty of the teleconsultant physician did not impact the decision made: 72.3, 72.6 and 66.5%, in relation to approval by neurologists, family doctors and other experts, respectively. Conclusion: Increasing access to specialists, not only for patients but also for doctors, helps in achieving early resolution of issues of greater difficulty for primary healthcare doctors, thus resulting in lower numbers of referrals.

RESUMO Introdução: O maior sistema público de saúde do mundo tem um grande desafio para estabelecer acesso à atenção especializada a todos os brasileiros. O Regula Mais Brasil é um projeto estruturante do Ministério da Saúde que visa otimizar o processo de referenciamento para atenção especializada no território brasileiro e utiliza a telemedicina para suporte de médicos da atenção primária. A elevada procura de apoio e encaminhamento na especialidade de neurologia desperta o questionamento sobre quais são as dificuldades e dúvidas no manejo desses pacientes e se a formação do médico regulador influencia a orientação e o desfecho do encaminhamento. Métodos: Em uma análise retrospectiva do banco de dados, foram avaliadas todas as teleconsultorias da especialidade de neurologia, os diagnósticos foram categorizados pelo CID-10 e por especialidade do teleconsultor regulador para comparações múltiplas. Resultados: No total, 1.687 teleconsultorias foram realizadas de 10 de janeiro a 2 de dezembro de 2019, nas cidades de Belo Horizonte, Porto Alegre e Distrito Federal. A área de dúvida mais frequente dos médicos era sobre epilepsia. Após a discussão por telemedicina, 25% dos encaminhamentos foram evitados e a especialidade do médico teleconsultor não impactou na decisão tomada (72,3, 72,6 e 66,5%) em relação à aprovação por neurologistas, médico de família e outros especialistas, respectivamente. Conclusão: Aumentar o acesso não apenas de pacientes, mas dos médicos aos especialistas contribui para que os temas de maior dificuldade para os médicos da Atenção Primária à Saúde sejam resolvidos precocemente, resultando em um menor número de encaminhamentos.

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.

Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial.

AIMS: Although loop diuretics are widely used to treat heart failure (HF), there is scarce contemporary data to guide diuretic adjustments in the outpatient setting. METHODS AND RESULTS: In a prospective, randomized and double-blind protocol, we tested the safety and tolerability of withdrawing low-dose furosemide in stable HF outpatients at 11 HF clinics in Brazil. The trial had two blindly adjudicated co-primary outcomes: (i) symptoms assessment quantified as the area under the curve (AUC) of a dyspnoea score on a visual-analogue scale evaluated at 4 time-points (baseline, Day 15, Day 45, and Day 90) and (ii) the proportion of patients maintained without diuretic reuse during follow-up. We enrolled 188 patients (25% females; 59 ± 13 years old; left ventricular ejection fraction = 32 ± 8%) that were randomized to furosemide withdrawal (n = 95) or maintenance (n = 93). For the first co-primary endpoint, no significant difference in patients' assessment of dyspnoea was observed in the comparison of furosemide withdrawal with continuous administration [median AUC 1875 (interquartile range, IQR 383-3360) and 1541 (IQR 474-3124), respectively; P = 0.94]. For the second co-primary endpoint, 70 patients (75.3%) in the withdrawal group and 77 patients (83.7%) in the maintenance group were free of furosemide reuse during follow-up (odds ratio for additional furosemide use with withdrawal 1.69, 95% confidence interval 0.82-3.49; P = 0.16). Heart failure-related events (hospitalizations, emergency room visits, and deaths) were infrequent and similar between groups (P = 1.0). CONCLUSIONS: Diuretic withdrawal did not result in neither increased self-perception of dyspnoea nor increased need of furosemide reuse. Diuretic discontinuation may deserve consideration in stable outpatients with no signs of fluid retention receiving optimal medical therapy. CLINICALTRIALS.GOV IDENTIFIER: NCT02689180.

Prevalência e impacto clínico do diabetes mellitus em pacientes ambulatoriais com insuficiência cardíaca / Prevalence and clinical impact of diabetes mellitus on heart failure outpatients

Introdução: Diabetes mellitus (DM) é uma condição prevalente na população em geral, que parece aumentar o risco de insuficiência cardíaca (IC). Entretanto, a prevalência de DM tipo 2 em pacientes brasileiros com insuficiência cardíaca não é conhecida, e o impacto do DM no tratamento da IC ainda não está claro.Objetivo: Avaliar a prevalência de DM tipo 2 em pacientes ambulatoriais com insuficiência cardíaca, e sua correlação com características clínicas e com o tratamento da IC.Métodos: Foram incluídos 402 pacientes com IC em acompanhamento ambulatorial entre agosto de 2008 e setembro de 2009. Os pacientes foram comparados com relação às características clínicas, remodelamento cardíaco e tratamento da IC.Resultados: A prevalência de DM tipo 2 na amostra estudada foi de 31%. Os pacientes com DM tinham idade maior (65±10 vs. 60±14 anos; p<0,001) e maior prevalência etiologia isquêmica em comparação aos não diabéticos (52% vs.30%, respectivamente). Os parâmetros ecocardiográficos não diferiram entre os grupos, mas a pressão sistólica da artéria pulmonar (PSAP) foi maior nos pacientes diabéticos (50±14 vs. 43±14 mmHg; p=0,001). O tratamento da insuficiência cardíaca foi similar entre pacientes com e sem DM. Entre os com DM, cerca da metade dos pacientes tinha controle glicêmico adequado, e os principais tratamentos utilizados foram as drogas metformina e insulina.Conclusões: A prevalência de DM foi elevada nesta população de pacientes ambulatoriais com insuficiência cardíaca, sendo associada a etiologia isquêmica e comorbidades. Apesar de não haver associação com outras características degravidade da doença, remodelamento cardíaco ou com o IC, pacientes com DM tinham níveis mais elevados de PSAP. A repercussão clínica e prognóstica destes achados merece ser avaliada em estudos prospectivos futuros.

Background: Diabetes Mellitus (DM) is a prevalent condition in the general population that seems to increase the risk of heart failure development. However the prevalence of DM type 2 among Brazilians patients with HF is unknown and there are still questions regarding the impact of DM in the HF treatment.Aims: To evaluate the prevalence of DM type 2 among outpatients followed for chronic HF and the association with demographic and laboratory characteristics, remodeling and HF treatment.Results: The prevalence of DM type 2 was 31%. Patients with DM were older (65±10 vs. 60±14 years; p<0,001) and with a higher prevalence of ischaemic etiology (52% vs. 30%, respectively) and comorbidities. The echocardiographic parameters were similar in both groups, but pulmonary systolic arterial pressure (PSAP) was higher in diabetic patients (50±14 vs. 43±14 mmHg; p=0,002).Around half of diabetic patients had a good glycemic control, and metformin and insulin were predominantly used for DM control.Conclusions: We found an elevated prevalence of diabetic patients among Brazilians with HF, and DM was associated to ischaemic etiology and comorbidities. Regardless of no association with clinical characteristics, ventricular remodeling or HF treatment, diabetic patients had higher PSAP values. Clinical significance of these findings deserves further prospective studies.

Taquicardia ventricular associada com linfoma não-Hodgkin / Ventricular tachycardia associated with non-Hodgkin's lymphoma / Taquicardia ventricular asociada con linfoma no Hodgkin

Linfoma não-Hodgkin sistêmico pode afetar o miocárdio, particularmente em pacientes imunocomprometidos. Quando presentes, sinais e sintomas são geralmente inespecíficos, tornando o diagnóstico de envolvimento cardíaco muito difícil antes da autópsia. Arritmias ventriculares também são pouco usuais nesse cenário. Descrevemos um caso de linfoma não-Hodgkin miocárdico secundário, que se apresentou com taquicardia ventricular monomórfica sustentada e espessamento do septo interventricular basal. Completa remissão das lesões miocárdicas foi observada após o término da quimioterapia de segunda linha, sem recorrências posteriores de arritmias em oito meses.

Systemic non-Hodgkin's lymphoma can affect the myocardium, particularly in immunocompromised patients. When present, symptoms and signs are usually nonspecific, making the diagnosis of cardiac involvement very difficult before an autopsy. Ventricular arrhythmias are also unusual in this setting. We describe a case of secondary myocardial non-Hodgkin's lymphoma presenting with sustained monomorphic ventricular tachycardia and thickening of the basal interventricular septum. Complete remission of myocardial lesions was observed after completion of second-line chemotherapy treatment, without further recurrences of arrhythmias in eight months.

Linfoma no Hodgkin sistémico puede afectar el miocardio, particularmente en pacientes inmunocomprometidos. Cuando están presentes, señales y síntomas son generalmente inespecíficos, volviendo el diagnóstico de compromiso cardíaco muy difícil antes de la autopsia. Arritmias ventriculares también son poco usuales en ese escenario. Describimos un caso de linfoma no Hodgkin miocárdico secundario, que se presentó con taquicardia ventricular monomórfica sustentada y engrosamiento del septo interventricular basal. Completa remisión de las lesiones miocárdicas fue observada después del término de la quimioterapia de segunda línea, sin recurrencias posteriores de arritmias en ocho meses.

Ventricular tachycardia associated with non-Hodgkin's lymphoma.

Systemic non-Hodgkin's lymphoma can affect the myocardium, particularly in immunocompromised patients. When present, symptoms and signs are usually nonspecific, making the diagnosis of cardiac involvement very difficult before an autopsy. Ventricular arrhythmias are also unusual in this setting. We describe a case of secondary myocardial non-Hodgkin's lymphoma presenting with sustained monomorphic ventricular tachycardia and thickening of the basal interventricular septum. Complete remission of myocardial lesions was observed after completion of second-line chemotherapy treatment, without further recurrences of arrhythmias in eight months.

Efeitos do álcool na função ventricular da população geral e em pacientes assintomáticos com disfunção ventricular: revisão sistemática / Alcohol effects on ventricular function of general population and patients with asymptomatic ventricular dysfunction: a systematic review

A relação entre consumo excessivo de álcool e risco aumentado para desenvolvimento de miocardiopatia alcoólica é universalmente conhecida. No entanto, permanece não esclarecida qual é a dose de exposição ao álcool e o tempo de consumo necessários para o desenvolvimento dessa doença. Adicionalmente, não existem dados definitivos sobre o consumo leve a moderado de álcool e incidência de insuficiência cardíaca, tanto na população hígida como em pacientes assintomáticos com disfunção sistólica. Identificar as evidências disponíveis na literatura sobre a associação entre o consumo moderado de álcool e a insuficiência cardíaca na população em geral e em pacientes assintomáticos com disfunção ventricular sistólica. A busca de evidências foi realizada mediante pesquisa nos bancos de dados PubMed, LILACS e Cochrane e foi restrita a estudos de coorte prospectivo. Foram encontrados sete estudos (cinco estudos realizados na população em geral e dois estudos realizados em pacientes assintomáticos com disfunção ventricular sistólica) sugerindo existir uma correlação inversa entre consumo moderado de álcool e risco de insuficiência cardíaca na população geral. Esses achados são mais consistentes para pacientes com insuficiência cardíaca de etiologia isquêmica. Entre pacientes assintomáticos com disfunção sistólica, o consumo moderado parece não interferir na evolução para insuficiência cardíaca clínica. As evidências disponíveis na literatura sugerem que o consumo de álcool em doses moderadas está associado com redução de risco de insuficiência cardíaca clínica, tanto na população geral como em pacientes assintomáticos com disfunção ventricular estabelecida.

The relationship between excessive alcohol consumption and increased risk of alcoholic cardiomyopathy is largely known. However, there are still questions regarding the alcohol dose and the time of consumption necessary for the development of heart failure. Additionally, there are no conclusive data about mild to moderate alcohol consumption and the incidence of heart failure, not only in the healthy population but also in patients with asymptomatic left ventricular dysfunction. To identify the available data in the medical literature regarding moderate alcohol consumption and its association with heart failure in the general population and in patients with asymptomatic left ventricular dysfunction. A survey was performed on the Pub-Med, LILACS and Cochrane databases. Only prospective cohort studies were selected. A total of seven studies were selected (five studies were conducted among the general population and two studies were performed among asymptomatic patients with left ventricular dysfunction). The evidence suggests an inverse correlation between moderate alcohol consumption and heart failure risk in the general population. This evidence is even more consistent for ischemic cardiomyopathy. Among patients with left ventricular dysfunction, moderate alcohol consumption does not seem to determine progression to heart failure. The analysis of the studies published suggests that moderate alcohol consumption is associated with lower risk of heart failure. In the asymptomatic population with established left ventricular dysfunction, moderate alcohol consumption does not seem to determine heart failure.