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1.
JAMA ; 2020 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-32219386

RESUMO

Importance: Additional treatments are needed for heart failure with reduced ejection fraction (HFrEF). Sodium-glucose cotransporter 2 (SGLT2) inhibitors may be an effective treatment for patients with HFrEF, even those without diabetes. Objective: To evaluate the effects of dapagliflozin in patients with HFrEF with and without diabetes. Design, Setting, and Participants: Exploratory analysis of a phase 3 randomized trial conducted at 410 sites in 20 countries. Patients with New York Heart Association classification II to IV with an ejection fraction less than or equal to 40% and elevated plasma N-terminal pro B-type natriuretic peptide were enrolled between February 15, 2017, and August 17, 2018, with final follow-up on June 6, 2019. Interventions: Addition of once-daily 10 mg of dapagliflozin or placebo to recommended therapy. Main Outcomes and Measures: The primary outcome was the composite of an episode of worsening heart failure or cardiovascular death. This outcome was analyzed by baseline diabetes status and, in patients without diabetes, by glycated hemoglobin level less than 5.7% vs greater than or equal to 5.7%. Results: Among 4744 patients randomized (mean age, 66 years; 1109 [23%] women; 2605 [55%] without diabetes), 4742 completed the trial. Among participants without diabetes, the primary outcome occurred in 171 of 1298 (13.2%) in the dapagliflozin group and 231 of 1307 (17.7%) in the placebo group (hazard ratio, 0.73 [95% CI, 0.60-0.88]). In patients with diabetes, the primary outcome occurred in 215 of 1075 (20.0%) in the dapagliflozin group and 271 of 1064 (25.5%) in the placebo group (hazard ratio, 0.75 [95% CI, 0.63-0.90]) (P value for interaction = .80). Among patients without diabetes and a glycated hemoglobin level less than 5.7%, the primary outcome occurred in 53 of 438 patients (12.1%) in the dapagliflozin group and 71 of 419 (16.9%) in the placebo group (hazard ratio, 0.67 [95% CI, 0.47-0.96]). In patients with a glycated hemoglobin of at least 5.7%, the primary outcome occurred in 118 of 860 patients (13.7%) in the dapagliflozin group and 160 of 888 (18.0%) in the placebo group (hazard ratio, 0.74 [95% CI, 0.59-0.94]) (P value for interaction = .72). Volume depletion was reported as an adverse event in 7.3% of patients in the dapagliflozin group and 6.1% in the placebo group among patients without diabetes and in 7.8% of patients in the dapagliflozin group and 7.8% in the placebo group among patients with diabetes. A kidney adverse event was reported in 4.8% of patients in the dapagliflozin group and 6.0% in the placebo group among patients without diabetes and in 8.5% of patients in the dapagliflozin group and 8.7% in the placebo group among patients with diabetes. Conclusions and Relevance: In this exploratory analysis of a randomized trial of patients with HFrEF, dapagliflozin compared with placebo, when added to recommended therapy, significantly reduced the risk of worsening heart failure or cardiovascular death independently of diabetes status. Trial Registration: ClinicalTrials.gov Identifier: NCT03036124.

2.
Eur Heart J ; 2020 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-32221582

RESUMO

AIMS: In the DAPA-HF trial, the SGLT2 inhibitor dapagliflozin reduced the risk of worsening heart failure (HF) and death in patients with HF and reduced ejection fraction. We examined whether this benefit was consistent in relation to background HF therapy. METHODS AND RESULTS: In this post hoc analysis, we examined the effect of study treatment in the following yes/no subgroups: diuretic, digoxin, mineralocorticoid receptor antagonist (MRA), sacubitril/valsartan, ivabradine, implanted cardioverter-defibrillating (ICD) device, and cardiac resynchronization therapy. We also examined the effect of study drug according to angiotensin-converting enzyme inhibitor/angiotensin receptor blocker dose, beta-blocker (BB) dose, and MRA (≥50% and <50% of target dose). We analysed the primary composite endpoint of cardiovascular death or a worsening HF event. Most randomized patients (n = 4744) were treated with a diuretic (84%), renin-angiotensin system (RAS) blocker (94%), and BB (96%); 52% of those taking a BB and 38% taking a RAS blocker were treated with ≥50% of the recommended dose. Overall, the dapagliflozin vs. placebo hazard ratio (HR) was 0.74 [95% confidence interval (CI) 0.65-0.85] for the primary composite endpoint (P < 0.0001). The effect of dapagliflozin was consistent across all subgroups examined: the HR ranged from 0.57 to 0.86 for primary endpoint, with no significant randomized treatment-by-subgroup interaction. For example, the HR in patients taking a RAS blocker, BB, and MRA at baseline was 0.72 (95% CI 0.61-0.86) compared with 0.77 (95% CI 0.63-0.94) in those not on all three of these treatments (P-interaction 0.64). CONCLUSION: The benefit of dapagliflozin was consistent regardless of background therapy for HF.

3.
Circulation ; 141(2): 90-99, 2020 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-31736335

RESUMO

BACKGROUND: Goals of management in patients with heart failure and reduced ejection fraction include reducing death and hospitalizations, and improving health status (symptoms, physical function, and quality of life). In the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure), sodium-glucose cotransporter-2 inhibitor, dapagliflozin, reduced death and hospitalizations, and improved symptoms in patients with heart failure and reduced ejection fraction. In this analysis, we examine the effects of dapagliflozin on a broad range of health status outcomes, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). METHODS: KCCQ was evaluated at randomization, 4 and 8 months. Patients were divided by baseline KCCQ total symptom score (TSS); Cox proportional hazards models examined the effects of dapagliflozin on clinical events across these subgroups. We also evaluated the effects of dapagliflozin on KCCQ-TSS, clinical summary score, and overall summary score. Responder analyses were performed to compare proportions of dapagliflozin versus placebo-treated patients with clinically meaningful changes in KCCQ at 8 months. RESULTS: A total of 4443 patients had available KCCQ at baseline (median KCCQ-TSS, 77.1 [interquartile range, 58.3-91.7]). The effects of dapagliflozin vs placebo on reducing cardiovascular death or worsening heart failure were consistent across the range of KCCQ-TSS (lowest to highest tertile: hazard ratio, 0.70 [95% CI, 0.57-0.86]; hazard ratio, 0.77 [95% CI, 0.61-0.98]; hazard ratio, 0.62 [95% CI, 0.46-0.83]; P for heterogeneity=0.52). Patients treated with dapagliflozin had greater improvement in mean KCCQ-TSS, clinical summary score, and overall summary score at 8 months (2.8, 2.5 and 2.3 points higher versus placebo; P<0.0001 for all). Fewer patients treated with dapagliflozin had a deterioration in KCCQ-TSS (odds ratio, 0.84 [95% CI, 0.78-0.90]; P<0.0001); and more patients had at least small, moderate, and large improvements (odds ratio, 1.15 [95% CI, 1.08-1.23]; odds ratio, 1.15 [95% CI, 1.08-1.22]; odds ratio, 1.14 [95% CI, 1.07-1.22]; number needed to treat=14, 15, and 18, respectively; P<0.0001 for all; results consistent for KCCQ clinical summary score and overall summary score). CONCLUSIONS: Dapagliflozin reduced cardiovascular death and worsening heart failure across the range of baseline KCCQ, and improved symptoms, physical function, and quality of life in patients with heart failure and reduced ejection fraction. Furthermore, dapagliflozin increased the proportion of patients experiencing at least small, moderate, and large improvements in health status; these effects were clinically important. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03036124.

4.
N Engl J Med ; 381(21): 1995-2008, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31535829

RESUMO

BACKGROUND: In patients with type 2 diabetes, inhibitors of sodium-glucose cotransporter 2 (SGLT2) reduce the risk of a first hospitalization for heart failure, possibly through glucose-independent mechanisms. More data are needed regarding the effects of SGLT2 inhibitors in patients with established heart failure and a reduced ejection fraction, regardless of the presence or absence of type 2 diabetes. METHODS: In this phase 3, placebo-controlled trial, we randomly assigned 4744 patients with New York Heart Association class II, III, or IV heart failure and an ejection fraction of 40% or less to receive either dapagliflozin (at a dose of 10 mg once daily) or placebo, in addition to recommended therapy. The primary outcome was a composite of worsening heart failure (hospitalization or an urgent visit resulting in intravenous therapy for heart failure) or cardiovascular death. RESULTS: Over a median of 18.2 months, the primary outcome occurred in 386 of 2373 patients (16.3%) in the dapagliflozin group and in 502 of 2371 patients (21.2%) in the placebo group (hazard ratio, 0.74; 95% confidence interval [CI], 0.65 to 0.85; P<0.001). A first worsening heart failure event occurred in 237 patients (10.0%) in the dapagliflozin group and in 326 patients (13.7%) in the placebo group (hazard ratio, 0.70; 95% CI, 0.59 to 0.83). Death from cardiovascular causes occurred in 227 patients (9.6%) in the dapagliflozin group and in 273 patients (11.5%) in the placebo group (hazard ratio, 0.82; 95% CI, 0.69 to 0.98); 276 patients (11.6%) and 329 patients (13.9%), respectively, died from any cause (hazard ratio, 0.83; 95% CI, 0.71 to 0.97). Findings in patients with diabetes were similar to those in patients without diabetes. The frequency of adverse events related to volume depletion, renal dysfunction, and hypoglycemia did not differ between treatment groups. CONCLUSIONS: Among patients with heart failure and a reduced ejection fraction, the risk of worsening heart failure or death from cardiovascular causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes. (Funded by AstraZeneca; DAPA-HF ClinicalTrials.gov number, NCT03036124.).


Assuntos
Compostos Benzidrílicos/uso terapêutico , Glucosídeos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Idoso , Compostos Benzidrílicos/efeitos adversos , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/mortalidade , Terapia Combinada , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Quimioterapia Combinada , Feminino , Glucosídeos/efeitos adversos , Hemoglobina A Glicada/análise , Insuficiência Cardíaca/complicações , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Volume Sistólico/efeitos dos fármacos , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/tratamento farmacológico
5.
J Atr Fibrillation ; 11(5): 2128, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31139301

RESUMO

Introduction: Atrial fibrillation (AF) and heart failure (HF) often coexist with an increase in morbidity and mortality. AF catheter ablation (CA) has proved to be a safe and efficient option for HF patients, but long-term evolution and prognosis remain uncertain. The aim is to assess the efficacy and safety of CA in HF patients with AF, and analyze HF long-term evolution. Methods: We prospectively analyzed consecutive patients with AF and congestive HF or left ventricular ejection fraction (EF) less than 45%, who underwent CA of AF between 2011 and 2016. We excluded patients who did not complete one year of follow-up. Results: Seventy-nine patients were included. Mean age was 62.1 years, 72.4% were men, 67.2% had hypertension and 8.6% were diabetics. Mean EF was 49%, left atrial area was 26.5 cm2 and mean CHA2DS2-VASc score was 2. 70.6% were on NYHA FC II-III.The recurrence rate of AF was 60%, and after a second CA the rate decreased to 27.8%. Only persistent AF prior to the procedure was identified as independent predictor of recurrence. There was a significant NYHA FC improvement in the sinus rhythm (SR) group vs those with recurrence (63.6% vs 36.4%; p=0.047). None of the patients in SR were hospitalized, whereas six with recurrence were hospitalized due to HF (0% vs. 18.2%; p = 0.07). The rate of complications was 9.1%. Conclusions: Catheter ablation of atrial fibrillation in heart failure presents an adequate success rate, improving symptoms and reducing rehospitalizations due to heart failure.

7.
Medicina (B Aires) ; 78(6): 395-398, 2018.
Artigo em Espanhol | MEDLINE | ID: mdl-30504105

RESUMO

Transthyretin cardiac amyloidosis (ATTR) is a restrictive cardiomyopathy that leads to heart failure in considerable number of patients. Early diagnosis allows specific treatment options. However, ATTR diagnosis is complex and requires invasive procedures. The utility of 99mTc-phosphate tracers for non-invasive diagnosis is well-known but the experience in Argentina is insufficient. The aim of this work was to assess the utility of 99m Tc-phosphate tracers for the diagnosis of ATTR. A total of 46 scintigraphies for detection of cardiac amyloidosis performed between September 2016 and January 2018 were analyzed. Cardiac retention after one hour was assessed in relation to bone uptake using two methods: A semi-quantitative visual score (grade 0 = absent, I = low II = moderate-III = high) and a quantitative method (heart/lung ratio). The final diagnosis and the amyloidosis subtype were carried out by our institution cardiomyopathy team according to international guidelines. The positive and negative predictive values for Grade ≥ II were 96% and 100% respectively for diagnosis of ATTR. Using 1.38 as cut-off value for heart/lung ratio the sensitivity and the specificity were 96% and 100%, respectively for differentiating transthyretin cardiac amyloidosis from light-chain cardiac amyloidosis and other cardiopathies. Scintigraphy with 99m Tc-phosphate tracers enable noninvasive diagnosis and subtype classification of cardiac amyloidosis. The use of this non-invasive, inexpensive and widely available tool will result in better patient management.


Assuntos
Amiloidose/diagnóstico por imagem , Cardiomiopatias/diagnóstico por imagem , Fosfatos , Cintilografia/métodos , Compostos de Tecnécio , Idoso , Idoso de 80 Anos ou mais , Amiloidose/fisiopatologia , Cardiomiopatias/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Compostos Radiofarmacêuticos , Reprodutibilidade dos Testes , Estatísticas não Paramétricas
8.
Medicina (B.Aires) ; 78(6): 395-398, Dec. 2018. ilus, graf, tab
Artigo em Espanhol | LILACS-Express | ID: biblio-976136

RESUMO

La amiloidosis cardíaca del subtipo transtirretina (ATTR) es una cardiopatía restrictiva que causa insuficiencia cardíaca en un número considerable de pacientes. Su identificación temprana permitiría brindar tratamientos específicos. Sin embargo, el diagnóstico de ATTR es complejo y requiere métodos invasivos. Los fosfonatos marcados con 99mTecnecio han demostrado ser útiles para el diagnóstico, aunque en Argentina la experiencia es escasa. Nuestro objetivo fue evaluar la utilidad de este método para diagnosticar de forma no invasiva la ATTR. Se estudiaron 46 pacientes entre septiembre de 2016 y enero de 2018 por sospecha de amiloidosis cardíaca. Se evaluó el grado de captación cardíaca con relación al tejido óseo, a la hora, mediante dos métodos: semi-cuantitativo y cuantitativo. El diagnóstico definitivo de amiloidosis y el subtipo específico fue asignado por el centro de miocardiopatías de nuestra institución siguiendo recomendaciones internacionales. Una captación ≥ grado II presentó un valor predictivo positivo del 96% y negativo del 100% para el diagnóstico de amiloidosis cardíaca ATTR. El valor de corte de 1.38 en la relación corazón/pulmón presentó una sensibilidad del 96% y una especificidad del 100% para discriminar entre pacientes con ATTR de aquellos con amiloidosis por cadenas livianas u otras afecciones (área bajo la curva relación corazón/pulmón = 0.95 p < 0.001). La centellografía con fosfonatos marcados demostró ser un método no invasivo útil para diagnosticar ATTR. Dado que además de ser no invasiva, es una herramienta de bajo costo y ampliamente disponible en nuestro medio, su aplicación puede redundar en un beneficio clínico para muchos pacientes.


Transthyretin cardiac amyloidosis (ATTR) is a restrictive cardiomyopathy that leads to heart failure in considerable number of patients. Early diagnosis allows specific treatment options. However, ATTR diagnosis is complex and requires invasive procedures. The utility of 99mTc-phosphate tracers for non-invasive diagnosis is well-known but the experience in Argentina is insufficient. The aim of this work was to assess the utility of 99mTc-phosphate tracers for the diagnosis of ATTR. A total of 46 scintigraphies for detection of cardiac amyloidosis performed between September 2016 and January 2018 were analyzed. Cardiac retention after one hour was assessed in relation to bone uptake using two methods: A semi-quantitative visual score (grade 0 = absent, I = low II = moderate-III = high) and a quantitative method (heart/lung ratio). The final diagnosis and the amyloidosis subtype were carried out by our institution cardiomyopathy team according to international guidelines. The positive and negative predictive values for Grade ≥ II were 96% and 100% respectively for diagnosis of ATTR. Using 1.38 as cut-off value for heart/lung ratio the sensitivity and the specificity were 96% and 100%, respectively for differentiating transthyretin cardiac amyloidosis from light-chain cardiac amyloidosis and other cardiopathies. Scintigraphy with 99mTc-phosphate tracers enable noninvasive diagnosis and subtype classification of cardiac amyloidosis. The use of this non-invasive, inexpensive and widely available tool will result in better patient management.

9.
Rev. argent. cardiol ; 86(2): 96-102, abr. 2018.
Artigo em Espanhol | LILACS-Express | ID: biblio-1003184

RESUMO

RESUMEN: Introducción: La miectomía septal ampliada constituye el tratamiento de elección para pacientes con miocardiopatía hipertrófica obstructiva sintomática, refractarios al tratamiento farmacológico. Objetivos: Evaluar los resultados posoperatorios, el cambio en los síntomas y la evolución ecocardiográfica de una población sometida a miectomía septal ampliada por miocardiopatía hipertrófica obstructiva sintomática. Material y métodos: Desde noviembre de 2011 a octubre de 2017, se intervino un total de 28 pacientes. Se analizaron la evolución posoperatoria, clínica y ecocardiográfica al alta y al seguimiento. Resultados: Edad promedio 53,3 ± 13,4 años. La mortalidad perioperatoria (< 30 días) fue del 0%. Un paciente falleció a los 90 días (3,5%). No se produjeron comunicaciones interventriculares, daño de la válvula aórtica ni se reemplazó la válvula mitral en ningún paciente. El 91% de ellos se encontraban con disnea en CF III-IV en el preoperatorio, los restantes tenían angina o síncope. En el seguimiento, el 92,8% estaban asintomáticos, 1 paciente en CF III y otro en CF II. El gradiente preoperatorio basal promedio fue de 53,5 mmHg y con valsalva 86,4 mmHg; los gradientes basal y con valsalva posoperatorios fueron 9,4 mmHg y 13,5 mmHg (p < 0,01). Al seguimiento, los gradientes en reposo y con valsalva fueron aún más bajos, 8,3 mmHg y 10,7 mmHg, respectivamente (p: NS). Nueve pacientes (32%) presentaban insuficiencia mitral moderada a grave previa por movimiento anterior sistólico o patología intrínseca mitral. Se detectó solo un paciente con insuficiencia mitral moderada asintomática en el seguimiento (3,5%). La mediana de seguimiento fue de 400 días, Pc 25-75 de 695 días (mínimo de 30 días y el máximo de 1868 días). Conclusión: Con la miectomía septal ampliada se obtiene una mejoría hemodinámica y clínica de los pacientes sintomáticos, con bajo número de complicaciones posoperatorias. Esto tiene como resultado una mejor calidad de vida.

10.
Value Health Reg Issues ; 14: 73-80, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29254545

RESUMO

OBJECTIVES: Heart failure has a great impact on health budget, mainly due to the cost of hospitalizations. Our aim was to describe health resource use and costs of heart failure admissions in three important institutions in Argentina. METHODS: Multi-center retrospective cohort study, with descriptive and analytical analysis by subgroups of ejection fraction, blood pressure and renal function at admission. Generalized linear models were used to assess the association of independent variables to main outcomes. RESULTS: We included 301 subjects; age 75.3±11.8 years; 37% women; 57% with depressed ejection fraction; 46% of coronary etiology. Blood pressure at admission was 129.8±29.7 mmHg; renal function 57.9±26.2 ml/min/1.73 m2. Overall mortality was 7%. Average length of stay was 7.82±7.06 days (median 5.69), and was significantly longer in patients with renal impairment (8.9 vs. 8.18; p=0.03) and shorter in those with high initial blood pressure (6.08±4.03; p=0.009). Mean cost per patient was AR$68,861±96,066 (US$=8,071; 1US$=AR$8.532); 71% attributable to hospital stay, 20% to interventional procedures and 6.7% to diagnostic studies. Variables independently associated with higher costs were depressed ejection fraction, presence of valvular disease, and impaired renal function. CONCLUSIONS: Resource use and costs associated to hospitalizations for heart failure is high, and the highest proportion is attributable to the costs related to hospital stay.


Assuntos
Custos e Análise de Custo , Recursos em Saúde/estatística & dados numéricos , Insuficiência Cardíaca , Hospitalização/estatística & dados numéricos , Idoso , Argentina , Feminino , Recursos em Saúde/economia , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/terapia , Humanos , Hipertensão , Tempo de Internação/economia , Masculino , Insuficiência Renal/complicações , Insuficiência Renal/economia , Estudos Retrospectivos
12.
Rev. argent. cardiol ; 84(3): 1-10, jun. 2016. ilus
Artigo em Espanhol | LILACS-Express | ID: biblio-957725

RESUMO

Introducción: La miocardiopatía hipertrófica es una enfermedad compleja que se ha asociado durante años con tasas altas de morbimortalidad. Sin embargo, mucha de la información que tenemos en relación con su evolución proviene de centros en los que se incluyeron pacientes seleccionados, principalmente de riesgo alto. Objetivo: Evaluar los eventos en el seguimiento de pacientes con miocardiopatía hipertrófica en nuestro medio. Material y métodos: Se evaluó una cohorte retrospectiva de pacientes con diagnóstico de miocardiopatía hipertrófica. Se analizó la evolución de la clase funcional junto con la ocurrencia de eventos clínicos. Se recabaron datos del ecocardiograma y de la resonancia magnética cardíaca. Resultados: Se incluyeron 259 pacientes, con una mediana de seguimiento de 3,5 años (2-10). La edad promedio fue de 56 ± 16,8 años y el 38,2% de los pacientes tenían formas obstructivas de la enfermedad. Al inicio del seguimiento, el 67% se encontraban en clase funcional I. En la evolución, la mortalidad global fue del 1,6%, con el 1,1% de muerte súbita o choque apropiado de desfibrilador y el 6,6% de los pacientes presentaron fibrilación auricular. La tasa de internación por insuficiencia cardíaca resultó del 5,8% y en el 14,3% de los pacientes empeoró la clase funcional. Se realizaron 22 procedimientos de ablación septal y 15 miectomías, con mejoría significativa de la sintomatología. Conclusiones: El trabajo muestra que en el seguimiento de esta cohorte de pacientes con miocardiopatía hipertrófica la tasa de morbimortalidad fue baja; el principal evento adverso fue el empeoramiento de la clase funcional, seguido por el desarrollo de fibrilación auricular y la insuficiencia cardíaca, con una tasa baja de muerte súbita.

13.
Cardiol J ; 23(1): 78-83, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26412605

RESUMO

BACKGROUND: The aim of the study was to evaluate the value of high-sensitivity cardiac troponin (hs-cTn) for identifying high-risk patients. METHODS AND RESULTS: One hundred and eighty-seven patients admitted with acute heart failure (HF) (without myocardial infarction) were consecutively included; hs-cTn was measured at admission; the relation between elevated hs-cTn and the clinical outcome during hospitalization and at 90 days was analyzed; 93% (n = 174) had hs-cTn above the maximal normal value (14 ng/L); median hs-cTn was 42 ng/L (IQR 24-81). Patients with ejection fraction (EF) ≤ 45% had higher hs-cTn values (p = 0.0004). Patients with low cardiac output syndrome (LCOS) or shock had higher troponin levels compared with those with less severe clinical presentations (p = 0.004). Patients who required inotropic presented higher troponin values (p = 0.002), troponin values were also higher in those requiring complex therapies (intra-aortic balloon pump, mechanical ventilation or hemodialysis, p = 0.002). At 90-day follow-up, 28 (15.5%) patients died and 27 rehospitalizations occurred (55 events). The risk of events was greater in patients with hs-cTn > 42 ng/L (0.021), low blood pressure at admission (p = 0.002), LCOS or shock (p < 0.0001), EF ≤ 45% (p = 0.005) and inotropic use (p < 0.0001). In multivariate analysis, only inotropic agents requirements was associated independently with a high risk of death or rehospitalizations at 90 days (p = 0.007). CONCLUSIONS: Elevation of hs-cTn is a finding almost constant in patients with decompensated HF. In subjects with higher troponin levels ventricular dysfunction is frequent. The use of hs-cTn for risk stratification at admission helps to identify populations with poor outcome during hospitalization and increased risk of death or rehospitalizations during follow-up who will require rapid implementation of aggressive treatment.


Assuntos
Insuficiência Cardíaca/sangue , Troponina/sangue , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Argentina/epidemiologia , Biomarcadores/sangue , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Valor Preditivo dos Testes , Prevalência , Prognóstico , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco , Fatores de Tempo , Regulação para Cima
14.
Rev. argent. cardiol ; 83(3): 1-10, June 2015. ilus
Artigo em Inglês | LILACS-Express | ID: biblio-957609

RESUMO

background: Percutaneous septal ablation is a therapeutic option for patients with obstructive hypertrophic cardiomyopathy refrac-tory to optimal medical therapy. However, results of initial persistence and long-term safety are still controversial. Objectives: The aim of this study was to report percutaneous alcohol septal ablation technique, clinical and functional outcome, cardiovascular events and its impact on long-term follow-up. Methods: A total of 23 patients were included in the study. Functional class (FC), left ventricular outflow tract gradient before and after the procedure and long-term cardiovascular events were evaluated. results: Median follow-up was 52 months (IR 33-72). All patients were in FC III or IV prior to the procedure, under maximum tolerated medical therapy. The procedure was successful in 91% of cases, with 85% of patients currently in FC I and 15% in FC II. Baseline left ventricular outflow tract gradient decreased from 75 mmHg (95% CI 51-89) to 25 mmHg (95% CI 10-37) (p <0.003) and with Valsalva maneuver from 118 mmHg (95% CI 88-152) to 38 mmHg (95% CI 16-69) (p <0.0002), persisting in the long-term follow-up. During hospitalization, two patients presented with complete atrioventricular block requiring permanent pacemaker implantation. No cardiovascular deaths occurred during follow up. Conclusions: Alcohol septal ablation is a promising option for the treatment of a selected population with hypertrophic obstructive cardiomyopathy, generating sustained clinical and functional improvement with low incidence of events in the long-term follow up.

17.
Rev. am. med. respir ; 13(4): 239-242, dic. 2013. ilus
Artigo em Espanhol | LILACS-Express | ID: lil-708613

RESUMO

La hipertensión arterial pulmonar (HAP) es una enfermedad rara caracterizada por un incremento progresivo de las resistencias vasculares pulmonares que lleva a la falla cardíaca derecha y muerte prematura. La enfermedad puede ser idiopática o asociada a otras condiciones como la hipertensión portal, el virus de la inmunodeficiencia humana, las enfermedades del tejido conectivo, las cardiopatías congénitas con cortocircuitos de izquierda a derecha o asociadas a diferentes toxinas o drogas. Se han realizado avances en el tratamiento farmacológico enfocados en el remodelado de la vasculatura pulmonar. En este sentido, se encuentran en evaluación los inhibidores de la tirosina kinasa (ITK). El imatinib es un ITK selectivo aprobado para el tratamiento de la leucemia mieloide crónica (LMC) que ha demostrado beneficios en el tratamiento de la HAP en estudios de fase II. Paradójicamente, el ITK dasatinib, también aprobado para el tratamiento de la LMC, ha sido asociado a HAP, falla ventricular derecha y a derrame pleural, lo que sugiere la posibilidad de un efecto adverso a nivel pulmonar vinculado con esta droga.


Pulmonary arterial hypertension is a rare disease that is characterized by a progressive increase in vascular pulmonary resistance, chronic right ventricle failure and premature death. Pulmonary arterial hypertension can be either idiopathic or associated to other conditions such as portal hypertension, human immunodeficiency virus, connective tissue diseases, congenital systemic-to-pulmonary shunts or associated to different drugs/toxins. Encouraging progress has been made by targeting the main vasoproliferative aspects of the disease. Tyrosine kinase inhibitors (TKI) are promising emerging therapeutics. Imatinib, a selective TKI approved for the treatment of chronic myeloid leukaemia, has demonstrated some efficacy in treating pulmonary arterial hypertension in a phase II study. However, the TKI dasatinib, also approved for therapy of chronic myeloid leukaemia, has been linked to reversible pulmonary arterial hypertension and right ventricular failure, with pleural effusion, suggesting the possibility of drug-related pulmonary arterial hypertension.

18.
Rev. am. med. respir ; 13(4): 239-242, dic. 2013. ilus
Artigo em Espanhol | BINACIS | ID: bin-130272

RESUMO

La hipertensión arterial pulmonar (HAP) es una enfermedad rara caracterizada por un incremento progresivo de las resistencias vasculares pulmonares que lleva a la falla cardíaca derecha y muerte prematura. La enfermedad puede ser idiopática o asociada a otras condiciones como la hipertensión portal, el virus de la inmunodeficiencia humana, las enfermedades del tejido conectivo, las cardiopatías congénitas con cortocircuitos de izquierda a derecha o asociadas a diferentes toxinas o drogas. Se han realizado avances en el tratamiento farmacológico enfocados en el remodelado de la vasculatura pulmonar. En este sentido, se encuentran en evaluación los inhibidores de la tirosina kinasa (ITK). El imatinib es un ITK selectivo aprobado para el tratamiento de la leucemia mieloide crónica (LMC) que ha demostrado beneficios en el tratamiento de la HAP en estudios de fase II. Paradójicamente, el ITK dasatinib, también aprobado para el tratamiento de la LMC, ha sido asociado a HAP, falla ventricular derecha y a derrame pleural, lo que sugiere la posibilidad de un efecto adverso a nivel pulmonar vinculado con esta droga.(AU)


Pulmonary arterial hypertension is a rare disease that is characterized by a progressive increase in vascular pulmonary resistance, chronic right ventricle failure and premature death. Pulmonary arterial hypertension can be either idiopathic or associated to other conditions such as portal hypertension, human immunodeficiency virus, connective tissue diseases, congenital systemic-to-pulmonary shunts or associated to different drugs/toxins. Encouraging progress has been made by targeting the main vasoproliferative aspects of the disease. Tyrosine kinase inhibitors (TKI) are promising emerging therapeutics. Imatinib, a selective TKI approved for the treatment of chronic myeloid leukaemia, has demonstrated some efficacy in treating pulmonary arterial hypertension in a phase II study. However, the TKI dasatinib, also approved for therapy of chronic myeloid leukaemia, has been linked to reversible pulmonary arterial hypertension and right ventricular failure, with pleural effusion, suggesting the possibility of drug-related pulmonary arterial hypertension.(AU)

19.
J Am Coll Cardiol ; 62(11): 949-58, 2013 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-23850910

RESUMO

Heart failure (HF) data in Latin America (LA) were reviewed to guide health service planning in the prevention and treatment of HF. The HF epidemiology and the adequacy of relevant health service provision related to HF in LA are not well delineated. A systematic search of the electronic databases and the World Health Organization website was undertaken for HF in LA. LA countries have reduced gross income and lower total expenditure on health per capita. LA is a heterogeneous region with HF risk factors of developed and nondeveloped countries, including lower risk of raised blood glucose levels, obesity, tobacco, and aging, whereas systemic hypertension (SH), rheumatic fever, and Chagas' disease (C'D) are higher in LA. Main etiologies of HF in LA are idiopathic dilated cardiomyopathy (from 1.3% to 37%), C'D (from 1.3% to 21%), ischemic (from 68% to 17%), SH (from 14% to 76%), valvular (from 3% to 22%), and alcohol related (from 1.1% to 8%). The prognosis of C'D HF is worse than for other etiologies. Chronic HF is the cause of death in 6.3% of cases. Decompensated HF is the main cause of cardiovascular hospitalization. The prevalence of systolic HF varies from 64% to 69%. LA is under the awful paradox of having the HF risk factors and HF epidemiology of developed countries with the added factors of SH, C'D, and rheumatic fever. Overall, in the scenario of lower total expenditure on health per capita and lower gross national income per capita, new strategies are essential for prevention and treatment of HF in LA.


Assuntos
Insuficiência Cardíaca/epidemiologia , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , América Latina/epidemiologia , Masculino , Prevalência , Prognóstico , Fatores de Risco
20.
Rev. argent. cardiol ; 81(1): 45-52, feb. 2013. ilus, graf, tab
Artigo em Espanhol | LILACS-Express | ID: lil-694837

RESUMO

Introducción La miocardiopatía periparto es una forma infrecuente de insuficiencia cardíaca congestiva con una evolución impredecible. Su verdadera incidencia y prevalencia no se conoce con certeza y su etiología aún no se ha aclarado, aunque se han involucrado varios mecanismos en los que se reconocen diversos factores de riesgo. Objetivo Analizar predictores pronósticos de mortalidad o de requerimiento de trasplante cardíaco. Material y métodos Entre 1992 y noviembre de 2011 se evaluaron retrospectivamente 23 pacientes. En aquellas con insuficiencia cardíaca descompensada se realizó monitorización hemodinámica. La mediana de seguimiento fue de 7,3 años (3,2-17,5). El análisis univariado se realizó por regresión de Cox y la supervivencia global se calculó con el método de Kaplan-Meier. Resultados La edad media fue de 28,7 ± 8,8 años, ocho pacientes eran multíparas. El 73% estaban en clase funcional III-IV. La presión arterial sistólica y diastólica fue de 103 ± 23 y 67 ± 11 mm Hg, respectivamente, y la frecuencia cardíaca, de 92 ± 19 lpm. El 100% se encontraba en ritmo sinusal. El índice cardiotorácico fue de 0,56 ± 0,07. El diámetro diastólico y sistólico del ventrículo izquierdo fue de 67,5 ± 10,2 y 56,7 ± 10,1 mm, respectivamente, el diámetro auricular izquierdo fue de 42,5 ± 6 mm y la fracción de eyección del ventrículo izquierdo, del 24,6% ± 10,8%. La presión media de la arteria pulmonar fue de 25 ± 9 mm Hg y la capilar pulmonar, de 18,4 ± 7,8 mm Hg; el índice cardíaco fue de 2,6 ± 0,6 L/min/m². Siete pacientes fallecieron y tres fueron sometidas a trasplante cardíaco. En el análisis univariado, la clase funcional, el índice cardíaco, la presión arterial sistólica y diastólica, la presión capilar y pulmonar media, el índice cardiotorácico y el diámetro auricular izquierdo se asociaron con mortalidad y trasplante cardíaco. La supervivencia a 1, 3 y 6 años fue del 91%, 82% y 64%, respectivamente. Conclusiones La mortalidad hospitalaria fue del 4,3% y el requerimiento de trasplante cardíaco o la muerte en el seguimiento fueron del 39%. Los parámetros hemodinámicos al ingreso fueron los principales predictores de mortalidad y de trasplante.


Background Peripartum cardiomyopathy is an uncommon form of congestive heart failure with an unpredictable outcome. Very little is known about its real incidence and prevalence, and its etiology is still unknown, although a number of contributing factors, including diverse risk factors, have been proposed. Objective To analyze the predictors of mortality or need for heart transplantation. Methods Between 1992 and November 2011, 23 patients were retrospectively evaluated. Patients with decompensated heart failure were managed with hemodynamic monitoring. Me­dian follow-up was of 7.3 years (3.2-17.5). Univariate Cox regression analysis was performed and overall survival was calculated using the Kaplan-Meier method. Results Mean age was 28.7±8.8 years; eight patients were multipara. Seventy three percent were in functional class III-IV. Systolic blood pressure and diastolic blood pressure were 103±23 and 67±11 mm Hg, respectively, and heart rate was 92±19 bpm. All the patients were in sinus rhythm. The cardiothoracic index was 0.56±0.07. End-diastolic and end-systolic left ventricular dimensions were 67.5±10.2 and 56.7±10.1 mm, respectively; left atrial dimension was 42.5±6 mm and left ventricular ejection fraction was 24.6%±10.8%. Mean pulmonary artery pressure was 25±9 mm Hg and pulmonary wedge pressure, was 18.4±7.8 mm Hg; cardiac index was 2.6±0.6 L/min/m². Seven patients died and three patients underwent heart transplantation. Univariate analysis revealed that functional class, cardiac index, systolic and diastolic blood pressure, pulmonary wedge pressure and mean pulmonary artery pressure, cardiothoracic index and left atrial dimension were associated with mortality and heart transplantation. Survival at one, three and six years was of 91%, 82% y 64%, respectively. Conclusions In-hospital mortality was of 4.3% and the need for heart transplantation or mortality during follow-up was of 39%. The hemodynamic parameters at admission were the main predictors of mortality and transplant.

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