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1.
Eur J Heart Fail ; 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31410955

RESUMO

AIMS: To compare characteristics of left ventricular assist device (LVAD) recipients receiving a cardiac implantable electronic device (CIED) with a defibrillator component (implantable cardioverter-defibrillator and cardiac resynchronization therapy with defibrillation, CIED-D) vs. those without one, and to assess whether carrying such a device contiguously with an LVAD is associated with outcomes. METHODS AND RESULTS: Overall, 448 patients were analysed (mean age 52 ± 13 years, 82% male) in the multicentre European PCHF-VAD registry. To account for all active CIED-Ds during ongoing LVAD treatment, outcome analyses were performed by a time-varying analysis with active CIED-D status post-LVAD as the time-varying covariate. At the time of LVAD implantation, 235 patients (52%) had an active CIED-D. Median time on LVAD support was 1.1 years (interquartile range 0.5-2.0 years). A reduction of 36% in the risk of all-cause mortality was observed in patients with an active CIED-D [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.46-0.91; P = 0.012), increasing to 41% after adjustment for baseline covariates (HR 0.59, 95% CI 0.40-0.87; P = 0.008) and 39% after propensity score adjustment (HR 0.61, 95% CI 0.39-0.94; P = 0.027). Other than CIED-D, age, LVAD implant as redo surgery, number of ventricular arrhythmia episodes and use of vasopressors pre-LVAD were remaining significant risk factors of all-cause mortality. Incident ventricular arrhythmias post-LVAD portended a 2.4-fold and 2.6-fold increased risk of all-cause and cardiovascular death, respectively; carrying an active CIED-D remained associated with a 47% and 43% reduction in these events, respectively. CONCLUSIONS: In an analysis accounting for all active CIED-Ds, including those implanted during LVAD support, carrying such a device was associated with significantly better survival during LVAD support.

2.
Int J Cardiol ; 293: 39-44, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31178223

RESUMO

Abnormalities of myocardial energy metabolism appear as a common background of the two major cardiac disorders: ischemic heart disease (IHD) and heart failure (HF). Myocardial ischemia has been recently conceived as a multifaceted syndrome that can be precipitated by a number of mechanisms including metabolic abnormalities. HF is a progressive disorder characterised by a complex interaction of haemodynamic, neurohormonal and metabolic disturbances. HF may further promote metabolic changes, generating a vicious cycle. Thus, targeting cardiac metabolism in IHD patients may prevent the deterioration of left ventricular function, stopping the progression to HF. For these reasons, several studies have explored the potential benefits of trimetazidine (TMZ), an inhibitor of free fatty acids oxidation that shifts cardiac and muscle metabolism to glucose utilization. Because of its mechanism of action, TMZ has been found to provide a cardioprotective effect in patients with angina, diabetes mellitus, and left ventricular (LV) dysfunction, and those undergoing revascularization procedures, without relevant side effects. In addition, the lack of interference with heart rate, arterial pressure, and most of frequent comorbidities, makes TMZ an attractive option for patients and clinicians as well. The impact of TMZ on long term mortality and morbidity in ischemic syndromes and in heart failure need to be conclusively confirmed in properly designed RCT.

3.
Eur J Heart Fail ; 2019 May 26.
Artigo em Inglês | MEDLINE | ID: mdl-31129923

RESUMO

The European Society of Cardiology (ESC) has published a series of guidelines on heart failure (HF) over the last 25 years, most recently in 2016. Given the amount of new information that has become available since then, the Heart Failure Association (HFA) of the ESC recognized the need to review and summarise recent developments in a consensus document. Here we report from the HFA workshop that was held in January 2019 in Frankfurt, Germany. This expert consensus report is neither a guideline update nor a position statement, but rather a summary and consensus view in the form of consensus recommendations. The report describes how these guidance statements are supported by evidence, it makes some practical comments, and it highlights new research areas and how progress might change the clinical management of HF. We have avoided re-interpretation of information already considered in the 2016 ESC/HFA guidelines. Specific new recommendations have been made based on the evidence from major trials published since 2016, including sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus, MitraClip for functional mitral regurgitation, atrial fibrillation ablation in HF, tafamidis in cardiac transthyretin amyloidosis, rivaroxaban in HF, implantable cardioverter-defibrillators in non-ischaemic HF, and telemedicine for HF. In addition, new trial evidence from smaller trials and updated meta-analyses have given us the chance to provide refined recommendations in selected other areas. Further, new trial evidence is due in many of these areas and others over the next 2 years, in time for the planned 2021 ESC guidelines on the diagnosis and treatment of acute and chronic heart failure.

4.
Eur J Heart Fail ; 21(5): 553-576, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30989768

RESUMO

Cardiomyopathies are a heterogeneous group of heart muscle diseases and an important cause of heart failure (HF). Current knowledge on incidence, pathophysiology and natural history of HF in cardiomyopathies is limited, and distinct features of their therapeutic responses have not been systematically addressed. Therefore, this position paper focuses on epidemiology, pathophysiology, natural history and latest developments in treatment of HF in patients with dilated (DCM), hypertrophic (HCM) and restrictive (RCM) cardiomyopathies. In DCM, HF with reduced ejection fraction (HFrEF) has high incidence and prevalence and represents the most frequent cause of death, despite improvements in treatment. In addition, advanced HF in DCM is one of the leading indications for heart transplantation. In HCM, HF with preserved ejection (HFpEF) affects most patients with obstructive, and ∼10% of patients with non-obstructive HCM. A timely treatment is important, since development of advanced HF, although rare in HCM, portends a poor prognosis. In RCM, HFpEF is common, while HFrEF occurs later and more frequently in amyloidosis or iron overload/haemochromatosis. Irrespective of RCM aetiology, HF is a harbinger of a poor outcome. Recent advances in our understanding of the mechanisms underlying the development of HF in cardiomyopathies have significant implications for therapeutic decision-making. In addition, new aetiology-specific treatment options (e.g. enzyme replacement therapy, transthyretin stabilizers, immunoadsorption, immunotherapy, etc.) have shown a potential to improve outcomes. Still, causative therapies of many cardiomyopathies are lacking, highlighting the need for the development of effective strategies to prevent and treat HF in cardiomyopathies.

5.
Heart Fail Clin ; 15(2): 147-158, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30832807

RESUMO

Despite the rapid development of emerging imaging technologies, left ventricular ejection fraction represents the cornerstone of diagnosis, choice of treatment, and prognosis in heart failure. However, true myocardial function often remains underestimated or overestimated in different conditions underlying this heterogeneous syndrome. Changes in left ventricular size and left ventricular ejection fraction, termed reverse remodeling, are among the main goals of treatment in heart failure, aimed at halting or attenuating disease progression. The lack of effective therapeutic approaches in nearly one-half of the heart failure population highlights the need for integrating novel echocardiographic measures to better understand the underlying pathophysiologic mechanisms.


Assuntos
Ecocardiografia/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Função Ventricular Esquerda/fisiologia , Remodelação Ventricular/fisiologia , Animais , Insuficiência Cardíaca/fisiopatologia , Humanos , Prognóstico
6.
Eur J Prev Cardiol ; 26(8): 824-835, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30739508

RESUMO

AIMS: The aim of this study was to determine whether the Joint European Societies guidelines on secondary cardiovascular prevention are followed in everyday practice. DESIGN: A cross-sectional ESC-EORP survey (EUROASPIRE V) at 131 centres in 81 regions in 27 countries. METHODS: Patients (<80 years old) with verified coronary artery events or interventions were interviewed and examined ≥6 months later. RESULTS: A total of 8261 patients (females 26%) were interviewed. Nineteen per cent smoked and 55% of them were persistent smokers, 38% were obese (body mass index ≥30 kg/m2), 59% were centrally obese (waist circumference: men ≥102 cm; women ≥88 cm) while 66% were physically active <30 min 5 times/week. Forty-two per cent had a blood pressure ≥140/90 mmHg (≥140/85 if diabetic), 71% had low-density lipoprotein cholesterol ≥1.8 mmol/L (≥70 mg/dL) and 29% reported having diabetes. Cardioprotective medication was: anti-platelets 93%, beta-blockers 81%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75% and statins 80%. CONCLUSION: A large majority of coronary patients have unhealthy lifestyles in terms of smoking, diet and sedentary behaviour, which adversely impacts major cardiovascular risk factors. A majority did not achieve their blood pressure, low-density lipoprotein cholesterol and glucose targets. Cardiovascular prevention requires modern preventive cardiology programmes delivered by interdisciplinary teams of healthcare professionals addressing all aspects of lifestyle and risk factor management, in order to reduce the risk of recurrent cardiovascular events.

7.
J Am Heart Assoc ; 8(4): e011190, 2019 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-30764687

RESUMO

Background We hypothesized that female sex is a treatment effect modifier of blood flow and related 30-day mortality after primary percutaneous coronary intervention ( PCI ) for ST -segment-elevation myocardial infarction and that the magnitude of the effect on outcomes differs depending on delay to hospital presentation. Methods and Results We identified 2596 patients enrolled in the ISACS - TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry from 2010 to 2016. Primary outcome was the occurrence of 30-day mortality. Key secondary outcome was the rate of suboptimal post- PCI Thrombolysis in Myocardial Infarction ( TIMI ; flow grade 0-2). Multivariate logistic regression and inverse probability of treatment weighted models were adjusted for baseline clinical covariates. We characterized patient outcomes associated with a delay from symptom onset to hospital presentation of ≤120 minutes. In multivariable regression models, female sex was associated with postprocedural TIMI flow grade 0 to 2 (odds ratio [ OR ], 1.68; 95% CI , 1.15-2.44) and higher mortality ( OR, 1.72; 95% CI , 1.02-2.90). Using inverse probability of treatment weighting, 30-day mortality was higher in women compared with men (4.8% versus 2.5%; OR , 2.00; 95% CI , 1.27-3.15). Likewise, we found a significant sex difference in post- PCI TIMI flow grade 0 to 2 (8.8% versus 5.0%; OR , 1.83; 95% CI , 1.31-2.56). The sex gap in mortality was no longer significant for patients having hospital presentation of ≤120 minutes ( OR , 1.28; 95% CI , 0.35-4.69). Sex difference in post- PCI TIMI flow grade was consistent regardless of time to hospital presentation. Conclusions Delay to hospital presentation and suboptimal post- PCI TIMI flow grade are variables independently associated with excess mortality in women, suggesting complementary mechanisms of reduced survival. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01218776.

9.
Ann Noninvasive Electrocardiol ; : e12610, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30383318

RESUMO

AIMS: Microvolt T-wave alternans (MTWA) testing is a beat-to-beat fluctuation in the amplitude of T wave. We investigated whether: (a) MTWA can be new non-invasive tool for detection of reversible ischemia in patients with suspected CAD without structural heart disease, (b) MTWA can detect ischemia earlier and with greater test accuracy compared with exercise ECG ST-segment testing, and (c) threshold value of MTWA and heart rate at which the alternans is estimated can be different compared to standard values. METHODS: A total of 101 patients with suspected stable coronary disease, but without structural heart disease, were included. Echocardiography, exercise ECG test, MTWA with classical and modified threshold alternans values, and coronary angiography were performed. RESULTS: About 33.3% patients had a false-positive result on exercise ECG test. The sensitivity of exercise ECG ST-segment test in the detection of coronary artery disease was 97.8%, and the specificity was 42.5% (DOR 33.89). In a group of angiographically positive patients, standard MTWA accurately identified 60% of patients, while 40% had a false-negative result. About 91.8% patients with negative angiography result were accurately identified with 8.2% false positives. The sensitivity of MTWA was 59.61% and specificity 91.83%. Best ratio of sensitivity and specificity (86.53% and 95.91%, DOR 151.06) had modified criteria for positive MTWA (MTWA >1.5 µV at heart rate 115-125/min). CONCLUSIONS: This study showed that MTWA can be the new non-invasive tool for the detection of reversible ischemia in patients with suspected CAD without structural heart disease. Also, MTWA can detect ischemia earlier and with greater accuracy compared with exercise ECG testing.

10.
Croat Med J ; 59(5): 224-231, 2018 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-30394014

RESUMO

AIM: To assess the association between renal replacement therapy (RRT) and post-transplant infection incidence. METHODS: This single-center retrospective cohort study included 158 patients who underwent heart transplantation (HTx) in our center from 2008 to 2016, survived beyond the first post-procedural day, and had available microbial data. The patients were dichotomized according to the need for periprocedural RRT. Twenty-seven patients in RRT group had lower preoperative creatinine clearance, greater body mass index, and higher likelihood of having diabetes. Propensity score adjustment was used to account for multiple covariates. The primary outcome measure was the presence of bacteremia in patients with and without the need for RRT. The secondary outcome measures were the presence of microbial isolates from any culture and clinical outcome data. RESULTS: Unadjusted analysis showed that the RRT group had higher incidence of any positive microbial isolate (93% vs 73%; odds ratio [OR] 4.77, 95% confidence interval [CI] 1.01-30.53; P=0.026) and an increased susceptibility to bacteremia (50% vs 22%; OR 3.50, 95% CI 1.28-9.67; P=0.012). Propensity score-adjusted analysis corroborated the between-group difference in positive blood cultures (OR 3.97, 95% CI 1.28-12.32; P=0.017). There was no difference in the incidence of total microbial isolates between the groups (OR 4.55, 95% CI 0.90-23.05; P=0.067). CONCLUSIONS: Patients requiring RRT after HTx had an increased susceptibility to infections via various portals of entry, predominantly due to an increase in blood-borne infections. Understanding the underlying conditions leading to infection-related morbidity is important for infection control and prevention.

11.
Artigo em Inglês | MEDLINE | ID: mdl-30448166

RESUMO

BACKGROUND: Neurological complications after coronary artery bypass grafting (CABG) reduce quality of life, increase mortality, and inflate resource utilization. The risk of postoperative neurological complications parallels the increasing risk burden of the contemporary patient population. We evaluated the efficacy of remote ischemic preconditioning (RIPC) on inducing neuroprotection. METHODS: Seventy patients undergoing first-time CABG were randomly assigned to RIPC or a sham procedure. Structural brain magnetic resonance imaging (MRI) was complemented with functional connectivity MRI to gain a whole-brain global connectivity analysis. Paired neurocognitive and MRI data were acquired pre- and postoperatively. The primary end point was a composite of new ischemic brain lesions and neurocognitive impairment. Secondary end points included brain connectivity profiles, pooled ischemic volumes, and individual components of the primary outcome. The Shapiro-Wilk test was used to determine whether a data set followed a normal distribution. The Fisher exact test was used to calculate the measures of association for categorical variables, whereas continuous data were tested with either the Mann-Whitney U test or the Student t test. RESULTS: There was no between-group difference in the incidence of the primary end point (9 [27%] in the RIPC group vs 8 [24%] in the control group, odds ratio, 1.17 [95% confidence interval, 0.34-4.06]; P = 1.0). Although RIPC did not reduce the incidence of brain ischemia (8/33 [24%] vs 7/33 [21%]; P = 1.0), the pooled ischemic volume was lower in the RIPC group (157 [interquartile range, 125-231] vs 777 [interquartile range, 564-965] mm3; P = .004). Postoperative neurocognition was marginally superior in the RIPC group as evidenced by a lower absolute number of abnormal neurocognitive tests in the RIPC group (7/99 [7%] vs 16/99 [16%]; odds ratio, 0.40 [95% confidence interval, 0.14-1.09]; P = .074). Robust reductions of functional connectivity profiles for the associative thalamus were documented in both groups, irrespective of RIPC (RIPC group, t = 3.31; P < .01; and the control group, t = 3.52; P < .01). CONCLUSIONS: Silent brain ischemia occurs frequently after CABG. RIPC did not reduce the incidence of the primary outcome. However, RIPC significantly reduced the pooled volume of ischemic brain lesions. Surgery adversely affected global brain connectivity, with RIPC conferring no demonstrable protection. The association of RIPC with superior neurocognitive test scores failed to cross the threshold for significance.

12.
Eur J Epidemiol ; 2018 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-30353266

RESUMO

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.

13.
Eur Heart J ; 2018 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-30226525

RESUMO

Aims: The provision of high-quality education allows the European Society of Cardiology (ESC) to achieve its mission of better cardiovascular practice and provides an essential component of translating new evidence to improve outcomes. Methods and results: The 4th ESC Education Conference, held in Sophia Antipolis (December 2016), brought together ESC education leaders, National Directors of Training of 43 ESC countries, and representatives of the ESC Young Community. Integrating national descriptions of education and cardiology training, we discussed innovative pathways to further improve knowledge and skills across different training programmes and health care systems. We developed an ESC roadmap supporting better cardiology training and continued medical education (CME), noting: (i) The ESC provides an excellent framework for unbiased and up-to-date cardiovascular education in close cooperation with its National Societies. (ii) The ESC should support the harmonization of cardiology training, curriculum development, and professional dialogue and mentorship. (iii) ESC congresses are an essential forum to learn and discuss the latest developments in cardiovascular medicine. (iv) The ESC should create a unified, interactive educational platform for cardiology training and continued cardiovascular education combining Webinars, eLearning Courses, Clinical Cases, and other educational programmes, along with ESC Congress content, Practice Guidelines and the next ESC Textbook of Cardiovascular Medicine. (v) ESC-delivered online education should be integrated into National and regional cardiology training and CME programmes. Conclusion: These recommendations support the ESC to deliver excellent and comprehensive cardiovascular education for the next generation of specialists. Teamwork between international, national and local partners is essential to achieve this objective.

14.
Eur Heart J ; 2018 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-30137263

RESUMO

Congenital heart disease (CHD) is the most common inborn defect. Due to advances in paediatric care, surgical, and catheter procedures the number of adults with CHD has grown remarkably in recent years. Most of these patients, however, have residua from their original operation/s and require life-long care, many of them are subjected to further haemodynamic and electrophysiological interventions during adulthood. While such re-do surgical or catheter interventions together with device therapy and transplantation play a key therapeutic role, increasingly, adults with CHD require drug therapy for late complications namely heart failure (HF), arrhythmias, pulmonary and systemic hypertension, thromboembolic events, etc. Unlike other cardiovascular areas, drug therapy in adult CHD is based on scarce clinical data and remains largely empiric. Consequently, pharmacological therapies are individualized to ameliorate patients' symptoms and/or degree of haemodynamic impairment. Thus far, recommendations have been difficult to make and formalized guidelines on drug therapy are lacking. We review herewith the rationale, limited evidence and knowledge gaps regarding drug therapy in this growing cardiovascular field and discuss pharmacotherapy options in specific conditions namely HF, arrhythmias, thrombosis, pulmonary arterial hypertension, contraception, and pregnancy.

15.
Circ Heart Fail ; 11(7): e004962, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29980595

RESUMO

BACKGROUND: To describe the baseline characteristics of patients with heart failure and preserved left ventricular ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in HFpEF) comparing sacubitril/valsartan to valsartan in reducing morbidity and mortality. METHODS AND RESULTS: We report key demographic, clinical, and laboratory findings, and baseline therapies, of 4822 patients randomized in PARAGON-HF, grouped by factors that influence criteria for study inclusion. We further compared baseline characteristics of patients enrolled in PARAGON-HF with those patients enrolled in other recent trials of heart failure with preserved ejection fraction (HFpEF). Among patients enrolled from various regions (16% Asia-Pacific, 37% Central Europe, 7% Latin America, 12% North America, 28% Western Europe), the mean age of patients enrolled in PARAGON-HF was 72.7±8.4 years, 52% of patients were female, and mean left ventricular ejection fraction was 57.5%, similar to other trials of HFpEF. Most patients were in New York Heart Association class II, and 38% had ≥1 hospitalizations for heart failure within the previous 9 months. Diabetes mellitus (43%) and chronic kidney disease (47%) were more prevalent than in previous trials of HFpEF. Many patients were prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (85%), ß-blockers (80%), calcium channel blockers (36%), and mineralocorticoid receptor antagonists (24%). As specified in the protocol, virtually all patients were on diuretics, had elevated plasma concentrations of N-terminal pro-B-type natriuretic peptide (median, 911 pg/mL; interquartile range, 464-1610), and structural heart disease. CONCLUSIONS: PARAGON-HF represents a contemporary group of patients with HFpEF with similar age and sex distribution compared with prior HFpEF trials but higher prevalence of comorbidities. These findings provide insights into the impact of inclusion criteria on, and regional variation in, HFpEF patient characteristics. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01920711.

16.
Curr Pharm Des ; 24(25): 2954-2959, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29938612

RESUMO

The idea of coronary microcirculation playing a role in the pathophysiology of heart failure dates from decades ago, with authors hypothesizing that structural and functional alterations in the coronary microcirculation could potentially contribute to heart failure. It is known that in a wide range of primary cardiomyopathies, from dilated to hypertrophic, there are pathological alterations in myocardial vasculature structure and function, playing a role in the clinical course of the disease. Needless to say, many patients with normal epicardial coronary arteries can suffer from coronary microvascular dysfunction, that could lead to a wide variety of clinical problems - from impaired functional capacity to stable and unstable angina, Takotsubo syndrome, myocardial infarction with normal coronary arteries and can also end up with either acute or chronic heart failure. Furthermore, nowadays, it has been recognized that pathophysiology of the heart failure with preserved ejection fraction (HFpEF) is mainly due to the myocardial microcirculatory impairment. In heart failure with reduced ejection fraction (HFrEF) neurohumoral mechanisms affecting the peripheral vasculature have been identified as important factors in the development and progression of heart failure, leading to unfavourable remodelling, and thus some of them being important treatment targets. Among many new clinical scenarios where both myocardial and peripheral microcirculation play an important role, raising field of implantable continuous flow assist devices opens many questions and implies better understanding of their effects of microcirculation, as they usually lead to the improvement of end organ dysfunction caused by previous heart failure, which is probably through the positive effects of peripheral microcirculation.

17.
Transpl Int ; 31(11): 1223-1232, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29885002

RESUMO

Internationally 3% of the donor hearts are distributed to re-transplant patients. In Eurotransplant, only patients with a primary graft dysfunction (PGD) within 1 week after heart transplantation (HTX) are indicated for high urgency listing. The aim of this study is to provide evidence for the discussion on whether these patients should still be allocated with priority. All consecutive HTX performed in the period 1981-2015 were included. Multivariate Cox' model was built including: donor and recipient age and gender, ischaemia time, recipient diagnose, urgency status and era. The study population included 18 490 HTX, of these 463 (2.6%) were repeat transplants. The major indications for re-HTX were cardiac allograft vasculopathy (CAV) (50%), PGD (26%) and acute rejection (21%). In a multivariate model, compared with first HTX hazards ratio and 95% confidence interval for repeat HTX were 2.27 (1.83-2.82) for PGD, 2.24 (1.76-2.85) for acute rejection and 1.22 (1.00-1.48) for CAV (P < 0.0001). Outcome after cardiac re-HTX strongly depends on the indication for re-HTX with acceptable outcomes for CAV. In contrast, just 47.5% of all hearts transplanted in patients who were re-transplanted for PGD still functioned at 1-month post-transplant. Alternative options like VA-ECMO should be first offered before opting for acute re-transplantation.

18.
Eur J Heart Fail ; 20(11): 1505-1535, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29806100

RESUMO

This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.

19.
JAMA Intern Med ; 178(5): 632-639, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29630703

RESUMO

Importance: Previous works have shown that women hospitalized with ST-segment elevation myocardial infarction (STEMI) have higher short-term mortality rates than men. However, it is unclear if these differences persist among patients undergoing contemporary primary percutaneous coronary intervention (PCI). Objective: To investigate whether the risk of 30-day mortality after STEMI is higher in women than men and, if so, to assess the role of age, medications, and primary PCI in this excess of risk. Design, Setting, and Participants: From January 2010 to January 2016, a total of 8834 patients were hospitalized and received medical treatment for STEMI in 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776). Exposures: Demographics, baseline characteristics, clinical profile, and pharmacological treatment within 24 hours and primary PCI. Main Outcomes and Measures: Adjusted 30-day mortality rates estimated using inverse probability of treatment weighted (IPTW) logistic regression models. Results: There were 2657 women with a mean (SD) age of 66.1 (11.6) years and 6177 men with a mean (SD) age of 59.9 (11.7) years included in the study. Thirty-day mortality was significantly higher for women than for men (11.6% vs 6.0%, P < .001). The gap in sex-specific mortality narrowed if restricting the analysis to men and women undergoing primary PCI (7.1% vs 3.3%, P < .001). After multivariable adjustment for comorbidities and treatment covariates, women under 60 had higher early mortality risk than men of the same age category (OR, 1.88; 95% CI, 1.04-3.26; P = .02). The risk in the subgroups aged 60 to 74 years and over 75 years was not significantly different between sexes (OR, 1.28; 95% CI, 0.88-1.88; P = .19 and OR, 1.17; 95% CI, 0.80-1.73; P = .40; respectively). After IPTW adjustment for baseline clinical covariates, the relationship among sex, age category, and 30-day mortality was similar (OR, 1.56 [95% CI, 1.05-2.3]; OR, 1.49 [95% CI, 1.15-1.92]; and OR, 1.21 [95% CI, 0.93-1.57]; respectively). Conclusions and Relevance: Younger age was associated with higher 30-day mortality rates in women with STEMI even after adjustment for medications, primary PCI, and other coexisting comorbidities. This difference declines after age 60 and is no longer observed in oldest women.

20.
Psychiatr Danub ; 29(4): 421-430, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29197198

RESUMO

Posttraumatic stress disorder (PTSD) is a chronic condition related to severe stress and trauma. There is a mounting evidence about increased prevalence and mortality from cardiovascular diseases (CVD) in patients with PTSD. This review summarizes the current data on possible relations between PTSD and increased risks of CVD, including biological, psychological and behavioral factors. Biological factors refer to increased prevalence of metabolic syndrome (MetS), hypertension, elevation of pro-inflammatory cytokines and homocysteine levels. Peripheral Brain-derived neurotropic factor (BDNF), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and quantitative electroencephalogram (qEEG) are promising surrogate markers of increased cardiovascular risk. Among psychological factors, some personality traits, such as neuroticism and trait impulsivity/hostility, contribute to the development of PTSD, and are associated with general cardiovascular distress. Recently, type-D (distressed) personality is usually investigated in relation to cardiovascular morbidity, but in populations other than PTSD patients. Behavioral factors refer to unhealthy life-styles, encompassing high smoking rate, drug substances abuse and addiction, physical inactivity and unhealthy diet. The relationships among all these factors are complex and yet incompletely taken into consideration. Because of a high prevalence of CVD in patients with PTSD, there is a strong need for a more intensive focus on this vulnerable population in both primary and secondary cardiovascular prevention as well as in effective treatment possibilities.


Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/psicologia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/psicologia , Doenças Cardiovasculares/mortalidade , Caráter , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Síndrome Metabólica/diagnóstico , Síndrome Metabólica/mortalidade , Síndrome Metabólica/psicologia , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Resiliência Psicológica , Risco , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/mortalidade , Taxa de Sobrevida , Personalidade Tipo D
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