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1.
Dis Markers ; 2019: 7512805, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31583030

RESUMO

Background: The ratio of early mitral inflow velocity to the global diastolic strain rate (E/E'sr) and global longitudinal systolic strain (GLS) of the left ventricle (LV) are emerging indices of diastolic and systolic functions, respectively, for the LV. Their prognostic significance in the prediction of mortality and cardiovascular (CV) outcomes remains underexplored in hemodialysis (HD) patients. Methods: This prospective study included 190 maintenance HD patients. The E/E'sr ratio and GLS were assessed using two-dimensional speckle tracking echocardiography. The clinical outcomes included overall mortality, CV mortality, and major adverse cardiovascular events (MACE). The associations between the E/E'sr ratio, GLS, and clinical outcomes were evaluated using multivariate Cox regression analysis. The incremental values of the E/E'sr ratio and GLS in outcome prediction were assessed by χ 2 changes in Cox models. Results: Over a median follow-up period of 3.7 years, there were 35 overall deaths, 16 CV deaths, and 45 MACE. Impaired diastolic function with a higher E/E'sr ratio was associated with overall mortality (HR, 1.484; 95% CI, 1.201-1.834; p < 0.001), CV mortality (HR, 1.584; 95% CI, 1.058-2.371; p = 0.025), and MACE (HR, 1.205; 95% CI, 1.040-1.397; p = 0.013) in multivariate adjusted Cox analysis. Worsening GLS was associated with overall mortality (HR, 1.276; 95% CI, 1.101-1.480; p = 0.001), CV mortality (HR, 1.513; 95% CI, 1.088-2.104; p = 0.014), and MACE (HR, 1.214; 95% CI, 1.103-1.337; p < 0.001). The E/E'sr ratio and GLS had better outcome prediction than the E to early diastolic mitral annular velocity (E/E') ratio and left ventricular ejection fraction (LVEF). Moreover, adding the E/E'sr ratio and GLS to Cox models containing relevant clinical and conventional echocardiographic parameters improved the prediction of overall mortality (p < 0.001), CV mortality (p < 0.001), and MACE (p < 0.001). Conclusion: The E/E'sr ratio and GLS, as emerging indices of LV diastolic and systolic functions, significantly predict mortality and CV outcomes and outperform conventional echocardiographic parameters in outcome prediction in HD patients.


Assuntos
Diástole , Insuficiência Cardíaca Sistólica/mortalidade , Infarto do Miocárdio/mortalidade , Diálise Renal , Sístole , Disfunção Ventricular Esquerda/mortalidade , Idoso , Biomarcadores/análise , Velocidade do Fluxo Sanguíneo , Ecocardiografia , Feminino , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/etiologia , Insuficiência Cardíaca Sistólica/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/fisiopatologia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/terapia , Volume Sistólico , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia
2.
Transplant Proc ; 51(6): 1950-1955, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303409

RESUMO

OBJECTIVES: The purpose of this study was to identify risk factors that may predict heart failure with reduced ejection fraction (HFrEF) following orthotopic liver transplantation (OLT) and associated mortality. BACKGROUND: HFrEF following OLT is a poorly understood phenomenon, reported in 3% to 7% of transplanted patients. METHODS: This is a retrospective analysis of 176 consecutive patients who underwent OLT from 2010 to 2017. Multivariate logistic regression was used to identify associations between cardiovascular risk factors and perioperative variables with post-OLT HFrEF, defined as reduction in left ventricular ejection fraction of at least 10% and left ventricular ejection fraction less than or equal to 40% with acute heart failure symptoms. Multivariate cox proportional hazards regression (with inverse probability weighting by propensity scores) was used to evaluate effects of HFrEF on 1-year mortality. RESULTS: Of the176 patients, 14% developed HFrEF with a median of 5 days. History of heart failure (OR 10.99, 2.15-56.09; P = .04) and intraoperative transfusion of greater than 11 units of packed red blood cells (OR 3.377, 1.025-11.13; P = .045) were associated with increased incidence of HFrEF. Pre-transplant hemoglobin greater than 8.5 g/dL (OR 0.252, CI 0.0954- 0.665; P = .05) was protective against HFrEF. Thirty-three percent of HFrEF group died within 1 year (HR 7.36, 2.57-21.12; P < .001). CONCLUSIONS: The incidence of acute HFrEF post-OLT is 14% and is associated with a 7-fold increase in 1-year mortality. Cirrhotic cardiomyopathy and stress-induced cardiomyopathy maybe the underlying mechanisms. Our study identified risk factors associated with post-OLT HFrEF and should provide additional guidance for risk stratification of patients undergoing OLT.


Assuntos
Cardiomiopatias/complicações , Insuficiência Cardíaca Sistólica/mortalidade , Transplante de Fígado/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Cardiomiopatias/fisiopatologia , Feminino , Insuficiência Cardíaca Sistólica/etiologia , Hemoglobinas/metabolismo , Humanos , Incidência , Transplante de Fígado/métodos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Função Ventricular Esquerda
3.
Amyloid ; 26(3): 156-163, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31210553

RESUMO

Objective: Cardiac amyloid infiltration can lead to systolic heart failure (HF) or to conduction disorders (CD). Patients with transthyretin (ATTR) amyloidosis are particularly exposed. We sought to determine the prevalence of ATTR and AL among patients >60 years admitted with CD or unexplained systolic HF and increased wall thickness. Materials and Methods: We studied 143 patients (57% males, 79 ± 9 years) with HF (N = 28) or CD requiring pacemaker implantation (N = 115). In total, 139 (97%) patients (28 with HF and 111 with CD) underwent 99mTc-DPD scintigraphy to detect ATTR, and 105 (73%; 19 HF and 86 CD) underwent AL screening. Results: Five patients (4%; 95%CI:0-7%) exhibited wild-type ATTR (ATTRwt) amyloidosis, 2 (2%; 95%CI:0-4%) had CD and 3 (11%; 95%CI:0-23%) HF. No patient showed AL. The 2 ATTRwt patients with CD were previously asymptomatic, did not show classical ECG signs and exhibited mild LV hypertrophy with preserved LVEF. By contrast, all ATTRwt patients with HF had ECG and echocardiographic signs of amyloid. During a mean follow-up of 18 ± 11 months, 3(60%) patients with ATTRwt amyloidosis (1 CD and 2 HF) and 14(10.4%) without died. Conclusion: Prevalence of ATTRwt amyloidosis in patients with CD requiring pacemaker is low. Although, additional studies are needed, prevalence seems to be higher in elderly patients with systolic HF.


Assuntos
Neuropatias Amiloides Familiares/diagnóstico por imagem , Arritmias Cardíacas/diagnóstico por imagem , Cardiomiopatias/diagnóstico por imagem , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Neuropatias Amiloides Familiares/complicações , Neuropatias Amiloides Familiares/mortalidade , Neuropatias Amiloides Familiares/cirurgia , Arritmias Cardíacas/complicações , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/cirurgia , Biomarcadores/metabolismo , Cardiomiopatias/complicações , Cardiomiopatias/mortalidade , Cardiomiopatias/cirurgia , Estudos Transversais , Ecocardiografia , Feminino , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/cirurgia , Humanos , Hipertrofia Ventricular Esquerda/complicações , Hipertrofia Ventricular Esquerda/mortalidade , Hipertrofia Ventricular Esquerda/cirurgia , Masculino , Marca-Passo Artificial , Pré-Albumina/metabolismo , Estudos Prospectivos , Cintilografia , Análise de Sobrevida
4.
Can J Cardiol ; 35(4): 462-470, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30935637

RESUMO

BACKGROUND: Growth differentiation factor-15 (GDF-15) is a stress-inducible cytokine and member of the transforming growth factor-ß cytokine superfamily that refines prognostic assessment in subgroups of patients with heart failure (HF). We evaluated its role in HF patients with chronic kidney disease (CKD, estimated glomerular filtration rate <60 mL/min/1.73 m2). METHODS: A total of 358 patients with stable systolic HF were followed for a median of 1121 (interquartile range, 379-2600) days. Comprehensive evaluation including B-type natriuretic peptide (BNP) and GDF-15 testing was performed at study entry; the analysis was stratified according to kidney function. RESULTS: Patients with CKD (33.8%) were older, had more often diabetes, and were less often treated with angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB). GDF-15 was associated with estimated glomerular filtration rate, whereas BNP was associated with left ventricular-end diastolic diameter and ejection fraction (P < 0.01). During follow-up, 244 patients (68.2%) experienced an adverse outcome (death, urgent transplantation, implantation of mechanical circulatory support). In patients with HF and CKD, the Cox proportional hazard model identified BNP, GDF-15, sex, systolic blood pressure, sodium, total cholesterol, and ACEi/ARB treatment as significant variables associated with an adverse outcome (P < 0.05). In multivariable analysis, BNP was replaced by GDF-15. Net reclassification improvement confirmed prognostic superiority of the model encompassing GDF-15 (GDF-15, sodium, total cholesterol, ACEi/ARB treatment) compared with the model without GDF-15 (BNP, sex, sodium, ACEi/ARB treatment), net reclassification improvement 0.62, P = 0.005. In contrast, in patients with HF and normal kidney function, BNP remained superior to GDF-15 in a multivariable model. CONCLUSIONS: In patients with systolic HF and CKD, GDF-15 is more strongly associated with adverse outcomes than the conventionally used BNP.


Assuntos
Fator 15 de Diferenciação de Crescimento/sangue , Insuficiência Cardíaca Sistólica/sangue , Insuficiência Cardíaca Sistólica/mortalidade , Transplante de Coração/estatística & dados numéricos , Coração Auxiliar/estatística & dados numéricos , Insuficiência Renal Crônica/epidemiologia , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Biomarcadores/sangue , Pressão Sanguínea , Colesterol/sangue , Feminino , Seguimentos , Taxa de Filtração Glomerular , Insuficiência Cardíaca Sistólica/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Modelos de Riscos Proporcionais , Insuficiência Renal Crônica/tratamento farmacológico , Fatores Sexuais , Sódio/sangue , Sístole
5.
Circ Arrhythm Electrophysiol ; 12(3): e007022, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30866666

RESUMO

Background Patients with nonischemic systolic heart failure are at an increased risk of sudden cardiac death, but more discriminating tools are needed to identify those patients likely to benefit from implantable cardioverter-defibrillator (ICD) implantation. Whether right ventricular (RV) ejection fraction (RVEF) can identify patients with nonischemic systolic heart failure more likely to benefit from ICD implantation is not yet known. Methods In this post hoc analysis of the DANISH trial (Danish Study to Assess the Efficacy of ICDs in Patients with Nonischemic Systolic Heart Failure on Mortality), patients with nonischemic systolic heart failure randomized to ICD or control underwent cardiovascular magnetic resonance. RV systolic dysfunction was defined as RVEF ≤45%. Cox regression assessed the effects of RV function and ICD implantation on all-cause mortality, sudden cardiac death, and cardiovascular death. Results Overall, 239 patients had interpretable images of RV volume. Median RVEF was 51%, RV systolic dysfunction was present in 75 (31%) patients, and 55 (23%) patients died. RVEF was an independent predictor of all-cause mortality, hazards ratio 1.34 per 10% absolute decrease in RVEF (95% CI, 1.05-1.70), P=0.02. There was a statistically significant interaction between RVEF and the effect of ICD implantation ( P=0.001). ICD implantation significantly reduced all-cause mortality in patients with RV systolic dysfunction, hazards ratio 0.41 (95% CI, 0.17-0.97), P=0.04 but not in patients without RV systolic dysfunction, hazards ratio 1.87 (95% CI, 0.85-3.92), P=0.12, ( P=0.01 for the difference in effect of ICD between RV groups). Conclusions In this post hoc analysis of the DANISH trial, ICD therapy was associated with survival benefit in patients with biventricular heart failure. These findings need confirmation in a prospective study. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00542945.


Assuntos
Cardioversão Elétrica/instrumentação , Insuficiência Cardíaca Sistólica/terapia , Volume Sistólico , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Direita/terapia , Função Ventricular Esquerda , Função Ventricular Direita , Idoso , Tomada de Decisão Clínica , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Dinamarca , Feminino , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/mortalidade , Disfunção Ventricular Direita/fisiopatologia
6.
Clin Res Cardiol ; 108(10): 1117-1127, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30874886

RESUMO

AIMS: In the IN-TIME trial, automatic daily implant-based multiparameter telemonitoring significantly improved clinical outcomes in patients with chronic systolic heart failure and implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D). We compared IN-TIME results for ICD and CRT-D subgroups. METHODS: Patients with LVEF ≤ 35%, NYHA class II/III, optimized drug treatment, no permanent atrial fibrillation, and a dual-chamber ICD (n = 274) or CRT-D (n = 390) were randomized 1:1 to telemonitoring or no telemonitoring for 12 months. Primary outcome measure was a composite clinical score, classified as worsened if the patient died or had heart failure-related hospitalization, worse NYHA class, or a worse self-reported overall condition. RESULTS: The prevalence of worsened score at study end was higher in CRT-D than ICD patients (26.4% vs. 18.2%; P = 0.014), as was mortality (7.4% vs. 4.1%; P = 0.069). With telemonitoring, odds ratios (OR) for worsened score and hazard ratios (HR) for mortality were similar in the ICD [OR = 0.55 (P = 0.058), HR = 0.39 (P = 0.17)] and CRT-D [OR = 0.68 (P = 0.10), HR = 0.35 (P = 0.018)] subgroups (insignificant interaction, P = 0.58-0.91). CONCLUSION: Daily multiparameter telemonitoring has a potential to reduce clinical endpoints in patients with chronic systolic heart failure both in ICD and CRT-D subgroups. The absolute benefit seems to be higher in higher-risk populations with worse prognosis.


Assuntos
Terapia de Ressincronização Cardíaca/métodos , Desfibriladores Implantáveis , Insuficiência Cardíaca Sistólica/terapia , Volume Sistólico/fisiologia , Telemedicina/métodos , Idoso , Causas de Morte/tendências , Feminino , Seguimentos , Alemanha/epidemiologia , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento
7.
Eur J Intern Med ; 62: 58-66, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30737061

RESUMO

PURPOSE: Although guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) should be treated with renin-angiotensin system (RAS) inhibitors, the long-term efficacy of RAS inhibitors in HFrEF patients with moderate-to-severe chronic kidney disease (CKD) remains unclear. METHODS: The present study included consecutive patients hospitalized for acute heart failure across five Japanese teaching hospitals. The impact of RAS inhibitors on 2-year all-cause mortality was evaluated in patients with an ejection fraction ≤40% and CKD, defined as an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2, at discharge. Its severity was subclassified from 3B to 5 according to eGFR. RESULTS: Overall, 553 patients (age, 76 ±â€¯11 years; 68% male) were included. RAS inhibitors were prescribed more frequently in 227 patients with stage 3B (71.2%) than in 107 patients with stage 4 or 5 CKD (45.7%). All-cause mortality was recorded in 119 patients (23.4%) (55 [18.5%] patients with stage 3B; 64 [30.3%] patients with stage 4 or 5 CKD), within the median follow-up period of 609 (220-983) days. After many-to-one propensity score matching (87 pairs in stage 3; 60 pairs in stage 4 or 5 CKD), those with RAS inhibitors had reduced mortality rate in stage 3B (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.19-0.83) but not in stage 4 or 5 CKD (HR, 1.08; 95% CI, 0.57-2.03). CONCLUSIONS: In HFrEF patients with CKD, RAS inhibitors are associated with reduction in mortality in stage 3B CKD, but the association is less clear in stage 4 or 5 CKD.


Assuntos
Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Insuficiência Cardíaca Sistólica/tratamento farmacológico , Insuficiência Renal Crônica/induzido quimicamente , Idoso , Idoso de 80 Anos ou mais , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Causas de Morte , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Insuficiência Cardíaca Sistólica/mortalidade , Humanos , Japão/epidemiologia , Masculino , Análise Multivariada , Pontuação de Propensão , Estudos Prospectivos , Insuficiência Renal Crônica/mortalidade , Análise de Sobrevida
8.
Clin Res Cardiol ; 108(7): 806-814, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30604047

RESUMO

BACKGROUND: Increased resting heart rate is a risk factor for cardiovascular mortality and morbidity. Mineralocorticoid receptor antagonists (MRAs) have been shown to improve cardiac sympathetic nerve activity, reduce heart rate and attenuate left ventricular remodelling. Whether or not the beneficial effects of MRA are affected by heart rate in heart failure patients with reduced ejection fraction (HFREF) is unclear. METHODS: We undertook a secondary analysis of data from the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure study to assess if clinical outcomes, as well as the efficacy of eplerenone, varied according to heart rate at baseline. RESULTS: High resting heart rate of 80 bpm and above predisposed patients to greater risk of all outcomes in the trial, regardless of treatment allocation. The beneficial effects of eplerenone were observed across all categories of heart rate. Eplerenone reduced the risk of primary endpoint, the composite of cardiovascular death and hospitalisation for heart failure, by 30% (aHR 0.70; 95% CI 0.54-0.91) in subjects with heart rate ≥ 80 bpm, and by 48% (aHR 0.52; 95% CI 0.33-0.81) in subjects with heart rate ≤ 60 bpm. Eplerenone also reduced the risks of hospitalisation for heart failure, cardiovascular deaths and all-cause deaths independently of baseline heart rate. CONCLUSIONS: Baseline heart rate appears to be an important predictor of major clinical outcome events in patients with HFREF, as has been previously reported. The benefits of eplerenone were preserved across all categories of baseline heart rate, without observed heterogeneity in the responses.


Assuntos
Eplerenona/administração & dosagem , Insuficiência Cardíaca Sistólica/tratamento farmacológico , Frequência Cardíaca/efeitos dos fármacos , Volume Sistólico/fisiologia , Relação Dose-Resposta a Droga , Europa (Continente)/epidemiologia , Feminino , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas de Receptores de Mineralocorticoides/administração & dosagem , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
Acta Cardiol ; 74(3): 216-221, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29914304

RESUMO

Objective: The aim of this study is research relation of serum neopterin level with mortality and morbidity due to systolic HF and also its role in diagnosis of patients with systolic HF. Material and methods: Eighty-one patients with systolic heart failure (HF group) and eighty-one age- and gender-matched healthy subjects (the control group) were enrolled in the study. Echocardiographic examination was performed accordingly. At the beginning of the study, serum B type natriuretic peptide (BNP), neopterin, and high sensitive C-reactive protein (hs-CRP) were measured accordingly. The subjects were followed for one year then after. Mortality rate and number of hospitalisation due to HF were recorded. Results: Age and gender distribution over the groups were statistically similar (p > .05). LVEF of the control and HF groups were 62 ± 3 and 27 ± 3%, respectively (p < .001). Average neopterin value of HF group was significantly higher than that of the control group (p < .001). Both hs-CRP and BNP values were well correlated to neopterin values (p = .667 and .778, respectively). There was a significant correlation between number of hospitalisation and neopterin values among patients in HF group (p = .008). Also among HF group, neopterin value of patients died within first year of follow-up (n = 29) was higher than that of patients survived beyond first year (n = 52 and p = .011). Conclusions: Neopterin is a biomarker reflecting ongoing inflammatory process in deteriorating heart. High level of serum neopterin concentrations was associated with mortality and morbidity in systolic HF.


Assuntos
Insuficiência Cardíaca Sistólica/sangue , Mediadores da Inflamação/sangue , Neopterina/sangue , Idoso , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Estudos de Casos e Controles , Progressão da Doença , Feminino , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Regulação para Cima , Função Ventricular Esquerda
11.
Clin Res Cardiol ; 108(2): 185-193, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30091083

RESUMO

BACKGROUND: Differentiating heart failure from chronic obstructive pulmonary disease (COPD) in a patient presenting with breathlessness is difficult but may have implications for outcome. We investigated the prognostic impact of diagnoses of COPD and/or heart failure in consecutive patients presenting to a secondary care clinic with breathlessness. METHODS: In patients with left ventricular systolic dysfunction (LVSD) by visual estimation, N-terminal pro B-type natriuretic peptide (NTproBNP) levels and spirometry were evaluated (N = 4986). Heart failure was defined as either LVSD worse than mild (heart failure with reduced ejection fraction) or LVSD mild or better and raised NTproBNP levels (> 400 ng/L) (heart failure with normal ejection fraction). COPD was defined as forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) ratio < 0.7. The primary outcome was all-cause mortality. RESULTS: 1764 (35%) patients had heart failure alone, 585 (12%) had COPD alone, 1751 (35%) had heart failure and COPD, and 886 (18%) had neither. Compared to patients with neither diagnosis, those with COPD alone [hazard ratio (HR) = 1.84 95% confidence interval (CI) 1.40-2.43], heart failure alone [HR = 4.40 (95% CI 3.54-5.46)] or heart failure and COPD [HR = 5.44 (95% CI 4.39-6.75)] had a greater risk of death. COPD was not associated with increased risk of death in patients with heart failure on a multivariable analysis. CONCLUSION: While COPD is associated with increased risk of death compared to patients with neither heart failure nor COPD, it has a negligible impact on prognosis amongst patients with heart failure.


Assuntos
Dispneia/etiologia , Insuficiência Cardíaca Sistólica/mortalidade , Doença Pulmonar Obstrutiva Crônica/mortalidade , Medição de Risco , Idoso , Dispneia/mortalidade , Ecocardiografia , Feminino , Seguimentos , Volume Expiratório Forçado , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Espirometria , Volume Sistólico , Taxa de Sobrevida/tendências , Reino Unido/epidemiologia
12.
Clin Res Cardiol ; 108(3): 244-253, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30097684

RESUMO

BACKGROUND: Depression is more common in females than in males and is 3-5 times more prevalent in patients with heart failure (HF) than in the general population. The 9-item Patient Health Questionnaire (PHQ-9) is a validated depression screening instrument; higher sum-scores predict adverse clinical outcomes. Sex- and gender differences in PHQ-9 symptom profile, diagnostic and prognostic properties, and impact on health-related quality of life (HRQOL) have not been comprehensively studied in HF patients. METHODS AND RESULTS: This post hoc analysis from the Interdisciplinary Network Heart Failure program enrolled 852/1022 participants (67 ± 13 years, 28% female) who completed the PHQ-9 at hospital discharge after cardiac decompensation. All had a left ventricular ejection fraction ≤ 40%. Women had a higher mean PHQ-9 sum-score than men (8.4 ± 5.6 vs. 7.4 ± 5.5; p = 0.027), and higher proportions rated the following items ≥ 2 (i.e., present on ≥ 50% of days): 'feeling down, hopeless' (25.8 vs. 18.0%; p = 0.011); 'fatigue' (51.9 vs. 37.2%; p < 0.001); and 'trouble concentrating' (21.6 vs. 15.4%; p = 0.032). A PHQ-9 sum-score ≥ 10 predicted increased mortality in women [hazard ratio 1.91 (95% confidence interval 1.06-3.43); p = 0.030] and men [2.10 (1.43-3.09); p < 0.001] and was associated with worse HRQOL (p < 0.001 for all comparisons). Sum-scores ≥ 10 predicted higher re-hospitalization rates in men only [1.35 (1.08-1.69); p = 0.008]. CONCLUSIONS: Differences in several PHQ-9 items indicated sex- or gender-specific depression symptomatology in HF. For both sexes, HRQOL and survival were worse when PHQ-9 sum-score was ≥ 10, but higher sum-scores predicted higher re-hospitalization rates in men only. Considering these specific aspects might help optimize care strategies in HF.


Assuntos
Depressão/epidemiologia , Insuficiência Cardíaca Sistólica/diagnóstico , Ventrículos do Coração/fisiopatologia , Qualidade de Vida , Função Ventricular Esquerda/fisiologia , Idoso , Depressão/etiologia , Depressão/psicologia , Ecocardiografia , Feminino , Alemanha/epidemiologia , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/mortalidade , Ventrículos do Coração/diagnóstico por imagem , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Morbidade/tendências , Prognóstico , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Inquéritos e Questionários , Taxa de Sobrevida/tendências
13.
ESC Heart Fail ; 5(6): 1060-1068, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30334369

RESUMO

AIMS: Echocardiography is known as the most useful diagnostic test in the assessment of patients with heart failure (HF), and the prognostic significance of echocardiographic findings in HF is well known. In this report, we aim to present the prognostic significance of a limited set of echocardiographic parameters obtained within 24 h of admission of patients enrolled in the Rajaie Acute Systolic Heart Failure registry. METHODS AND RESULTS: A total of 230 patients with the diagnosis of acute systolic HF (left ventricular ejection fraction ≤ 35%) were enrolled into the study. Transthoracic echocardiography was performed for all study population within 24 h of admission. The primary endpoint of the study was the occurrence of worsening renal function (WRF) during the hospitalization course.Acquiring data of transthoracic echocardiography within 24 h of admission was feasible in all study participants. The median (inter-quartile range) of left ventricular ejection fraction was 20% (15-23%). Severe right ventricular dysfunction was observed in 21.5% of patients. The grade of inferior vena cava collapse and right ventricular systolic dysfunction were associated with WRF. In multivariable analysis, right ventricular systolic dysfunction was among the independent predictors of WRF [ß = 0.8, P = 0.01, odds ratio (OR) = 2.4 (1.2-4.9)] and in-hospital mortality [ß = 0.6, P = 0.04, OR = 1.5 (0.5-4.6)]. CONCLUSIONS: Echocardiographic parameters are useful for baseline assessment and provide additional information besides other clinical variables for prognostication. Right ventricular dysfunction is the most important risk factor in developing WRF and in-hospital mortality in patients with acute HF.


Assuntos
Ecocardiografia/métodos , Insuficiência Cardíaca Sistólica/diagnóstico , Rim/fisiopatologia , Sistema de Registros , Insuficiência Renal/fisiopatologia , Volume Sistólico/fisiologia , Doença Aguda , Creatinina/sangue , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Insuficiência Renal/etiologia , Insuficiência Renal/metabolismo , Fatores de Risco , Taxa de Sobrevida/tendências
14.
Am J Cardiol ; 122(9): 1513-1519, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30172361

RESUMO

The metabolic syndrome (MetS), which incorporates insulin resistance, visceral adiposity, and dyslipidemia, is an independent risk factor for incident heart failure (HF), but the impact on survival is uncertain. We sought to determine the relation between the metabolic syndrome and survival in ambulatory systolic HF patients and the impact of MetS on cardiopulmonary exercise test (CPET). We identified adults with ejection fraction ≤40% who underwent CPETs between 2000 and 2011. Baseline MetS status was defined by 3 or more of: (1) Triglycerides ≥150 mg/dl; (2) High density lipoprotein <40 mg/dl males or <50 mg/dl females; (3) Diabetes mellitus; (4) Hypertension; (5) Body mass index ≥35 kg/m2. Minimally-adjusted (for age, sex, transplantation and left ventricular assist device implantation) and fully-adjusted Cox proportional hazards models were constructed for all-cause mortality. MetS prevalence was 37% (716 of 1,953) and median follow-up 5 years. Mortality was 36% for +MetS and 29% for -MetS (p = 0.006), with highest mortality in the subgroup with both MetS plus diabetes (39%). The minimally-adjusted hazard ratio for mortality with MetS was 1.27 (95% confidence interval, 1.08 to 1.49, p = 0.004). After adjustment, MetS was no longer independently associated with mortality (hazard ratio 1.01, 95% confidence interval 0.85 to 1.19, p = 0.921). Patients with MetS achieved poorer CPET performance compared and MetS was independently associated with a lower peak VO2. MetS was associated with a higher hazard of mortality in the minimally-adjusted model, which was primarily driven by the unfavorable impact of diabetes on mortality, but this association was no longer significant after full adjustment. In conclusion, there was no independent association between MetS and survival in an ambulatory systolic HF population.


Assuntos
Aptidão Cardiorrespiratória/fisiologia , Insuficiência Cardíaca Sistólica/mortalidade , Síndrome Metabólica/mortalidade , Teste de Esforço , Feminino , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Síndrome Metabólica/fisiopatologia , Pessoa de Meia-Idade , Ohio/epidemiologia , Consumo de Oxigênio/fisiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Volume Sistólico/fisiologia
15.
Int J Cardiol ; 271: 324-330, 2018 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-30223365

RESUMO

BACKGROUND: Circulating concentrations of N-terminal fragment of the prohormone of brain natriuretic peptide (NT-proBNP) are influenced by age and common age-related comorbidities, such as renal dysfunction. Therefore, utility of NT-proBNP for prediction of prognosis in the aged has been questioned. We aimed to investigate the prognostic value of NT-proBNP across age classes in a cohort of patients with chronic systolic HF. METHODS AND RESULTS: We enrolled 2364 consecutive outpatients with HF and left ventricular ejection fraction ≤50%. Patients were classified according to age quartiles, and a very elderly subgroup was identified, aged ≥85 years. After baseline assessment (including NT-proBNP testing), patients were followed-up for the composite of cardiovascular death, heart transplantation or ventricular assistance device implantation (primary outcome) and for all-cause death (secondary outcome). Patients in the fourth quartile (Q4, age ≥ 77 years, n = 638) and in the very elderly subgroup (age ≥ 85 years, n = 153), had higher NT-proBNP (p < .001 vs Q1). NT-proBNP was independently associated with primary and secondary outcome at 1- and 5-years follow-up in the whole population, as well as in Q4 and in the very elderly subgroup (all p < .05). Compared to the whole population, Q4 and very elderly had higher NT-proBNP cut-off for prediction of 1-year primary (4188 and 9729 ng/l, respectively vs 3710 ng/l) and secondary outcome (4296 and 7634 ng/l, respectively vs 3056 ng/l). CONCLUSIONS: NT-proBNP predicts mortality in elderly and very elderly patients with chronic systolic HF, both at mid- and long-term follow-up. Higher NT-proBNP prognostic cut-off should be considered in the aged HF population.


Assuntos
Insuficiência Cardíaca Sistólica/sangue , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Doença Crônica , Feminino , Seguimentos , Insuficiência Cardíaca Sistólica/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos
16.
J Heart Lung Transplant ; 37(11): 1285-1288, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30197209

RESUMO

Emerging clinical evidence has suggested that short-term mechanical augmentation of cardiac output (CO) may not consistently improve mortality in patients with cardiogenic shock (CS), despite improvements in hemodynamics. Such failures could reflect the underlying complexity of the mechanisms that contribute to malperfusion and organ dysfunction in CS. Distinct molecular and physiologic shock endophenotypes likely exist among patients with CS, with hemodynamic aberrations as the inciting insult but not necessarily the primary drivers of clinical outcomes. We propose that building a framework that moves away from the current "hemodynamic model" in preference for a "mechanistic disease-modifying model" of CS may facilitate progress toward reducing the stagnant mortality rates in this population. Such a therapeutic paradigm shift in patients with chronic systolic heart failure-the shift away from strategies that augment CO to those that modulate the systemic responses to low CO-has been one of the single most important shifts in contemporary cardiovascular medicine.


Assuntos
Débito Cardíaco/fisiologia , Insuficiência Cardíaca Sistólica/fisiopatologia , Coração Auxiliar , Hemodinâmica/fisiologia , Modelos Cardiovasculares , Choque Cardiogênico/fisiopatologia , Causas de Morte , Doença Crônica , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/terapia , Ventrículos do Coração/fisiopatologia , Humanos , Insuficiência de Múltiplos Órgãos/mortalidade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Oxigênio/sangue , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico/mortalidade
17.
BMJ Open ; 8(7): e022185, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30068620

RESUMO

OBJECTIVES: Patients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre. DESIGN: A single-centre, retrospective, cohort study. SETTING: Conducted in an academic emergency department (ED) between January 2010 and January 2015. Patients' charts were queried via the hospital's electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population. PARTICIPANTS: A total of 174 patients, of which 87 (50%) were patients with CHF. PRIMARY AND SECONDARY OUTCOMES: The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups. RESULTS: Patients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p<0.001). ED length of stay was found to be lower in patients with CHF (15.12±24.45 hours vs 18.17±26.13 hours, p=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p=0.149). CONCLUSION: Patients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.


Assuntos
Serviço Hospitalar de Emergência , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência de Múltiplos Órgãos/mortalidade , Sepse/mortalidade , Centros de Atenção Terciária , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca Sistólica/fisiopatologia , Insuficiência Cardíaca Sistólica/terapia , Mortalidade Hospitalar , Humanos , Líbano/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Avaliação de Resultados da Assistência ao Paciente , Estudos Retrospectivos , Sepse/fisiopatologia , Sepse/terapia , Sinais Vitais
18.
Eur Heart J ; 39(39): 3584-3592, 2018 10 14.
Artigo em Inglês | MEDLINE | ID: mdl-30060125

RESUMO

Aims: The impact of tricuspid regurgitation (TR) in patients with left ventricular systolic dysfunction on presentation and clinical outcome is uncertain due to confounding comorbidities and mediocre regurgitation ascertainment. Methods and results: In a cohort of patients with left ventricular systolic dysfunction (ejection fraction, EF < 50%) and functional TR (assessed quantitatively), we matched TR grade-groups for age, sex, EF, and TR velocity. Association of quantified TR (effective regurgitant orifice, ERO, severe if ≥0.4 cm2) to clinical presentation and outcome was analysed. In the 291 cohort patients (age 70 ± 12 years) with left ventricular dysfunction (EF 31 ± 10%), functional TR ERO was 0.26 ± 0.3 cm2. Presentation with right heart failure was strongly related to TR quantified severity [adjusted odds ratios were 4.15 (1.95-8.84), P = 0.0002 for moderate TR and 6.86 (3.34-14.1), P < 0.0001 for severe TR]. Effective regurgitant orifice ≥0.4 cm2 was associated with increased mortality [hazard ratio 1.6 (1.17-2.2), P = 0.003] unadjusted and after comprehensive adjustment [hazard ratio 1.8 (1.16-2.8), P = 0.009]. Furthermore, ERO ≥0.4 cm2 was associated with increased cardiac events (mortality, new atrial fibrillation or heart failure) unadjusted [hazard ratio 1.9 (1.3-2.7), P = 0.002] and after comprehensive adjustment [hazard ratio 2.2 (1.1-4.6), P = 0.02]. Conclusion: Tricuspid regurgitation, even moderate, is associated at diagnosis with more severe heart failure presentation. While moderate TR is associated with heart failure at presentation, our quantitative data show that the threshold associated with reduced survival and more cardiac events is ERO ≥0.4 cm2. These data emphasize the clinical impact of functional TR and warrant large cohort-analysis and clinical trials of treatment of TR associated with left ventricular dysfunction.


Assuntos
Insuficiência Cardíaca Sistólica , Insuficiência da Valva Tricúspide , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/mortalidade , Insuficiência da Valva Tricúspide/terapia
19.
Int J Cardiol ; 266: 174-179, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-29887443

RESUMO

BACKGROUND: Heart Failure (HF) and end stage renal disease (ESRD) are associated with increased morbidity, mortality, and are responsible for an immense economic burden. We sought to evaluate the impact of ESRD in heart failure by using a national cohort. METHODS: This is a retrospective cohort study using the National Inpatient Sample (NIS) of patients hospitalized with HF from 2010 to 2014. The primary outcome was in-hospital mortality. Multivariate regression was used for the statistical analysis. RESULTS: We identified a total 1,587,172 patients with systolic HF and 1,316,220 with diastolic HF. Patients with systolic HF and ESRD had higher in-hospital mortality (4.6% vs 2.7% OR: 1.86, p < 0.001). The in-hospital mortality in diastolic HF and ESRD was 2.7% vs 2.5% in those without ESRD (OR:1.11, p = 0.03). Patients with systolic HF and ESRD had significantly higher rates of ICU admissions (OR: 1.56, p < 0.001), mean length of stay (+1.5 days, p < 0.001), median hospital costs (p < 0.001), and acute respiratory failure (OR: 1.58, p < 0.001). Similarly, patients with diastolic HF and ESRD also had significantly higher rates of ICU admissions (OR: 1.59, p < 0.001), acute respiratory failure (OR: 1.54, p < 0.001), mean length of stay (+1.1 days, p < 0.001), and median hospital costs (p < 0.001). CONCLUSION: ESRD is associated with significantly increased in-hospital mortality in HF but the increase is nearly two-fold (86%) for systolic HF and very modest (11%) in diastolic HF. However, hospital costs, ICU admissions, acute respiratory failure, and length of stay are similarly higher for patients with both systolic and diastolic HF and ESRD.


Assuntos
Insuficiência Cardíaca Diastólica/mortalidade , Insuficiência Cardíaca Sistólica/mortalidade , Mortalidade Hospitalar/tendências , Pacientes Internados , Falência Renal Crônica/mortalidade , Tempo de Internação/tendências , Adolescente , Adulto , Idoso , Estudos de Coortes , Estudos Transversais , Feminino , Insuficiência Cardíaca Diastólica/diagnóstico , Insuficiência Cardíaca Diastólica/fisiopatologia , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Pacientes Internados/estatística & dados numéricos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
20.
JACC Heart Fail ; 6(5): 413-420, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29724363

RESUMO

OBJECTIVES: This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. BACKGROUND: Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. METHODS: Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. RESULTS: Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). CONCLUSIONS: Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans.


Assuntos
Afro-Americanos/estatística & dados numéricos , Cardiologistas/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Insuficiência Cardíaca Diastólica/terapia , Insuficiência Cardíaca Sistólica/terapia , Afro-Americanos/etnologia , Idoso , Feminino , Disparidades em Assistência à Saúde/etnologia , Insuficiência Cardíaca Diastólica/etnologia , Insuficiência Cardíaca Diastólica/mortalidade , Insuficiência Cardíaca Sistólica/etnologia , Insuficiência Cardíaca Sistólica/mortalidade , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
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